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Paediatric Cardiology for Paediatric Cardiology for General PaediatriciansGeneral Paediatricians
Dr Talal FarhaDr Talal Farha
Consultant PaediatricianConsultant PaediatricianSpR Regional Teaching SpR Regional Teaching
Taunton 22 Jan 2008Taunton 22 Jan 2008
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Essentials in looking at an ECG
Rhythm (sinus….nonsinus)
Rate, Atrial and ventricular rates.
QRS axis, T axis, QRS-T angle
Intervals: PR. QRS, and QT
P wave amplitude and duration
QRS amplitude and R/S ratio
Q wave
St- Segment and T wave abnormalities
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ECG tipsECG tips
How do you determine Sinus rhythm?How do you determine Sinus rhythm?
What is T axis?What is T axis?
What is QRS/T angle?What is QRS/T angle?
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RhythmRhythm
P before every QRSP before every QRS P axis (0-90). P inverted in aVR P axis (0-90). P inverted in aVR
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P wave axisP wave axis
The location of the P-wave axis determines the origin of The location of the P-wave axis determines the origin of an atrial-derived rhythm:an atrial-derived rhythm:
0 to 90 degrees = a high right (normal sinus rhythm) 0 to 90 degrees = a high right (normal sinus rhythm)
90 to 180 degrees = a high left90 to 180 degrees = a high left
180 to 270 degrees = a low left180 to 270 degrees = a low left
270 to 0 degrees = a low right270 to 0 degrees = a low right
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T waveT wave
In most leads, the T wave is positive. In most leads, the T wave is positive.
A negative T wave is normal in lead aVR. A negative T wave is normal in lead aVR.
Lead V1 may have a positive, negative, or biphasic T Lead V1 may have a positive, negative, or biphasic T wave. In additionwave. In addition
It is not uncommon to have an isolated negative T wave It is not uncommon to have an isolated negative T wave in lead III, aVL, or aVF.in lead III, aVL, or aVF.
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Inverted (or negative) T waves can be a sign of Inverted (or negative) T waves can be a sign of Coronary ischemiaCoronary ischemia Left ventricular hypertrophyLeft ventricular hypertrophy
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T axisT axis
Determined by the same methods as QRSDetermined by the same methods as QRS
0 to + 90 is normal0 to + 90 is normal
T Axis out side the normal quadrant could suggest T Axis out side the normal quadrant could suggest conditions with Myocardial dysfunction.conditions with Myocardial dysfunction.
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QRS-T AngleQRS-T Angle
Formed by the QRS axis and the T axisFormed by the QRS axis and the T axis
QRS-T angle >60 degrees is unusual but if > 90 QRS-T angle >60 degrees is unusual but if > 90 degrees, it is abnormal.degrees, it is abnormal.
Abnormally wide angle, with T axis outside the normal Abnormally wide angle, with T axis outside the normal quadrant is seen in quadrant is seen in
- - severe ventricular hypertrophy with starinsevere ventricular hypertrophy with starin
- Ventricular conduction disturbances- Ventricular conduction disturbances
- Myocardial dysfunction of a metabolic or ischemic nature.- Myocardial dysfunction of a metabolic or ischemic nature.
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Top Tip For ECGTop Tip For ECG
Read more ECGs Read more ECGs
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Do not forget, nothing replaces good traditional Do not forget, nothing replaces good traditional clinical examination and detailed historyclinical examination and detailed history
teaching 1.asx
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SyncopeSyncope
How often related to the heart?How often related to the heart?
What are the related cardiac conditions?What are the related cardiac conditions?
How do we approach it?How do we approach it?
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DefinitionDefinition
Syncope is a transient loss of consciousness and muscle Syncope is a transient loss of consciousness and muscle tone.tone.
Near syncope: Near syncope:
premonitory signs and symptoms of imminent syncope premonitory signs and symptoms of imminent syncope occur; dizziness with or without blackout, pallor, occur; dizziness with or without blackout, pallor, diaphoresis, thready pulse and low BPdiaphoresis, thready pulse and low BP
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CauseCause
Brain function depends on Oxygen and glucose.Brain function depends on Oxygen and glucose.
Circulatory, metabolic, or neuropsychiatric causes.Circulatory, metabolic, or neuropsychiatric causes.
Adults syncope mostly cardiac.Adults syncope mostly cardiac.
Children’s mostly benign.Children’s mostly benign.
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Causes of Syncope in ChildrenCauses of Syncope in Children
Extra cardiac causesExtra cardiac causesVasovagalVasovagalOrthostaticOrthostaticFailure of systemic venous returnFailure of systemic venous returnCerebrovascular occlusive diseaseCerebrovascular occlusive diseaseHyperventilationHyperventilationBreath holdingBreath holding
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1- Vasovagal Syncope1- Vasovagal SyncopeNeurocardiogenicNeurocardiogenicCommon SyncopeCommon Syncope
Predrome for few seconds; dizziness, light-headedness, Predrome for few seconds; dizziness, light-headedness, pallor, palpitation, nausea, hyperventilation then Loss of pallor, palpitation, nausea, hyperventilation then Loss of consciousness and muscle toneconsciousness and muscle tone
Falls without injury Falls without injury
Lasts about a minute, awake graduallyLasts about a minute, awake gradually
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Vasovagal Syncope Vasovagal Syncope
AnxietyAnxiety FrightFright PainPain BloodBlood FastingFasting Hot and humid conditionsHot and humid conditions Crowded placesCrowded places Prolonged motionless standingProlonged motionless standing
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Vasovagal Syncope Vasovagal Syncope PathophysiologyPathophysiology
Standing posture without movement shifts blood to the Standing posture without movement shifts blood to the lower extremitieslower extremities
Decrease venous return, stroke volume, BPDecrease venous return, stroke volume, BP
Less stretching of vent muscle and mechanoreceptors Less stretching of vent muscle and mechanoreceptors (mrcpts), decline in neural traffic form mrcpts, decreased (mrcpts), decline in neural traffic form mrcpts, decreased arterial pressure, increase sympathetic output witharterial pressure, increase sympathetic output with
Higher HR, vasoconstriction (higher diastolic pressure)Higher HR, vasoconstriction (higher diastolic pressure)
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Vasovagal SyncopeVasovagal Syncope Patients Patients
Decreased venous return produces large increase in Decreased venous return produces large increase in ventricular contraction forceventricular contraction force
Activation of LV mechanoreceptors (normally only Activation of LV mechanoreceptors (normally only responds to stretch) responds to stretch)
Increase neural traffic mimicking high BP condition Increase neural traffic mimicking high BP condition
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Paradoxical withdrawal of sympathetic activity, Paradoxical withdrawal of sympathetic activity, vasodilatation, hypotension and bradycardiavasodilatation, hypotension and bradycardia
Reduction of brain perfusion Reduction of brain perfusion
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DiagnosesDiagnoses
ECG, Holter, EEG, glucose tolerance test all are ECG, Holter, EEG, glucose tolerance test all are normally negative in V V Enormally negative in V V E
Tilt test Tilt test
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ManagementManagement
Supine +/- feet upSupine +/- feet up Prevention Prevention
PseudoephedrinePseudoephedrine MetoprololMetoprolol FludrocortisoneFludrocortisone DisopyramideDisopyramide ScopolamineScopolamine
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2- Orthostatic Hypotension2- Orthostatic Hypotension
What happen when we stand up? What happen when we stand up?
HR, vasoconstrictionHR, vasoconstriction
Absent or inadequate upright position response, Absent or inadequate upright position response, Hypotension without increased HRHypotension without increased HR
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DiagnosesDiagnoses
BP and HR supine and standing up.BP and HR supine and standing up.
BP drop after 5-10 minutes up still by 10-15 mmHGBP drop after 5-10 minutes up still by 10-15 mmHG
Positive tilt test without autonomic signsPositive tilt test without autonomic signs
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ManagementManagement
Elastic stockingsElastic stockings High salt dietHigh salt diet Corticosteroids Corticosteroids Slow upright positionSlow upright position
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Micturition SyncopeMicturition Syncope
Rare form of orthostaticRare form of orthostatic
Rapid bladder decompression associated with Rapid bladder decompression associated with degreased total peripheral vascular resistance. degreased total peripheral vascular resistance.
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3- Failure of systemic venous return3- Failure of systemic venous return
Increased intrathoracic pressureIncreased intrathoracic pressure
Decreased venous tone (drugs; nitroglycerin)Decreased venous tone (drugs; nitroglycerin)
Decreased volume (bleed…)Decreased volume (bleed…)
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4- Cerebrovascular occlusive disease4- Cerebrovascular occlusive disease
Mainly adult Mainly adult
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Cardiac causes of SyncopeCardiac causes of Syncope
Structural heart diseaseStructural heart disease
ArrhythmiaArrhythmia
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Why Cardiac ?Why Cardiac ?
Syncope at restSyncope at rest Provoked by exercise Provoked by exercise Chest painChest pain Heart diseaseHeart disease FH of sudden deathFH of sudden death
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What CardiacWhat Cardiac
Obstructive lesionsObstructive lesions
Myocardial dysfunctionMyocardial dysfunction
ArrhythmiasArrhythmias
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Obstructive lesionsObstructive lesions
AS, PS, HOCM, PHTXAS, PS, HOCM, PHTX
Precipitated by exercise, no increase in cardiac output to Precipitated by exercise, no increase in cardiac output to accommodate increased demand.accommodate increased demand.
Examination, CXR, ECG, EchoExamination, CXR, ECG, Echo
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Myocardial DysfunctionMyocardial Dysfunction
Ischemia, infarction secondary to CHD, Kawasaki’s..Ischemia, infarction secondary to CHD, Kawasaki’s..
MyocarditisMyocarditis
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ArrhythmiaArrhythmia
ArrhythmiaLack of output Lack of output
(Fast or slow heart)(Fast or slow heart) SVT, VT, SSS, CHB,SVT, VT, SSS, CHB,
Normal heart structure
Long QT, WPW
Abnormal Heart Structure
Ebstein's, MS, MR, Ebstein's, MS, MR, CCTGACCTGA
Post op, TOF, TGAPost op, TOF, TGAMVP VTMVP VT
Cmpthy SVT, VT, Cmpthy SVT, VT, s bradys brady
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Long QTLong QT
Syncope, seizures, palpitation during exercise or with Syncope, seizures, palpitation during exercise or with emotionemotion
ECGECG
Ventricular arrhythmias (Tachy) with risk of sudden Ventricular arrhythmias (Tachy) with risk of sudden deathdeath
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Long QTDefective ion
channels
CongenitalOver 50 mutations in
4 sitesJarvell-lange-nielson Jarvell-lange-nielson
Deafness ARDeafness AR Romano-ward Romano-ward no deafness ADno deafness ADSporadic no FH Sporadic no FH
no Deafnessno Deafness
AcquiredDrugs, illnesses,
AutoimmuneNeurologicalNutritional
Electrolytes
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clinicallyclinically
FH 60%FH 60%
Deafness 5%Deafness 5%
PresentationPresentation with Syncope 26%, seizure 10%, cardiac arrest 9%, with Syncope 26%, seizure 10%, cardiac arrest 9%, presyncope palpitation 6%presyncope palpitation 6%
Symptoms during exercise or emotionSymptoms during exercise or emotion
Normally symptoms related to ventricular arrhythmias, mostly end of Normally symptoms related to ventricular arrhythmias, mostly end of second decade of life.second decade of life.
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Syncope in adrenergic arousal, exercise (swimming is a Syncope in adrenergic arousal, exercise (swimming is a particular trigger)particular trigger)
Abrupt noises (Alarm, doorbell, phone..)Abrupt noises (Alarm, doorbell, phone..)
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TestsTests
ECG with QTc >0.46 secondsECG with QTc >0.46 seconds Frequently finding abnormal T waveFrequently finding abnormal T wave Bradycardia (20%)Bradycardia (20%)
Exercise test, maximum prolongation after 2 minutes of Exercise test, maximum prolongation after 2 minutes of recovery, ventricular arrhythmia in 30% during exerciserecovery, ventricular arrhythmia in 30% during exercise
Holter monitoring may show longer QTc Holter monitoring may show longer QTc
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Diagnoses CriteriaDiagnoses Criteria
Electrophysiological societyElectrophysiological society- QTc >0.44 with no other causes (0.46 sec)QTc >0.44 with no other causes (0.46 sec)- Positive family history plus unexplained syncope, Positive family history plus unexplained syncope,
seizure or cardiac arrest proceeded by trigger such as seizure or cardiac arrest proceeded by trigger such as exercise, emotionexercise, emotion
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TreatmentTreatment
Discuss with cardiologistDiscuss with cardiologist Avoid drugs associated with long QTAvoid drugs associated with long QT Avoid swimming, competitive sportsAvoid swimming, competitive sports Beta blockersBeta blockers Demand cardiac pacing (Pacemaker and defib)Demand cardiac pacing (Pacemaker and defib) Left cardiac sympathetic denervationLeft cardiac sympathetic denervation
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PrognosesPrognoses
Untreated 75-80% mortalityUntreated 75-80% mortality
Beta blockers reduce mortality to some extentBeta blockers reduce mortality to some extent
The adjusted annual mortality rate on treatment is 4.5% The adjusted annual mortality rate on treatment is 4.5% (10 year mortality of 50%)(10 year mortality of 50%)
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Advise related to CHDAdvise related to CHD
If one child has CHD, what are the chances of the If one child has CHD, what are the chances of the second?second?
One parent has CHD, can offspring be affected? What One parent has CHD, can offspring be affected? What are the chances? are the chances?
See Handouts, statistical list of potential risksSee Handouts, statistical list of potential risks
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Pathophysiology of congenital heart lesionsPathophysiology of congenital heart lesions
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Pathophysiology of left to right shunt lesions ASDPathophysiology of left to right shunt lesions ASD
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Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions VSDlesions VSD
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Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions PDAlesions PDA
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Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions AVSDlesions AVSD
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Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions MRregurgitation lesions MR
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Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions ARregurgitation lesions AR
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Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions PRregurgitation lesions PR
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Pathophysiology Cyanotic lesions Pathophysiology Cyanotic lesions TGA with good mixingTGA with good mixing
RV 80% LV 90%
65%
LA 90%
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PathophysiologyPathophysiologyTGA with poor mixingTGA with poor mixing
RV 45% LV 92%
100%30%
LA 92%
45%
45%
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PathophysiologyPathophysiologyTGA with poor mixingTGA with poor mixing
RV 45% LV 92%
100%30%
LA 92%
45%
45%
![Page 56: Paediatric Cardiology for General Paediatricians Dr Talal Farha Consultant Paediatrician SpR Regional Teaching Taunton 22 Jan 2008](https://reader033.vdocuments.net/reader033/viewer/2022050909/56649dfe5503460f94ae6a96/html5/thumbnails/56.jpg)
TipsTips
Read ECGs, easy to loose ECG skills.Read ECGs, easy to loose ECG skills. Ask for helpAsk for help As all specialties, it is only common sense.As all specialties, it is only common sense.