Pediatric Cardiology Problems Facing the Primary Care

William F. Waltz, Ph.D., M.D.

Pediatric Cardiology Problems Facing the Primary Care Provider

Nurse Practitioner Association of South Dakota Fall Conference

5 November 2009

Objectives

• Discuss recognizing cardiac disease in the primary care setting

• Describe cardiac evaluation by the primary care provider

• Explain when to refer to Pediatric Cardiology

Common “Cardiac” Problems

• Chest pain

• Syncope

• Hypertension

• Murmur

• Family history

The Plan

• Discuss common pediatric cardiology referrals for non-cardiac problems

• Compare non-cardiac complaints with serious cardiac issues

Chest pain

Syncope

Case -Chest Pain• A 13 year old boy complains of sharp chest

pain at the mid left sternal border that came on during cross country running.

• Stopped running because of the pain. He was short of breath, had tingling hands and feet.

• Pain was worse with a deep breath.

• Physical Exam- BP 110/60 P 90 R 16- Pulses strong and equal- 2/6 ejection murmur at LUSB- Discrete tenderness at site of pain

Chest Pain

• Common reason for referral

• Do not equate adult CP with childhood CP

• If benign; reassure, don’t refer

• If suspect cardiac-don’t echo-please refer

Chest Pain Breakdown• Idiopathic: 12-85%

• Chest wall/musculoskeletal: 15-95%

• Psychogenic : 20-29%

• Respiratory: 12-21%

• Gastrointestinal: 4-7%

• Cardiac: 1-6%

• Organic and functional causes can coexist

• Non-cardiac chest pain typically occurs at rest-can be worse with movement/exercise, deep inspiration, palpation

• Chest wall pain-precordial catch syndrome

*sharp pain at rest*worse with deep breath*localized over precordium*lasts seconds to minutes

-costochondritis-pleuritis-trauma

• Other non-cardiac; SS crisis, Asthma, Zoster, Pneumonia, GI reflux, Pneumothorax

Chest Pain Breakdown

Chest Wall Pain• Common in teen athletes

• Frequently seen in association with handsprings, shooting baskets, volleyball, weight lifting, martial arts

• Often comes on as new activity starts

• Frequently worse with deep breathing

• Discrete tenderness over site (sometimes)

• Acute at first, can last for weeks, migrate

Therapy for Chest Wall Pain

• Reassurance

• NSAIDs: scheduled dose for two weeks

• Avoid offending activity

• Referral for reassurance?

Counseling About Chest Wall Pain

• Time well spent in evaluation

• Discuss mechanism for pain

• Pain is real, but not a threat

• Pain not due to heart!

• cardiac cause in 1-6%

• patients c/o having a heart attack (44%), heart disease (12%), cancer (12%).

• adolescents more likely to have psychogenic chest pain with stress

• younger children more likely to have true cardiorespiratory cause

Chest Pain Of Concern

• Myocarditis/Cardiomyopathy-associated with GI/Respiratory symptoms-associated with fever, or recent history of fever-appear ill, tachycardia, weak

• Chest pain with exercise should be evaluated before activity continues

• React quickly if patient has known or suspected Marfan’s and tearing chest pain or back pain

Chest Pain Of Concern

• Pericarditis: lean forward for comfort, friction rub, distended neck veins, hepatomegaly, pulsus paradoxus, low voltage EKG, diffuse ST changes

• Arrhythmias-May be felt as or described as chest pain

-eg. SVT: sudden on/off, >200/min at restpallor, hypotension, syncopenarrow complex tachycardia on EKG

-eg. VT: chest pain and syncope 120-240/min

Chest Pain Of Concern

• Respiratory-asthma-pneumonia/effusion-spontaneous pneumothorax

• Cancer-primary-metastasis/infiltration

• Trauma

Chest Pain Of Concern

• frequency

• duration: seconds, minutes, hours

• location: sternum, apex, subxiphoid, right, left, diffuse, “point with one finger”, epigastric

• quality: burning, stabbing, sharp, dull, crushing, tearing

• clustering

• setting

Taking a Chest Pain Historydescribing the pain

• time of day

• relation to meals

• precipitating factors

• exacerbating factors

• relieving factors

• association with rest, body position, deep inspiration

• recent trauma

Taking a Chest Pain Historydescribing the pain

• Palpitations: fast, slow, irregular, skips, hard

• headaches

• shortness of breath/dyspnea-wheeze/ cough -prolonged expiration-”can’t get air out”-response to bronchodilators

• paresthesias

Taking a Chest Pain Historyassociated symptoms

• syncope

• near syncope

• dizziness

• sensation of impending doom

• Anginal chest pain: cardiac ischemia in a child produces pain similar to that in adults

• History of Kawasaki with abnormal coronaries

Taking a Chest Pain Historyassociated symptoms

• Family history

• Social History/Social Dynamic

Taking a Chest Pain History

• Full Examination

FOCUSED ON

• Vital signs

• murmurs, rubs, clicks, rhythm, abnormal pulses, abnormal heart sounds

• Lung exam

• Palpation of chest, gentle sternum compression

• Reproducing the chest pain by compression or palpation is very reassuring

Physical Exam For Chest Pain

• Laboratory studies non-contributory• EKG if indicated: normal is reassuring

almost all HCM have abnormal EKG (LVH)almost all coronary anomalies have abnormal EKG (LVH, ST changes, precordial T wave changes)

• Chest radiograph if indicated-cardiomegaly, abnormal aortic root

Consider referral• Echocardiogram• Holter Monitor• Event monitor• Exercise test: if symptoms with exercise

Testing/Labs For Chest Pain

SYNCOPE

True or False

False

All syncope is cardiacuntil proven otherwise

Case -Syncope• A 13 year old girl passed out in the shower the

morning after a basketball game

• Felt dizzy, vision went black

• Woke up on shower floor

• She says she drinks enough fluid

• Physical Exam- sitting: BP 115/70 P 60 R 16- standing: BP 95/65 P 90 R 16- Pulses strong and equal- 2/6 ejection murmur at LUSB- lean, healthy looking

• Definition: temporary loss of consciousness due to lack of cerebral perfusion

• Most frequent cause is vasovagal=vasodepressor = neurocardiogenic

SYNCOPE

VASODEPRESSOR SYNCOPEBezold-Jarisch reflex

venous return

blood pressure

baroreceptors

mechanoreceptorsC fibers

vagus activitysympathetic activity

Blood Pressure

vigorouscontractions

catecholaminessympathetics

heart ratecontractilityvascular tone

The possibility of serious injury during a faint precludes considering recurrent syncopal episodes of any cause as

benign.

(Gutgesell, AFP, 1997)

SYNCOPE

• Abnormalities of blood pressure control (common)

• Cardiac abnormalities (uncommon)

• Metabolic abnormalities (rare)

• Seizure disorders (rare with just syncope)

• Psychiatric conditions (rare)

• Drugs (rare)

Causes of Syncope

• Usually teenagers (13 years +/- 3) • 2.3 female: 1 male (Balaji, ACC, 1994)

-may be associated with menstrual cycle• Usually some precipitating factor

-dehydration/underhydration*illness, heat (shower)

-poor physical condition-more common in morning-fasting-prolonged standing/position change to more upright-can occur standing or sitting-fright/anger/stress/sight of blood/smells/injury-cough, voiding, hair grooming

Typical Vasovagal SyncopeThe Setup

• Disorientation/feeling of warmth/dizziness• Nausea• Visual changes: field narrowing, blurring, spots, dark• Loss of hearing/rushing noise• Weakness• Pallor/clammy skin/sweating• Going to ground• May be followed by tonic-clonic movement• No incontinence• Resolves within a minute• Wake up: may be groggy, not post-ictal• May feel tired for hours

Typical Vasovagal SyncopeThe Event

• If the history is typical for simple vasovagal syncope, a careful physical examination is generally the only evaluation required.

(Gutgesell, AFP, 1997)

• Recurrence rate 7% at one year, 15% at two years (Ruiz, Am Heart J, 1995)

Typical Vasovagal Syncope

Treatment of Vasovagal Syncope• Reassurance• Hydration: 90% effective (Younoszai, Arch Ped Adol Med, 1998)

-”Eight 8 ounces glasses/day” +/- two gallons-Urine should look like water-Never thirsty

• Salt• Avoid caffeine• Activity restrictions?• G-maneuvers• Medications: fludrocortisone, SSRI, beta-blockers,

alpha agonists (pseudoephedrine)• Pacing?

Evaluation of Syncope

• Complete history

• Complete physical examination

• Careful attention to heart rhythm

• Orthostatic blood pressures?

