9/3/19 annual... · • closure of aor1c and pulmonic valves • should split into 2 components...

9/3/19

1

CommonCardiacCondi+ons:WhattoWatchWhattoRefer

Objec&ves

Outline

MurmursPalpita1onsandHeartRacingChestPainSyncope

9/3/19

2

Outline


Murmurs

• Approx80%ofchildrenages3-4mayhaveamurmur•  61%ofmurmursreferredtospecialistareinnocent•  Lessthan1%ofallmurmursareresultsofcongenitalheartdisease

JourPedNurse.2014Nov;29(6):700-702

What is a murmur?

•  Soundsproducedbyvibra1onscausedbyturbulentbloodflowthroughtheheart• Canalsobecausedbynormalbloodflowthroughnormalstructures(innocent)• Canbeintensifiedbyanythingthatdecreasescardiacoutput•  Anemia•  Fever•  exercise


9/3/19

3

Murmurs

•  Systolicmurmurshaveonlyafewpossiblecauses•  BloodflowacrossanouVlowtract(pulmonaryoraorta)•  VSD(ventricularseptaldefect)•  Atrioventricularvalveregurgita1on(AVV)•  Patentductusarteriosus(PDA)•  Canbefunc1onal(benign)

AmFamPhysician.1999Aug1;60(2):558-564

History

FamilyHistory� Suddencardiacdeathorcongenitalheartdefects

Prenatal/MaternalHistory� Advancedmaternalage� Diabetesmellitus� Exposuretoteratogensoralcoholduringpregnancy� Maternalinfec1on(e.g.Rubella)


History

PostnatalHistory� Poorweightgain� Poororbrieffeedings� Diaphoresiswithfeeding� Tachypneaorincreasedworkofbreathing� Colorchanges


9/3/19

4

History

Olderchildren� Chestpain� Syncope� Exerciseintolerance/Recentchangeinlevelofphysicalac1vity


Physical Exam - Palpa&on � Ac1vePrecordium•  CanbeASD,VSD,PDA•  Anxiety,anemia,hyperthyroidism

� DiscrepantBrachialandFemoralPulses•  Comparerightandfemoral(CoAo)

� Thrill•  LLSB–couldbeVSD•  ULSB–couldbePVstenosis•  Suprasternalnotch–canbeaor1cstenosis


Physical Exam - Ausculta&on

FirstHeartSound–S1•  Lealowersternalborder•  Causedbyclosureofmitralandtricuspidvalves•  Normallyasinglesound•  Canbe“holosystolic”

•  S1soundisobscuredbymurmurthatoccursthroughoutsystole•  CanindicateVSD,AVVregurgita1on,PDA,pulmonaryvalvestenosis

� Clicks•  Listeninall4areas–addmoremeaninghere?


9/3/19

5

Physical Exam: Ausculta&on

SecondHeartSound–S2•  Leauppersternalborder•  Closureofaor1candpulmonicvalves•  Shouldsplitinto2componentswithinspira1on

•  A2–closureofaor1cvalve•  P2–closureofpulmonicvalve•  Occursbecauseinspira1onbringsmorebloodintotherightventricle,RVejec1onisprolongedandpulmonaryvalvecloseslater

� Loud,singleS2Canindicatepulmonaryhypertensionorcongenitalheartdisease


Describing Murmurs

Grades•  1-6•  1isbarelyaudible•  4isloudandhaspalpablethrill•  6isaudiblewithoutstethoscope� 3oraboveconsidered

pathologic

Timing• Canoccurearly,middle,lateinsystole� Holosystolic

Quality� Harsh


Features that Increase Likelihood of Cardiac Pathology � Symptomssuchaschestpain� FamilyhistoryofMarfansyndromeorsuddendeathinyoungfamilymembers� Malforma1onsyndrome(e.g.Downsyndrome)� Increasedprecordialac1vity� Decreasedfemoralpulses� Abnormalsecondheartsound� Clicks� Loudorharshmurmur� Increasedintensityofmurmurwhenpa1entstands


9/3/19

6

Who Needs Referral

� Cyano1cpa1entsorimpairedperfusion� Neonateswithmurmursandsymptoms

(allpa1entswithtrisomy21)

� Harshmurmurs� Persistentmurmursinlaterchildhood

SAFER Approach to Pediatric Murmurs

Helpsiden1fythoseathighriskforunderlyingstructuralheartdefect:

• Syndromicfeatures• Age• FamilyHistory• Evalua1onoffeedingandgrowth• Rheuma1cfever

PedChildHealth.2017Feb;27(2):90-92

Ventricular Septal Defect (VSD)

