Cardiology Flashcards
(31 cards)
What are some outflow obstruction conditions? Which ones are cyanotic vs non-cyanotic?
Aortic and pulmonary stenosis, aortic coarctation (all non-cyanotic) and hypo plastic left-heart syndrome (cyanotic)
What occurs in aortic and pulmonary stenosis and how does it present?
What are some associations/other abnormalities with AS?
What is the management for it?
The aortic and pulmonary valve leaflets are partially fused together
- > AS often coexistent with coarctation of aorta +/- mitral valve stenosis
- > AS associated with William’s syndrome
Sx:
- > ESM
- > AS = carotid thrill
- > PS = no carotid thrill, harsh heart murmur at left sternal edge, no other symptoms
- > No cyanosis
Mx:
- AS: Balloon valvuloplasty or trans-catheter aortic valve replacement (TAVR)
- PS: Transcatheter balloon dilatation for if moderate-severe
- Endocarditis prophylaxis
How does coarctation of the aorta present?
Narrowing of the aorta - 98% occur distal to L subclavian artery
Sx:
- > Asymptomatic OR
- > ESM
- > Systolic HTN + high BP in arms, lower BP in legs
- > Absent femoral pulses/peripheral pulses
- > ‘Rib notching’ - due to large collateral intercostal arteries forming (CXR)
- > NO cyanosis
- > Often presents after 48h due to PDA closure
How would you Ix and Mx coarctation of the aorta?
Ix:
- > Echo
- > MRA
Mx:
- IF a sick infant - then follow ABC and prostaglandin infusion guidelines
- > If well, surgical repair OR balloon angioplasty +/- stent
note: re-coarctation can occur later
What is hypoplastic left-heart syndrome? How does it present and how is it managed?
Sickest child of all outflow obstruction presentations in a neonate - presents as CYANOTIC
–> V small/absent LV
Mx:
- > 1st = ABCs and prostaglandin infusion
- > 2nd = Blalock-Taussig (BK - artificial PDA) shunt OR Norwood stage 1
- > 3rd = BK shunt removed –> Glenn/Hemi-Fontan –> Fontan or Total cavo-pulmonary connection
How may arrhythmias present in a child? How would you Ix the child?
SVT is the most common childhood arrhythmia
Sx:
- > HR 250-300 bpm –> poor CO, pulmonary oedema
- > Neonates - HF, hydrops fetalis
- > Foetus - IUD
Ix:
- > ECG - narrow complex tachycardia, delta wave in WPW, T wave inversion due to ischaemia
- > Echocardiography
How would you manage SVT in a child?
Mx: need to restore sinus rhythm promptly
- Circulatory and respiratory support - PPV if needed, tissue acidosis corrected
- VAGAL stimulating manoevers + raised legs (ice pack to face, carotid sinus massage) = 80% success
If fails: - IV ADENOSINE = induces AV block and terminates tachycardia
If fails: - DC cardioversion (or chemical: amiodarone/flecainide) + requires maintenance therapy after
- If haemodynamically unstable, attempt vagal manouveres and adenosine as above but don’t delay DC cardioversion
90% children have no further attacks in infancy
–> Catheter ablation is recommended if recurrent/accessory pathway
What is rheumatic fever and how + in who does it present?
What is the criteria required for diagnosis?
What is a complication of it?
Rheumatic fever is caused by GAS (Group A beta-haemolytic streptococcus)
- > Children aged 5-15y
- > Long term damage leads to MITRAL STENOSIS
Sx:
-> Latent interval of 2-6w after pharyngeal infection and then PPE (Polyarthritis, Pericarditis/myo/endo and erythema marginatum - map like outlines)
-> 2-6m later may get Syndenhams chorea (involuntary movements)
-> Diagnosis via JONES criteria where there is evidence of recent strep throat (increased ISO titre/strep Abs or culture) and
2 MAJORS or 1 MAJOR + 2 MINORs of:
MAJOR = CASES (Carditis, arthritis, subcutaneous nodules, erythema marginatum and sydenhams chorea) MINOR = FRAPP (Fever, raised ESR/CRP, Arthralgia, Prolonged PR interval and previous RF)
How is Rheumatic Fever treated? (acute vs long-term)
Mx:
Acute:
- Bed rest + anti-inflammatory agents (high dose ASPIRIN for 1-2 or 6-8w)
- ABx (Penicillin/Amoxicillin) if suspecting persistent infection
- CS if the fever and inflammation doesn’t resolve rapidly
Prophylaxis:
- monthly injections of benzathine penicillin until 10y after last episode/21yo OR lifelong if severe valve disease
- Surgical treatment with valve repair/replacement may be needed
How may infective endocarditis present in a child? What are some risk factors?
RF = any congenital heart defect or abnormality that gives rise to turbulent blood flow e.g. VSD
Sx:
- Fever, anaemia, pallor, petechiae
- Janeway lesions, Osler’s nodes
- Nectrotic skin lesions (infected emboli)
- Clubbing, splinter haemorrhages
- Changing cardiac signs
- Splenomegaly
- Microscopic haematuria
- Neurosigns from cerebral infarct
- Arthritis/arthralgia
How is IE diagnosed and managed?:
- -> Initial blind therapy - native and prosthetic valves
- -> Streptotococci which is penicillin-sensitive or less-sensitive; native and prosthetic valves
- -> Stapylococci; native and prosthetic valve
- -> Other options
Ix:
Dx = multiple blood cultures (before Abx) and Echo to identify vegetations
–> usually caused by Strep. viridans, S. aureus
Mx:
Initial blind therapy for native valves:
- Beta-lactam + low-dose gentamicin
- Low-dose gentamicin + vancomycin - if pen-allergy, severe sepsis or MRSA suspected
- Vancomycin + meropenem - if severe sepsis and RF for Gram-neg infection
Prosthetic valves:
- Vancomycin + rifampicin + low-dose gentamicin
Penicillin-sensitive streptococci
= Benzylpenicillin sodium for 4-6w (6w if prosthetic) or Vancomycin+low dose gentamicin if pen-allergy
If less-sensitive streptococci
= Benzylpenicillin sodium + low-dose gentamicin for 4-6w
Staphylococci:
- Native valve = continue Abx for 4w of Flucloxacillin or Vancomycin+Rifampcin if MRSA/pen-allergy
- Prosthetic = 6w Abx of Flucloxacillin + rifampicin + low-dose gentamicin or replace with Vancomycin if pen-allergy
- Surgical removal of infected prosthetic material
How may a child present with heart failure?
Sx:
- SOB
- Poor feeding, fatigue
- Recurrent chest infections
- Signs = poor weight gain/FTT, increased RR and HR, hepatomegaly, gallop rhythm, signs of venous congestion, enlarged heart, cool peripheries, pallor
What are some causes of HF in paediatric patients?
Neonates: duct dependent, obstructed systemic circulation - hypoplastic LHS - aortic stenosis - severe aortic coarctation - interruption of aortic arch [DO NOT close PDA]
Infants: defect -> high pulmonary flow -> L to R shunt
- persistent VSD, ASD, PDA
Older children: R or L-HF
- Eisenmenger (RHF), rheumatic HD, cardiomyopathy
Other = volume overload (anaemia/sepsis), pressure overload (HTN)
How would you Ix HF?
Ix:
- Basic obs
- CXR
- ECG
- Echo
How would you Mx HF? What are the aims of treatment linking this? [5]
Mx:
Multi faceted with specific aims:
- Reduce preload = diuretics (furosemide) or GTN
- Enhance cardiac contractility = IV dopamine or digoxin/ dobutamine/adrenaline
- Reduce after load = oral ACEi or IV agents e.g. hydralzine
- Improve O2 delivery = B-blockers e.g. carvedilol
- Enhance nutrition + routine daily exercise
- If cyanotic then PROSTAGLANDIN INFUSION
How can congenital heart disease be separated, and examples of these?
What are key Ix required for suspected congenital heart disease?
R–>L shunts (cyanotic)
- Tricuspid atresia
- ToGA
- ToF
- AVSD
- Eisenmenger
L–>R shunts (non-cyanotic)
- ASD
- VSD
- PDA
+ Outflow obstructions, infections etc
Ix:
- -> ECG
- -> CXR
- -> ECHO
When do each of the congenital heart diseases generally present?
Within time of birth:
- Few hours = AVSD, TA, hypo plastic left heart syndrome
- Few days = ToGA (d2), ToF (days-months), large PDA
- Few weeks = aortic stenosis, co-arctation of the aorta
- Few months = any L->R shunt as pulmonary resistance falls
What are features of innocent murmurs? When may they be detected? What are 2 examples?
Think S’s:
- Soft
- aSymptomatic
- Systolic
- Short
- left Sternal edge
- Sitting/standing variation
Can be observed more easily in illness or anaemia (increased CO)
Stills murmur
Venous hum = blowing noise, above clavicles
What are the KEY differentiating features in presentation of:
- Cyanotic
- Non-cyanotic
- Outflow-obstruction in a well child
- Outflow-obstruction + collapse and shock?
Cyanotic
= BLUE baby
Non-cyanotic
= breathless baby
OO in well child
= A or P stenosis
OO with collapse and shock
= Coarctation of aorta
What are ASDs caused by? How do they present?
Either due to:
- -> patent foramen ovale and defect of atrial septum (Secundum) = 80%
- -> defect of AV septum = partial AVSD/primum ASD = 20%
S/S:
- Asymptomatic
- Recurrent chest infections/wheeze
- ESM at ULSE + fixed wide splitting of S2
- Arrhythmias from 40yo
How would you Ix an ASD and what would they show? How would you manage them?
Ix:
- CXR
- ECG - RBBB and RAD in secundum
- ECHO is diagnostic
Mx
- Only required if Sx, RV dilation or Qp:Qs (pul flow 1.5x > systemic)
- usually at 3yo
- Secundum ASD = transcatheter closure - cardiac catherterisation and insertion of occlusive device
- Partial AVSD = open heart surgical correction
How would VSD’s present (think size)?
NOTE: commonest heart defect
Classified by size:
Small <3mm (80-90%)
- Asymptomatic
- LOUD PSM at LLSE
- Soft pulmonary 2nd sound
- E.g. a breathless 3m baby with normal sats, LOUD murmur, poor feeding/tiredness
Large >3mm
- SOB, recurrent infections, hepatomegaly
- HEART FAILURE
- Soft PSM, mid diastolic murmur
- Loud pulmonary 2nd sound
How would you Ix and manage VSDs? What are the aims with the management?
Ix:
- CXR: HF for large VSDs (ABCDE)
- ECG: Large R wave for hypertrophy (>8mm) for large VSDs
- ECHO for Dx
<3mm - higher risk of endocarditis
- Prophylactic amoxicillin
- Self-limiting, close themselves
> 3mm - want to prevent Eisenmenger syndrome
- Calorie input
- Diuretics
- Captopril
- Surgery at 3-6m
How do PDAs present and how may they be managed? Why should they be closed?
PDA = connects pulmonary artery to descending aorta, should close at 1m
- Closed as risk of endocarditis and pulmonary vascular disease
S/S:
- Continuous machine-like murmur/Gibson’s at ULSE
- Heaving apex beat
- Wide pulse pressure
- Bounding, collapsing pulses
- