mark zittergruen, md, mba mercy pediatric …p.mercycare.org/app/files/public/1210/pediatric...vsd...
TRANSCRIPT
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Mark Zittergruen, MD, MBA Mercy Pediatric Cardiology
February 3, 2018
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AGENDA Heart murmurs and structural heart
disease Pediatric chest discomfort Pediatric syncope Pediatric arrhythmias in the office setting
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Fluid Dynamics 101 Q α ΔP/R Differences between flow and velocity Magnitude of shunt vs. velocity of flow
Fluid flow follows a pressure gradient No gradient = no flow Think newborn – no murmur if RVP=LVP
Influence of resistance – diameter of orifice R α 1/r4 ›››› Q α ΔPr4
Double the radius, resistance decreases by 16X – flow increases by 16X
Applies to airways as well
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Physics of the Murmur Murmurs generally related to turbulence which is
proportional to velocity (Reynolds number) and inversely proportional to diameter and viscosity
Heart sounds related to deceleration of blood with abrupt valve closure and its effect on surrounding structures
Children’s chests vs. adults
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How many murmurs are out there? Prevalence in infancy estimated at 60% Prevalence in school-age children ranges
from 75-90% at some time CHD – approximately 8/1000 at birth and
4/1000 in school age children Therefore – most murmurs (99%) are
benign
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Importance of the Diagnosis Obviously important to diagnose CHD and react
appropriately May be asymptomatic in childhood with dire
consequences later in life (Eisenmenger’s syndrome)
Innocent murmur is not a disease Psychological issues – school, reproduction Socioeconomic issues
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Clues to the Significance History and Physical are VERY IMPORTANT!!!
Growth and development Feeding pattern ? Symptoms: dyspnea/tachypnea, activity, cyanosis
(central vs. peripheral), chest discomfort, syncope Infant can have significant congenital heart disease
and have no murmur Transposition rarely has murmur unless VSD is
present HLHS rarely has a murmur
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Physical Exam “Across the room” assessment Height and weight plotted Complete vitals including BPs in UE and LE; use of
pulse oximetry Inspection of the chest and neck Palpation of chest Lungs, abdomen, and pulses Clubbing and cyanosis
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Precordial Thrill
Palpable manifestation of a loud murmur Often best felt with palm rather than finger
tips Related to large pressure gradients When might a thrill be a good thing? When might a thrill be a bad thing?
Makes the murmur an automatic grade 4
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Dr. Z’s Guide to Listening! Practice makes perfect Room has to be quiet Differentiate from respirations – “pinch the
nose” technique Supine and upright Don’t rush the exam “See the murmur”
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First Heart Sound S1 associated with closure of mitral and
tricuspid valves May hear splitting of S1 in normal children Especially if very trim and athletic with
slow heart rates Split S1 also heart frequently in RBBB and
Ebstein’s anomaly
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S2 – Critical Sound S2 represents closure of pulmonic and aortic
valves Normal splitting – A2 followed by P2 With inspiration – splitting increases PRACTICE LISTENING FOR THIS
Single S2 or widely split S2 may be only physical clue for pathology!
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S2 and Pathology Fixed split S2 – very common with ASD and
RBBB Single S2 found in pulmonary hypertension
(in which case P2 will be very loud) or if only one semilunar valve is present
Paradoxical splitting of S2 – when LV ejection is delayed such as LBBB or severe AS
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Cardiac Auscultation - Timing What happens during systole?
Cardiac contraction – VSD murmur AV valves closed – Tricuspid and mitral regurgitation Semilunar valves open – Aortic and pulmonic stenosis
What happens during diastole? AV valves open – Tricuspid and mitral stenosis Semilunar valves closed – Aortic and pulmonic
regurgitation Some murmur are continuous
PDA, coarctation
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Murmurs Must classify in terms of:
Intensity - Grades 1-6 Grade 1 - Barely audible Grade 2 - Soft, but easily heard Grade 3 - Moderately loud, no thrill Grade 4 - Moderately loud with thrill Grade 5 - Audible with stethoscope barely on chest Grade 6 – Audible with stethoscope off the chest
Timing – Systolic, diastolic, continuous Location Transmission Quality – Musical, vibratory, harsh, blowing
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Red Flags in Auscultation IMPORTANT SLIDE #1 Murmur is associated with a thrill Murmur is diastolic Murmur is continuous and not suppressible Murmur radiates to back or axillae (unless
patient is a baby) Murmur preceded by click or there is an
extra heart sound (gallop)
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The Still’s Murmur Most common benign murmur of childhood The vibratory, low frequency murmur heard
at the LLSB, Grade 1-3 Loudest when supine Little radiation Louder with activity, anemia, or illness Softer with Valsalva
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Pulmonic Outflow Murmur 15% of all innocent murmurs Very common in children with chest wall
abnormalities (pectus excavatum) Loudest at ULSB Blowing low frequency murmur, NO CLICK,
NORMAL S2, softer in inspiration May only be audible with anemia,
thyrotoxicosis, pregnancy, fever
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Peripheral Pulmonic Stenosis Very common murmur in infants –
especially premature infants Related to increasing cardiac output and
small peripheral branch pulmonary arteries LUSB with radiation to axillae Usually gone by 1 year of age
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Benign Venous Hum Related to flow in the superior vena cava Common in toddlers/preschoolers Continuous murmur heard under the right
clavicle Very positional – usually disappears when
child is supine Can be suppressed with neck pressure or
changes in child’s head position
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VSD Often high-pitched systolic murmur Huge VSD may have lower frequency Frequency/harshness of murmur related to
velocity of blood across the septum Harsher is usually better – signifies a nice
pressure gradient between LV and RV
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Echocardiogram
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VSD Echocardiogram - Color
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ASD You do NOT hear the blood as it crosses the septum –
WHY? What are we hearing? Murmur is a pulmonic murmur heard best at ULSB
related to large volume flow Usually a split S2 is key to the diagnosis PFO should not cause a murmur
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ASD ECHOCARDIOGRAM 1
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ASD ECHOCARDIOGRAM 2
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PFO
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Pulmonic Stenosis Same murmur as ASD May have an associated
thrill Usually preceded by a
systolic click Harsher is NOT better with
PS (or AS) Implies a larger gradient
across the valve
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PDA Classically the machinery continuous
murmur heard over upper left chest ?Why continuous
Sounds “extra-cardiac” May be tricky in infancy – often systolic only Pulse pressure should be wider
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PDA - Echocardiogram
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PDA - Echocardiogram
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Strategy In general – not a crisis May be very stressful to family Suddenly child is lethargic or dyspneic!
Confidence in your management will assist family
Importance of discussing murmur with family – my perspective
Defending your colleagues’ ears!
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Strategy Continued In otherwise asymptomatic child Observation usually very acceptable to
family ? Prudent suggestion for SBE precautions
until definitive diagnosis; certainly not usually needed
An EKG and CXR may be very beneficial – especially if murmur persists
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My Strategy If exam suggests benign murmur and
EKG/CXR demonstrate no concerns…. Educate family Follow up in 2 years unless there are
other issues (such as small child, symptoms that are likely unrelated, or subtle dysmorphic features)
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Smart Shopping Visit to Dr. Z Level 3 new consult - $452.20 EKG - $228.30 CXR - $78.00 – $235.50 TOTAL: $758.50 - $916.00 ECHO: $2,973.30
Potential savings on benign murmur: $2,057.5 - $2,214.8
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The Horrors of the ECHO-only Expensive and Non-Exact Test I only see what the technician shows me
Best echocardiograms are done in my clinic Difficult to know what I’m looking for given no
clinical information Missed diagnoses Certainly not defensible Not a fishing tool Often causes “problems” – PFO, TR, silent PDA
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However ….