• Mostcommoncardiacdefect•  Accountsfor20%ofallheartdefects

•  Incidence1in500livebirths• Holosystolicmurmurheardinfirstdaysoflife

9/3/19

7

Atrial Septal Defect (ASD)

•  Incidence1/1500livebirths•  Subtleejec1onmurmurandwidelysplitS2• Asymptoma1cinchildhood•  Symptomsdevelopwithage

Patent Ductus Arteriosus (PDA)

• Normallyclosesinfirst24hrsoflife• Canhavedelayedclosure•  Prematurity•  Hypoxia

• Occurrenceingirls2:1overboys

Atrioventricular Canal (AV Canal)

•  Incidence1/5000livebirths• AssociatedwithTrisomy21• Mayhavetransientpostnatalcyanosis• Minimalmurmurbuthyperdynamic•  EKGhelpfulindiagnosis• Maynothearamurmur

9/3/19

8

AV Canal - EKG

Outline


Palpita&ons and Heart Racing

•  Subjec1vefeelingofabnormalheartbeat

• Mostcausesarebenign

• Althoughcardiacdysrhythmiasarefrequentlytheunderlyinge1ologyofpalpita1onsinadults,sameisnottrueforchildren

•  Incidenceofdysrhythmiasis55per100,000perpediatricEDvisit•  50%ofthosearesinustachycardia

ClinPedEmergMed.2011;12(4):278-288

9/3/19

9

Palpita&ons - HPI

� Parentalreportof“fussiness”ininfants� Youngchild:“heartispounding”or“beeping”orc/ochestpain

Onsetanddura+onofsymptoms� Rapid,suddenonsetand/orresolu1on

Associatedsymptoms� Dizziness,syncope,shortnessofbreath,chestpain� Feverorgastrointes1nalillness


Palpita&ons - History

FamilyHistory� Suddencardiacdeathbeforeage40� DeafnessDietary&SocialHistory•  Evaluateforfood/substancesthatcanexplainpalpita1ons•  Caffeine•  Dietarysupplements•  Illicitdrugs(cocaine,amphetamines)


Palpita&ons - Physical Exam

� Murmur,gallop,click,rub� Hepatomegaly� Wheezing� Jugularveindistension� Peripheraledema


9/3/19

10

Differen&al Diagnosis of Palpita&ons

Cardiaccauses• Sinustachycardia• Tachydysrhythmias•  SVT• PVC/PAC• A-fluoer• A-fib• Vtach

• Repairedcongenitalheartdisease• Bradycardia• AVblock• Sinuspauses

• Cardiomyopathies• Myocardi1s• Mitralvalveprolapse


Differen&al Diagnosis of Palpita&ons

NoncardiacCauses• Electrolyteimbalances• Asthma• Hyperthyroidism• Pheochromocytoma

• Anxiety/Panicaoacks• Stress• Fever• Medica1ons/Drugs• DietarySubstances


Palpita&ons and Heart Racing

Realques+on:Aresymptomscausedbyarrhythmiaornormal(sinus)rhythm?

Diagnos+ctools• EKG• Holter• Event(loop)monitors

9/3/19

11

Normal Ac&va&on Sequence

Rhythm Analysis

HowarePandQRSrelated?

Wholeads?Whofollows?

Normal (Sinus) Rhythm

• PwaveprecedeseveryQRS• QRScomplexfollowseveryP• NormalPwaveaxis(0-90°oruprightinIandaVF)

9/3/19

12

Sinus Arrhythmia

• PwaveprecedeseveryQRS• QRScomplexfollowseveryP• NormalPwaveaxis• Ratevaries

Thisisnormalrespiratoryvaria1on

•  Early,abnormalPwaves• NarrowQRScomplex• Notusuallypathologicinnormalhearts

Atrial Ectopy (PAC)

Atrial Ectopy (PAC) Full tank =normal conduction Partially full tank

=aberrancy Empty tank =block

AV Node

QRS complex

P wave

9/3/19

13

Ventricular Ectopy (PVC)

•  Early,wideQRScomplex• Compensatorypausecommon• Notusuallypathologicinnormalhearts

Supraventricular Tachycardia (SVT)

• Mostcommonpediatrictachyarrhythmia•  Incidenceashighas1in250•  50%ofpediatriccasesoccurininfancy• Mostpa1entshavestructurallynormalhearts• Rate•  Infant:upto300bpm•  Smallchildren:>220bpm•  Olderchildren:>180bpm


SVT

•  Usuallynarrowcomplex•  Pwavesareabnormal(ifrecognizable)

9/3/19

14

SVT - Presenta&on

Infants•  Irritable,fussy,orfeedingpoorly•  CHF(diaphoresis,pallor,respdistress)ifepisodehasbeenuntreatedxseveralhours

