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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