Cardio 2 (starting at pericarditis)

Question 1

Pericarditis (4)

Answer 1

1. Pericardial inflammation
2. Viral versus bacterial
3. Bacterial causes include pneumococcus, S. aureus, H. influenzae type B
4. Cardiac tamponade possibly requiring pericardiocentesis
   a. Viral, bacteria, pneumococcal
   b. Cardiac tamponade

Question 2

Pericarditis clinical features (4)

Answer 2

a. Chest pain
b. Respiratory distress, CHF, or tamponade
c. Precordial “knock” or rub (like the sound of shoes walking on snow)
d. The classic signs include exercise intolerance, fatigue, jugular distension, lower extremity edema, hepatomegaly, poor distal pulses, diminished heart tones, and pulsus paradoxus.

Question 3

Endocarditis overview (3)

Answer 3

a. An infection of the endothelial surface of the heart, with a propensity for the valves
b. Increased risk in children with artificial valves and patches, and patients with central lines

c. 90% of cases are caused by gram positive cocci.
i. Alpha strep, Staph aureus, pneumococcus, group A ß hemolytic streptococci
ii. Bacterial infection in the heart and you get vegetation of bacteria on walls of heart
iii. Can lead to stroke = serious bacterial infection
iv. Big problem for kids
v. Gram positive cocci — strep and staph

Question 4

Clinical features of endocarditis (5)

Answer 4

a. Fever
b. Tachycardia, CHF, dysrhythmia, cardiogenic shock
c. History of recent cardiac surgery or indwelling vascular catheter
d. Heart murmur

e. Petechiae, septic emboli, or splenomegaly
I. Indwelling catheters, ports are at risk for endocarditis
ii. Drug Abusers

Question 5

Bacterial endocarditis (4)

Answer 5

1. Recurrent fevers
2. S. viridans, S. aureus
3. Conjunctival hemorrhages
4. Classic skin lesions
   i. Splinter hemorrhages
   ii. Petechiae and purpura*
   iii. Osler’s nodes (Lps, pain)
   iv. Janeway lesions (proximal palms soles); caused by septic emboli
   * Lesions caused by septic emboli and vasculitis

Question 6

Cardiomyopathies (4)

Answer 6

1. Hereditary condition
2. Most common genetic cardiovascular disease
3. Second most common form of cardiac muscle dysfunction in pediatrics
   * 35-40% of all pediatric cardiomyopathies
4. Most common cause of sudden cardiac death in children and young athletes
   a. Kid may not have murmur
   b. Hypertrophic cardiomyopathies may not be seen in preschool years
   c. Can be seen in later school age and adolescents

Question 7

Cardiomyopathies outcomes (4)

Answer 7

1. Most common outcome – sudden cardiac death
   * 36% of all sudden cardiac deaths are due to HCM
2. Can also cause arrhythmias, atrial fibrillation, endocarditis, heart block, and heart failure
3. Atrial fibrillation – 25% of HCM patients
4. Heart failure – most common complication of HCM

Question 8

Cardiomyopathy risk stratification (4 with info)

Answer 8

1. Family history
   - Sudden death
   - Presence of an identified gene

2. Clinical risk factors
I. Syncope 
ii. Non=sustained ventricular tachycardia
iii. Resuscitation after cardiac arrest 
iv. Severe left ventricular hypertrophy 
v. Abnormal BP responses to exercise 

3. Onset of symptoms in childhood
4. 2 or more = lower survival rates
   - Syncope with exercise** any abnormal BP response
   - 2 or more have lower survival rates

Question 9

Pathophysiology of cardiomyopathy (9)

Answer 9

1. Idiopathic, non-dilated, asymmetrical hypertrophy of the left ventricle
2. Intra-ventricular septum most common
3. Can lead to obstruction of left outflow tract – 25%
4. Gradient variable
5. Left ventricular systolic function generally normal
   a. Can cause atypical filling of heart and increased left ventricular end-diastolic pressure
6. Diastolic dysfunction
7. Increased resistance of blood flow
8. Reduction in the size of pumping chamber
9. Cellular remodeling
   a. Not dilated cardiomyopathies = managed medically
   b. Cannot get enough blood to coronary arteries, cannot push out and brain gets affected = death

Question 10

Cardiomyopathy comorbid conditions (11)

Answer 10

Neuromuscular disorders

1. Friedrich ataxia
2. Infantile myotonic dystrophy

Storage disorders

3. Danon disease
4. Pompe’s syndrome - cardiomyopathy 2nd to pompe
5. Fabry’s syndrome
6. Noonan’s syndrome
7. Down syndrome
8. Beckwith-Wiedemann syndrome - large kids
9. LEOPARD syndrome - pulmonic stenosis
10. Hunter syndrome
11. Hurler syndrome
    * Hunter and Hurler = abnormal mucopolysaccharides build up

Question 11

7 family hx questions to ask with cardiomyopathy

Answer 11

1. Has anyone in your family died prematurely, suddenly, or unexpectedly before the age of 35 years old?
2. Does anyone in your family under the age of 50 have a heart condition-related disability?
3. Do you have any knowledge of any heart conditions that family members may have?
4. Is there a family history of seizures, syncope, drowning, and/or motor vehicle accidents?
5. Is there a family history of heart defects, intellectual disabilities, or other birth defects?
6. Is there a family history of any genetic conditions?
7. Is there a family history of death at a young age, due to SIDS?