• EKG

When is syncope concerning?• Palpitations/heart rate irregularities• Syncope with no prodrome• Frequent syncope• Exercise-induced syncope• Family history of recurrent syncope• Family history of sudden death

• Outflow tract obstruction: HCM• Myocardial dysfunction: myocarditis, dilated

cardiomyopathy, ARVD• Coronary ischemia• Cardiac arrhythmias

Other Causes of Syncope

• Breath Holding Spell

• Respiratory Syncope

• Hyperventilation Syndrome

• Neurologic/Seizures/Migraines

• Emotional/Psychiatric

Hypertension

Definition of Pediatric Hypertension

blood pressure >95% on three separate occasions

It’s Out There• Based upon the Framingham study, pediatric

patients with hypertension are at risk for catastrophic events later in life

• 10,641 Dallas children: 1.6% HTN on 3 screens

• 6,622 Muscatine children:1% HTN on 4 screens

• 3,537 Harlem children: 1% HTN

• Overall Prevelance: 0.5-2% children have significant HTN

• Primary HTN -most common cause-usually no symptoms

• Secondary HTN: 74% renal/renal-vascular 19% coarctation 7% others: endocrine

-many are in medical care for other issues-BP usually more elevated than in primary HTN

It’s Out There

Blood Pressure Control

• HTN as child• Heredity• Obesity• Race• Dietary cations• Exercise, stress, anxiety• Smoking• Alcohol and drugs• Pregnancy-induced HTN• Diabetes• Uric acid• LV mass

Influences on Blood PressureChildhood Risk Factors for Later-Life Hypertension

• Obesity: prevalence of all forms of HTN in adults correlated with tip quintile for fatness 15 years earlier

• Race: Prevalance of HTN in black adults (27%) is twice that of white adults

-Kids not as clear• Dietary: sodium: trend to higher BP

potassium: trend to lower BPcalcium: trend to lower BP

• Exercise, stress, anxiety: -regular exercise decreases blood pressure-stress/anxiety raise blood pressure-difficult arithmetic, reaction time tasks, video games

Influences on Blood PressureChildhood Risk Factors for Later-Life Hypertension

• Smoking: duh• Alcohol and Meds

alcohol: heavy (>3 drinks/day) intake increases BP light (1-2 drinks/day) might be beneficial not recommended for kids

several medications can increase BP sympathomimetics, anticonvulsants, OCP, cyclosporine, steroidscaffeine, illicit drugs

• Pregnancy-induced HTN: predictor of later HTN in the pregnant one and her baby

Influences on Blood PressureChildhood Risk Factors for Later-Life Hypertension

• DiabetesHTN in pediatric diabetes unusual, but happens

ie. coexisting conditionsstrong predictor for adult HTN

• Uric Acid: elevated levels correlate with increased risk of HTN in kids and adults

-marker for HTN, not a cause -correlates with plasma renin activity

• Increased left ventricular mass: end organ damage

Influences on Blood PressureChildhood Risk Factors for Later-Life Hypertension

Cardiac Hypertension

Coarctation of the aorta

Coarctation of the Aorta

Coarctation of the Aorta

Balloon Angioplasty for Coarctation

Stenting for Coarctation

Coarctation - Surgery

Coarctation

HTN in Coarctation• Kidneys downstream from obstruction

-increased renin-angiotensin-aldosterone activity

• Baroreceptors upstream from coarctation-reset to higher pressures

• Intrinsic abnormality of aortic tissue

*lifelong issues

Picking up a Coarctation

• EXAM!

• elevated blood pressure

• decreased femoral pulses

• upper to lower extremity BP gradient

• non-innocent murmur

Renal Disorders Causing HypertensionRenal Parenchyma Renovascular

Acute glomerulonephrtitis renal artery thrombosis pyelonephritis sickle cell crisisHUS vasculitisrenal traumaureteral obstruction

Chronicglomerulonephrtitis fibromuscular dysplasia pyelonephritis renal artery aneurysm HUS arteriovenous fistula reflux nephropathy vasculitisobstructive uropathypolycystic diseasesrenal dysplasiarenal tumors

Vital Signs Measuring Blood Pressure

• Patient sitting or supine-be consistent

• Right arm

• Arm flexed

• Relaxed (if possible)

• Right arm & right leg pressures can help

• Method 1: Dynamap = random number generator

• Method 2: SphygmomanometerInflate cuff to 30mmHg above expected

BPDeflate 3mmHg/sec

• Method 3: SphygmomanometerInflate cuff until radial pulse disappearsDeflate 3mmHg/sec