•  Historyofnotbehavingperusualx1-2daysChildren•  Palpita1ons,racing,neckpounding,shortofbreath,dizzy•  CHFisrare

SVT - Mechanism

1.  Primaryatrialtachycardia

2.  AVNodalReentrantTachycardia(AVRNT)•  Re-entryoccurswithinAVnode•  Noaccessorypathway

3.  AVReentrantTachycardia(AVRT)•  Re-entryusesaccessorypathway• Wolff-Parkinson-White(WPW)isonetype

Wolff-Parkinson-White

Short PR

Delta waves

9/3/19

15

SVT - Treatment

Cardioversion• DCcardioversionifunstable• Adenosineifstable

SVT Treatment

• Valsalvamaneuvers• Preven1onwithdrugs•  digoxin,propranolol,flecainide,amio

• Radiofrequencyabla1on•  >90%successrate

Long QT Syndrome

•  LQTSpredisposestoventriculartachycardia

• QTvarieswithratebutnotage•  Ratecorrec1on:QT/(RR)1/2•  QTcnormally<450-460msec •  IfHR>78bpm,QT<1/2RRisnormal

•  LongQTcauses•  Hypocalcemia•  CNSinjury•  Drugeffect(Cisapride,Erythromycin)

•  LongQTsyndrome•  Diffusemyocardialdisease

9/3/19

16

Long QT Syndrome

Who Needs Referral

� AbnormalEKG• WPW,LongQTc,SVT

� Frequentsymptomssugges1ngSVT•  Paroxysmal•  HR>200bpm

Outline


9/3/19

17

Chest Pain

•  Secondtoheartmurmurforreferraltopediatriccardiologist• Oneofmostcommonreasonsforunscheduledprimarycarevisitandemergency• Accountsfor>650,000visitsperyearinpa1ents10-21years• Classifiedascardiacandnon-cardiacchestpain

PedReview.2010;23(1):e1-e9

Case Discussion: 12 year old female

•  Annualphysicalexam

•  HPI:chestpainx5days,leauppersternalborder,sharpandstabbing,5/10inintensity,increaseswithdeepbreathing,lasts1minute.Norecenthistoryoffever,cough,exerciseintolerance,palpita1ons,dizziness,orsyncope.

•  Exam:nosignsofinflamma1onoversternumorribcage;palpita1onelicitsmild-to-moderatetendernessoverlea2ndand3rdcostochondraljunc1ons.Pa1entreportsthatpainduringphysicalexamissimilartopainshehasexperiencedxlast5days.Cardiovascularandorgansystemexamnormal.

Whatisthemostlikelycauseofthischild’schestpain?Whatwillyourecommendforher?

Doessheneedreferraltoapediatriccardiologist?

Musculoskeletal(36%)

Gastrointes1nal(3%)

Anxiety(1%)

Cardiac(1%)Unknown(52%)

Pulmonary(7%)

SourcesofChestPaininKids


9/3/19

18

Noncardiac Sources of Chest Pain


Cardiac Sources of Chest Pain


Chest Pain – History

• DescripIon:dura1on,onset,loca1on,quality,severity,radia1on,precipita1ngandmi1ga1ngfactors• Pastmedicalhistory:asthma,sicklecelldisease,Kawasakidisease,cardiacdisease,hypercholesteremia•  Surgicalhistory:previoussurgeryofchestorabdomen•  Familyhistory:early/suddencardiacdeathsofunknowncause,arrhythmias,cardiomyopathies,hypercholesteremia• GeneIcdisorders:Marfan,Turner,Ehlers-Danlos• Historyoftrauma,drugabuse,psychologicalstressors


9/3/19

19

Chest Pain – Physical Exam

• Vitalsigns� Dysmorphicfeatures• Peripheralpulses• Chestinspec1on• Reproduciblechestpain� Hyperdynamicprecordium� Irregularheartbeats

� Distantheartsounds� Abnormalloudsecondheart

sound� Systolicclicks� Murmurs� Gallops� Absentfemoralpulses


Evalua&on of Chest Pain in Kids

ChestXray• Bonylesions,cardiomegaly,airways,lungparenchymalorpleurallesions

ECG• Rate• Rhythm•  Signsofischemia,pericardi1s,chamberhypertrophy


Treatment of Noncardiac Chest Pain

• Reassuranceandeduca1on• Rest• Analgesia


9/3/19

20

Who Needs Referral

� Exer1onalchestpain� Abnormalcardiacfindings� Exer1onalsyncope� Chestpainwithpalpita1ons� ECGabnormali1es� Significantfamilyhistoryofarrhythmias,suddendeath,orgene1cdisorders� Historyofcardiacsurgeryorinterven1ons� Orthotopichearttransplanta1on� HistoryofKawasakidisease� First-degreerela1veswithhypercholesteremia


Outline


Syncope

•  15%ofchildrenwillhavesyncopebyage18

•  Transientlossofconsciousnessandinabilitytomaintainpostureduetotransientglobalcerebralhypoperfusion

• Rapidonset,shortdura1on,spontaneouscompleterecovery

• Girlsmorecommonthanboys,peakincidenceage15-19

CPCSGuideline,2018

9/3/19

21

Classifica&on of Syncope in Children

Classes UnderlyingDiseases

Neurally-mediated*mostcommoncause Vasovagalsyncope

Posturaltachycardiasyndrome(POTS)Orthosta1chypotensionOrthosta1chypertensionSitua1onalsyncopeCaro1dsinussyndrome

CardiacSyncope(2%) ArrhythmiaStructuralcardiacorcardiomyopathy

UnexplainedSyncope(20%)CPCSGuideline,2018

Cardiac Syncope: History

SyncopeHistory� Onsetofsymptomsininfancyorearlychildhood� Occursduringexercise

•  Nottobeconfusedwithpost-exerIonalsyncope� Palpita1onsorchestpainbeforeorduringsyncopalepisode

FamilyHistory� Hypertrophiccardiomyopathy� Pacemaker/ICD� Channelopathy(LongQT,BrugadaSyndrome)� Suddenunexplaineddeathbeforeage40

CardinYoung.2013;23(1):54-60

Cardiac Syncope: Physical Exam

� Murmur� Evidenceofheartfailure

CardinYoung.2013;23(1):54-60

9/3/19

22

Cardiac Syncope: Addi&onal Evalua&on

•  EKG•  Lookingforventricularhypertrophy,ventricularpre-excita1on,LongQTinterval,abnormalTwaves,heartblock,maybenormal

• Orthosta1cvitalsigns•  SupineBPandHR,followedbyrepeatBPandHRaaerstandingx3minutes•  DropinsystolicBPof>20mmHgorriseinHR>30bpmwhenstandingisconsistentwithneutrallymediatedhypotension(NMS)

CardinYoung.2013;23(1):54-60

Who Needs Referral

� AbnormalEKG� ChestPainorpalpita1onsbeforeorduringsyncope� Occurringduringexercise� Concerningfamilyhistory(earlysuddendeath,hypertrophic

cardiomyopathy,LongQT)� Suspectedoriden1fiedcardiacdisease

CardinYoung.2013;23(1):54-60

Conclusion

9/3/19

23

References

•  2018ChinesePediatricCardiologySociety(CPCS)guidelinefordiagnosisandtreatmentofsyncopeinchildrenandadolescents.(2018).ScienceBulleIn,63(23),1558–1564.hops://doi.org/10.1016/j.scib.2018.09.019

•  Mcconnell,M.E.,Adkins,S.B.,&Hannon,D.W.(1999).HeartMurmursinPediatricPa1ents:WhenDoYouRefer?AMERICANFAMILYPHYSICIAN,(2),558.Retrievedfromhops://search-ebscohost-com.libdata.lib.ua.edu/login.aspx?direct=true&db=edsbl&AN=RN066047210&site=eds-live&scope=site

•  Mikrou,P.,&Ramesh,P.(2017).Generalpaediatricevalua1onofheartmurmurs.Paediatrics&ChildHealth,27(2),90–92.hops://doi-org.libdata.lib.ua.edu/10.1016/j.paed.2016.09.004

•  Reddy,S.,&Singh,H.(2010).Chestpaininchildrenandadolescents.PediatricsinReview,31(1),e1-e9.•  Renchen,B.(2014).Innocentmurmursandpediatricpa1ents:Whenshouldtheprimarycareproviderrefer?

JournalofPediatricNursing,29,700-702.

•  Rivera,R.F.,Chambers,P.,&Ceresnak,S.R.(2011).Evalua1onofChildrenWithPalpita1ons.ClinicalPediatricEmergencyMedicine,12(4),278–288.hops://doi-org.libdata.lib.ua.edu/10.1016/j.cpem.2011.09.002

•  Zhang,Q.,Zhu,L.,Wang,C.,Du,Z.,Hu,X.,Tian,H.,…Jin,H.(2013).Valueofhistorytakinginchildrenandadolescentswithcardiacsyncope.CardiologyintheYoung,23(1),54–60.hops://doi.org/10.1017/S1047951112000303

9/3/19 annual... · • closure of aor1c and pulmonic valves • should split into 2 components...

Documents