“Echocardiography is the greatest invention of the modern world”
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ECHOCARDIOGRAPHY Used to confirm diagnosis or evaluate
hemodynamics My bias – should have cardiologist
involved before the echo if done for murmur Has essentially made diagnostic cardiac
catheterization in childhood unnecessary
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KEY POINTS REGARDING MURMURS Important slide #2 Most murmurs in an otherwise healthy child
are benign Not usually a crisis – exams over time very
helpful You will not miss something urgently
important if perfusion/saturations are normal and child is thriving
Benign murmurs are benign Practice listening!! My number 319-560-9288; my pager 0705
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Primum ASD - Color
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ASD – Primum defect
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PEDIATRIC CHEST DISCOMFORT
Notice the wording!! Very common complaint in clinic and ER Most important thing to know: Almost
ALL pediatric chest discomfort has a non-cardiac etiology
Rare cases get a lot of media attention Parental anxiety often drives the evaluation
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Chest Discomfort Etiologies
Idiopathic (40%) Musculoskeletal (35%) Costochondritis/Tietze syndrome Muscle strain/trauma
Pulmonary – asthma, infection, pleuritis (10%) Gastrointestinal/Esophageal (5%) Psychogenic – conversion, relative with recent MI
(10%) Cardiac - rare
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Chest Discomfort Evaluation
Thorough history including family history Physical Exam – Don’t forget to palpate
chest wall! An EKG and CXR are reasonable tests
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Chest Pain Red Flags Important slide #3 History of Kawasaki disease, CTD, or Turner syndrome History of d-TGA or Ross procedure - coronaries Chest pain only during exertion Chest pain associated withsyncope/palpitations Abnormal cardiac examination The very common sharp, stabbing, and random
midsternal or left sided pain which lasts for a few seconds-to-minutes is not too worrisome (precordial catch syndrome)
Pain associated with a host of other symptoms is usually not too worrisome (CNS component)
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Cardiac Chest Discomfort Pericarditis – usually ill with fever; friction rub on
exam, pain constant and worse when supine Tachycardias may be reported as “pain” LV outflow tract obstruction – aortic stenosis,
hypertrophic cardiomyopathy History of Kawasaki disease – RED FLAG Coronary artery anomalies – exertional angina if lucky
enough to have symptoms Coronary vasospasm – think drug use (cocaine) Dissecting aortic aneurysm in CTD or Turner
syndrome
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Treatment of Chest Discomfort Education and reassurance that the discomfort is not
related to the heart Point out recurrent/chronic nature of these symptoms Treat underlying problem if known Scheduled ibuprofen/naprosyn Ice/heat Tight sports bra (for the female adolescents) Usually no physical restrictions needed but patient should
be aware that exercise may exacerbate the discomfort Rarely – pain clinic, chiropractic care, psychologic care to
deal with the discomfort
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Fetal Echocardiography
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Fetal Echocardiography - TGA
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Fetal - AVC
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Syncope Very common in adolescence 15.5%-22.3% of teenagers have at least one
episode Often a familial tendency 70-80% of cases are secondary to a neurally
mediated cause (“vaso-vagal”)
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Syncope – Mechanisms Decrease in perfusion of blood to the brain Drop in arteriolar resistance: neurally mediated
vasodepression, autonomic neuropathy Drop in preload: hypovolemia, autonomic
neuropathy Decrease in cerebrovascular tone: migraine,
hyperventilation Change in cardiac function: arrhythmia,
bradycardia, output issue
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Syncope Etiologies - Frequencies Autonomic-mediated 73.0% Unknown origin 18.9% Cardiac 2.9% Psychiatric 2.3% Neurologic 2.1% Metabolic 0.6% Hyperventilation 0.2%
Zhang, Acta Paediatric 2009:98:882
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Syncope – Usual Scenarios Most syncope occurs with standing for
prolonged periods or a sudden change to an upright position
Shower, hair grooming, choir, urination, warm environment, stressful situations, lunch lines, church
Usually poor fluid intake associated Patient often has warning or aura
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Syncope – First Responder ABCs of resuscitation Check pulse and BP (orthostatic) if
possible – helpful in determining cause Get student flat and prop up legs Get student out of harm’s way and check for
injuries DO NOT get up walking or drinking until
back to normal sensorium DO NOT let student go off alone
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Syncope – Red Flags Important Slide #4 Sudden and without any warning Association with tachycardia/palpitations During exercise Must differentiate syncope during exercise
from generalized collapse (exhaustion) following exercise
Injury Seizure Psychiatric causes
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Syncope Evaluation Assessment of incident as soon as possible – the
details are important Talk to by-standers, parents, coaches Ideal if witness (school nurse) could write
down a narrative of event including physical assessment/vital signs
H&P with orthostatic vital signs Significant if BP drops 15-20 mmHg or if pulse
increases >20 bpm My opinion - patients with syncope should have an
EKG
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Syncope Treatment The Zittergruen Trinity
INCREASE FLUID INTAKE SIGNIFICANTLY INCREASE SALT INTAKE VITAMIN WITH IRON
Beverages during the school day Need to use restroom frequently
Awareness Chronicity and ownership Exercise – legs/core and wall standing to “retrain
baroreceptor reflexes” Medications
Midodrine Florinef Beta blockers
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Coarctation
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Rhythm Issues in the Office Biggest question: who is concerned? Many children have an intermittent
sensation of their heart beating fast or irregular Some children find sinus tachycardia
bothersome Must distinguish pathological rhythms
from physiologic rhythms and then formulate a treatment plan
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Couple Things to Consider…. Children/adolescents have a wide variation
in pulse rate throughout the day Maximum heart rate is usually 220-age Gym teachers (enough said)
Sinus arrhythmia is common Heart rate speeds up during inspiration and
slows down during expiration P-waves do not change
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Sinus Arrhythmia
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A Few More Things Many anxious children/adolescents have
bothersome tachycardia Panic attack (If the shoe fits….)
Medication and drugs I see a lot of patients who receive ADHD/psychiatric
drugs with sinus tachycardia
Elevated average heart rate Caffeine Symptoms often occur at bedtime
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Tachycardia/Palpitations Assessment of rate and rhythm during
symptoms is the best way to arrive at diagnosis
Palpation and counting “Too fast to count”
How does student look/act during symptoms
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Diagnostic Tests EKG – look for any conduction
abnormalities, measure QTc, look for pre-excitation Event Monitor – best if trying to
capture an infrequent event Holter Monitor – best if symptoms are
daily or to quantitate number of ectopic events
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Irregular Heart Rhythms in Infants Usually due to premature ventricular contractions
(PVCs) or premature atrial contractions (PACs) Often transient and related to high circulating
catecholamines in infant after birth Document with rhythm strip or EKG If infant appears well, usually re-evaluate at 2
weeks and refer to cardiology if persisting at that time
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Supraventricular Tachycardia
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SVT SVT very common in first few days of life and
adolescence Usually secondary to a bypass tract Acute treatment: Ice water to face in infants Vagal maneuvers Adenosine – 50 micrograms per kilogram to
start Cardioversion – First choice if unstable patient
Chronic treatment: usually beta-blockers or digoxin
EKG, echocardiogram
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Atrial Flutter
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Tachycardia/Palpitations Treatment depends on etiology Often the problem “resolves” after diagnosis Beta blockers for tachycardia Implication for gym/activities
Fluid and rest Avoidance of caffeine/stimulants Assessment and treatment of stress/anxiety
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Significant Bradycardia - Infants Term baby may have dips in heart rate to 85-90 bpm
range when asleep but usually over 100 bpm If concerned, document that rhythm is sinus by EKG Heart block may be 2nd or 3rd degree Neonatal heart block needs further evaluation
Associated with l-TGA and more complex lesions Can be associated with a systemic maternal illness (SLE)
3rd degree HB usually requires pacer for normal growth and development of infant
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Significant Bradycardia - Adolescent May be physiologic in well-conditioned athlete Heart rate should be > 30 bpm – especially when
awake Holter monitor to assess minimum rate, average
rate, and to look for any heart block Consider anorexia if average heart rate is slow Wenckebach rhythm is usually benign but I would
suggest a referral – few hoops to jump through New heart block – what diagnosis to exclude?
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QUESTIONS???