• Method 4: Direct catheter measurement

Vital Signs Measuring Blood Pressure

• Method 3: Sphygmomanometer

Inflate cuff until radial pulse disappears

Deflate 3mmHg/sec

Best Method

Vital Signs Measuring Blood Pressure

Vital SignsKorotkoff Sounds

Korotkoff sounds first heard at all

Korotkoff sounds consistently heard = systolic BP

Korotkoff sounds get softer

Korotkoff sounds get suddenly softer

Korotkoff sounds disappear = diastolic BP

Korotkoff sounds get louder

80mmHg

120mmHg

Korotkoff sounds = sounds produced

by blood flowing past deflating cuff

Blood Pressure Assessment1. Measure blood pressure

-if abnormal, -history and exam

-repeat on another occasion

2. Repeat blood pressure-if still high (90-95%)

-talk about lifestyle issues -repeat in six months

-if still high (>95%), work it up

Detecting HTN in Children• Measure BP upon admission to the nursery• Measure BP at every well child check and

annual physical• Measure BP at other visits, if possible

• Also, do a good cardiac exam at each check and physical

• Also, do a good cardiac exam when guided by symptoms

• Pursue evaluation when indicated

Treatment of HTN in Children• PREVENTION• Make accurate measurements• Make accurate diagnosis• Treat underlying condition, if possible• Weight control• Low fat-high fiber diet• Sodium restriction• Exercise• Relaxation• Avoid alcohol, medications, drugs, caffeine• No tobacco

Meds for HTN in Children• Goal is normal pressures

• Individualized approach, not stepped-care

• Start with single drug therapy-ACE inhibitors-beta blockers-calcium channel blockers-diuretics*lowest effective dose

• Add additional med if needed

• Management is usually long-term

Summary

• Pediatric hypertension is uncommon but real

• Pediatric hypertension must be diagnosed and fully evaluated

• Pediatric hypertension must be treated for short and long term gain

• Refer to nephrology, cardiology, endocrinology as indicated

Murmurs

• Intensity (grade)

• Pitch

• Timing

• Location

• Radiation

• Quality

AuscultationMurmurs

• Grade 1 = faint

• Grade 2 = soft

• Grade 3 = loud

• Grade 4 = loud with thrill

• Grade 5 = heard with edge of stethoscope

• Grade 6 = heard with stethoscope off chest

AuscultationMurmurs- Intensity

• Pitch = frequency

• High

• Medium

• Low

• Reflects velocity of jet

• Reflects pressure gradient driving the jet

AuscultationMurmurs-Pitch

So Much Noise

• Systolic: S1-coincident, early, mid, late

• Diastolic: early, mid

• Continuous

AuscultationMurmurs-Timing

• Remember aortic, pulmonary, mitral, tricuspid areas for the tests

• Be wary of abnormal anatomy

• Describe location on chest

AuscultationMurmurs-Location

NL

• Listen everywhere!

• Determine if you hear radiation of one murmur or a different murmur

• Some may change pitch as you get further from focus

AuscultationMurmurs-Radiation

• Crescendo

• Decrescendo

• Crescendo-decrescendo

• Be creative: blowingharsh

coarse

honking

squeak

AuscultationMurmurs-Quality

ABNORMAL SYSTOLIC MURMURS

DIASTOLIC MURMURS

eg. Flow Rumble

Vital Signs • Weight• Height• Blood pressure• Heart rate

-compare with age norms-consider patient’s physiologic state

• Respiratory rate-compare with age norms

-consider patient’s physiologic state• Temperature• Oxygen saturation

General • Well-nourished?• Well-developed?• Syndromic?• Deformities?• Distress?• Respiratory effort?• Level of consciousness?• Pallor/cyanosis?• Anxiety?

Inspection • Precordium activity

• Neck pulses

• Chest deformity

• Respiratory effort

• Head bobbing

Inspection • Skin color/tone/texture

• Scars

• Rashes

• Vein distension

• Jugular venous distension

• Carotid thrill

• Cranial thrill

Rashes may point to the heart

Palpation and Percussion• Precordium activity: quiet, active,

hyperdynamic

• PMI (point of maximal impulse)

• Lifts, heaves, taps

• Palpable heart sounds

• Thrills

• The heart should percuss to the PMI

AuscultationPrinciples and Technique

• GET A GOOD STETHOSCOPE!!!!!!!!!

• Become one with the stethoscope

• Eliminate extraneous noise

• Breathing normally-breath hold helps

• Listening for heart sounds radiating to the back

• Listening for abnormal vascular sounds

• Listen on sides of chest and axillae

AuscultationStart with the back

• Standard lung exam

• Lung findings may not represent primary lung pathology

• Crackles may mean pulmonary vascular congestion

• Wheezing may be due to severe pulmonary congestion

• Percuss for effusions

AuscultationLung Sounds

Abdomen • Inspection: distension, veins

• Auscultation: bowel soundsbruit

• Palpation: liver size: breadth, liver edge, tender splenomegaly pulsatility mass

Palpating Pulses • Brachial/radial

• Femoral

• *at same time!

• pedal

• popliteal

• axillary

Extremities • perfusion

• edema

• clubbing

• deformity

Clubbing

Endocarditis

Janeway lesionsSplinter hemorrhages

Osler’s nodesRoth spots

Family History

We already talked about it…and more to come