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9/3/19
1
CommonCardiacCondi+ons:WhattoWatchWhattoRefer
Objec&ves
Outline
MurmursPalpita1onsandHeartRacingChestPainSyncope
9/3/19
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Outline
MurmursPalpita1onsandHeartRacingChestPainSyncope
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
JourPedNurse.2014Nov;29(6):700-702
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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)
JourPedNurse.2014Nov;29(6):700-702
History
PostnatalHistory� Poorweightgain� Poororbrieffeedings� Diaphoresiswithfeeding� Tachypneaorincreasedworkofbreathing� Colorchanges
JourPedNurse.2014Nov;29(6):700-702
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History
Olderchildren� Chestpain� Syncope� Exerciseintolerance/Recentchangeinlevelofphysicalac1vity
AmFamPhysician.1999Aug1;60(2):558-564
Physical Exam - Palpa&on � Ac1vePrecordium• CanbeASD,VSD,PDA• Anxiety,anemia,hyperthyroidism
� DiscrepantBrachialandFemoralPulses• Comparerightandfemoral(CoAo)
� Thrill• LLSB–couldbeVSD• ULSB–couldbePVstenosis• Suprasternalnotch–canbeaor1cstenosis
AmFamPhysician.1999Aug1;60(2):558-564
Physical Exam - Ausculta&on
FirstHeartSound–S1• Lealowersternalborder• Causedbyclosureofmitralandtricuspidvalves• Normallyasinglesound• Canbe“holosystolic”
• S1soundisobscuredbymurmurthatoccursthroughoutsystole• CanindicateVSD,AVVregurgita1on,PDA,pulmonaryvalvestenosis
� Clicks• Listeninall4areas–addmoremeaninghere?
AmFamPhysician.1999Aug1;60(2):558-564
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Physical Exam: Ausculta&on
SecondHeartSound–S2• Leauppersternalborder• Closureofaor1candpulmonicvalves• Shouldsplitinto2componentswithinspira1on
• A2–closureofaor1cvalve• P2–closureofpulmonicvalve• Occursbecauseinspira1onbringsmorebloodintotherightventricle,RVejec1onisprolongedandpulmonaryvalvecloseslater
� Loud,singleS2Canindicatepulmonaryhypertensionorcongenitalheartdisease
AmFamPhysician.1999Aug1;60(2):558-564
Describing Murmurs
Grades• 1-6• 1isbarelyaudible• 4isloudandhaspalpablethrill• 6isaudiblewithoutstethoscope� 3oraboveconsidered
pathologic
Timing• Canoccurearly,middle,lateinsystole� Holosystolic
Quality� Harsh
AmFamPhysician.1999Aug1;60(2):558-564
Features that Increase Likelihood of Cardiac Pathology � Symptomssuchaschestpain� FamilyhistoryofMarfansyndromeorsuddendeathinyoungfamilymembers� Malforma1onsyndrome(e.g.Downsyndrome)� Increasedprecordialac1vity� Decreasedfemoralpulses� Abnormalsecondheartsound� Clicks� Loudorharshmurmur� Increasedintensityofmurmurwhenpa1entstands
AmFamPhysician.1999Aug1;60(2):558-564
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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
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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
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AV Canal - EKG
Outline
MurmursPalpita1onsandHeartRacingChestPainSyncope
Palpita&ons and Heart Racing
• Subjec1vefeelingofabnormalheartbeat
• Mostcausesarebenign
• Althoughcardiacdysrhythmiasarefrequentlytheunderlyinge1ologyofpalpita1onsinadults,sameisnottrueforchildren
• Incidenceofdysrhythmiasis55per100,000perpediatricEDvisit• 50%ofthosearesinustachycardia
ClinPedEmergMed.2011;12(4):278-288
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Palpita&ons - HPI
� Parentalreportof“fussiness”ininfants� Youngchild:“heartispounding”or“beeping”orc/ochestpain
Onsetanddura+onofsymptoms� Rapid,suddenonsetand/orresolu1on
Associatedsymptoms� Dizziness,syncope,shortnessofbreath,chestpain� Feverorgastrointes1nalillness
ClinPedEmergMed.2011;12(4):278-288
Palpita&ons - History
FamilyHistory� Suddencardiacdeathbeforeage40� DeafnessDietary&SocialHistory• Evaluateforfood/substancesthatcanexplainpalpita1ons• Caffeine• Dietarysupplements• Illicitdrugs(cocaine,amphetamines)
ClinPedEmergMed.2011;12(4):278-288
Palpita&ons - Physical Exam
� Murmur,gallop,click,rub� Hepatomegaly� Wheezing� Jugularveindistension� Peripheraledema
ClinPedEmergMed.2011;12(4):278-288
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Differen&al Diagnosis of Palpita&ons
Cardiaccauses• Sinustachycardia• Tachydysrhythmias• SVT• PVC/PAC• A-fluoer• A-fib• Vtach
• Repairedcongenitalheartdisease• Bradycardia• AVblock• Sinuspauses
• Cardiomyopathies• Myocardi1s• Mitralvalveprolapse
ClinPedEmergMed.2011;12(4):278-288
Differen&al Diagnosis of Palpita&ons
NoncardiacCauses• Electrolyteimbalances• Asthma• Hyperthyroidism• Pheochromocytoma
• Anxiety/Panicaoacks• Stress• Fever• Medica1ons/Drugs• DietarySubstances
ClinPedEmergMed.2011;12(4):278-288
Palpita&ons and Heart Racing
Realques+on:Aresymptomscausedbyarrhythmiaornormal(sinus)rhythm?
Diagnos+ctools• EKG• Holter• Event(loop)monitors
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Normal Ac&va&on Sequence
Rhythm Analysis
HowarePandQRSrelated?
Wholeads?Whofollows?
Normal (Sinus) Rhythm
• PwaveprecedeseveryQRS• QRScomplexfollowseveryP• NormalPwaveaxis(0-90°oruprightinIandaVF)
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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
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Ventricular Ectopy (PVC)
• Early,wideQRScomplex• Compensatorypausecommon• Notusuallypathologicinnormalhearts
Supraventricular Tachycardia (SVT)
• Mostcommonpediatrictachyarrhythmia• Incidenceashighas1in250• 50%ofpediatriccasesoccurininfancy• Mostpa1entshavestructurallynormalhearts• Rate• Infant:upto300bpm• Smallchildren:>220bpm• Olderchildren:>180bpm
ClinPedEmergMed.2011;12(4):278-288
SVT
• Usuallynarrowcomplex• Pwavesareabnormal(ifrecognizable)
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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
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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
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Long QT Syndrome
Who Needs Referral
� AbnormalEKG• WPW,LongQTc,SVT
� Frequentsymptomssugges1ngSVT• Paroxysmal• HR>200bpm
Outline
MurmursPalpita1onsandHeartRacingChestPainSyncope
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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
PedReview.2010;23(1):e1-e9
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Noncardiac Sources of Chest Pain
PedReview.2010;23(1):e1-e9
Cardiac Sources of Chest Pain
PedReview.2010;23(1):e1-e9
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
PedReview.2010;23(1):e1-e9
9/3/19
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Chest Pain – Physical Exam
• Vitalsigns� Dysmorphicfeatures• Peripheralpulses• Chestinspec1on• Reproduciblechestpain� Hyperdynamicprecordium� Irregularheartbeats
� Distantheartsounds� Abnormalloudsecondheart
sound� Systolicclicks� Murmurs� Gallops� Absentfemoralpulses
PedReview.2010;23(1):e1-e9
Evalua&on of Chest Pain in Kids
ChestXray• Bonylesions,cardiomegaly,airways,lungparenchymalorpleurallesions
ECG• Rate• Rhythm• Signsofischemia,pericardi1s,chamberhypertrophy
PedReview.2010;23(1):e1-e9
Treatment of Noncardiac Chest Pain
• Reassuranceandeduca1on• Rest• Analgesia
PedReview.2010;23(1):e1-e9
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Who Needs Referral
� Exer1onalchestpain� Abnormalcardiacfindings� Exer1onalsyncope� Chestpainwithpalpita1ons� ECGabnormali1es� Significantfamilyhistoryofarrhythmias,suddendeath,orgene1cdisorders� Historyofcardiacsurgeryorinterven1ons� Orthotopichearttransplanta1on� HistoryofKawasakidisease� First-degreerela1veswithhypercholesteremia
PedReview.2010;23(1):e1-e9
Outline
MurmursPalpita1onsandHeartRacingChestPainSyncope
Syncope
• 15%ofchildrenwillhavesyncopebyage18
• Transientlossofconsciousnessandinabilitytomaintainpostureduetotransientglobalcerebralhypoperfusion
• Rapidonset,shortdura1on,spontaneouscompleterecovery
• Girlsmorecommonthanboys,peakincidenceage15-19
CPCSGuideline,2018
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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
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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
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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