Question 12

Cardiomyopathy physical exam (12)

Answer 12

1. PE itself is insensitive screening tool
2. Hemodynamics alter nature of murmur
3. Louder with standing from squating or Valsalva maneuver
4. Systolic ejection murmur at RUSB
5. Holosystolic murmur at apex
6. May hear S3 heart sound
7. S4 heart sound often at apex
8. Mitral regurgitation
9. Palpate pulses
   a. Water=hammer pulse
10. Apical pulse
    a. May be sustained
    b. Two palpable components
11. Carotid pulse - Rises fast
12. Exertion
    a. Decreased peripheral pulses
    b. Decrease in systolic blood pressure

Question 13

Echocardiogram and cardiomyopathy (5)

Answer 13

a. Most sensitive and specific
b. Thickness ≥ 13mm
c. Tissue Doppler Echo – may determine prognosis
d. 3D=E – more accurate
e. False positives and false negatives

Question 14

electrocardiogram and cardiomyopathy (8)

Answer 14

1. Cost-effective vs lack of sensitivity
2. False positives
3. Screening tool
4. P wave peaks
5. QRS deviation
6. Increased Q, R, S wave amplitude
7. ST segment depressions
8. T wave flattening or inversion
   I. QT prolongation
   I. Echocardiogram = most sensitive
   ii. Athletes have thicker walls = make sure they have cardiomyopathy
   iii. AHA does not endorse doing an ECG - too many echos and expensive

Question 15

MRI and cardiomyopathy (4)

Answer 15

1. When echo cannot detect LVH
2. Identify areas of patchy left ventricular wall thickness
3. Ability to quantify thickness and left ventricular mass distribution
4. May expose delayed enhancement patterns

Question 16

Stress testing and cardiomyopathy (5)

Answer 16

a. Not for diagnosing, monitoring and prognostics
b. False positives due to athletic heart syndrome
c. Define presence of outflow tract obstruction with no gradient at rest
d. Define presence of high-risk status of exercise= induced myocardial dysfunction
e. Identify patients with coronary artery disease

Question 17

cardiomyopathy differentials (4)

Answer 17

1. Athletic heart syndrome
   a. Thickening of left ventricle
   b. Athletes at high levels: isometrics and iostonics
   * Long=distance runners, rowers, swimmers, and cyclists
   * Murmur softer, heard when laying, disappears when standing
2. Supraventricular tachycardia
3. Systolic murmurs
4. Asthma

Question 18

medical therapy for cardiomyopathy (7)

Answer 18

1. Use for relieving symptoms is controversial
   a. Only if clinical or morphological features
2. Goals: slow HR, prolong diastole to increase ventricular filling, relieve symptoms of obstruction
3. Beta-blockers (Propanolol)
   a. Angina and dyspnea
   b. Side effects common
   c. First line and help patients not have A-Fib
4. Calcium=channel blockers (Verapamil)
   a. Controversial in pediatrics
5. Disopyramide
   a. With beta=blockers
   b. Atrial fibrillation, atrial flutter
6. Amiodarone
   a. Use for Atrial fibrillation when others fail
   b. Last=line therapy
7. No: vasodilators, digoxin, diuretics, ACE-I

Question 19

surgery for cardiomyopathy (2)

Answer 19

1. Surgical septal myectomy
   a. Gold standard
   b. Enlarges outflow tract via resection of muscle from hypertrophied LV
   c. Reduces long-term risks, but recurrence common in peds
   d. Mortality < 1%
2. Implantable Cardioverter Defibrillator
   a. Complications
   b. Protects high-risk patients from sudden death
   c. Falling out of favor

Question 20

physical activity restriction and cardiomyopathy (4)

Answer 20

1. Exercise increases catecholamines  increases outflow obstruction
2. Patients refrain from intense training with ‘burst exertion’
3. No military service
4. May engage in low=impact activities if clinical status ok

Question 21

repercussions of cardiomyopathy (6)

Answer 21

1. Monitor ADLs closely
2. Control daily life
3. Less physically active events – families must change
4. Frustration common
5. Appear and feel healthy
6. Normalize lives

Question 22

school and cardiomyopathy (3)

Answer 22

1. 504 forms – accommodations for medical conditions
   * Tailor individually to the patient
2. Access to water, no carrying of heavy items (2 sets of books), extra travel time, elevator pass, avoid extreme temperatures
3. Emergency action plans
   I. Tailor to student
   ii. AED always available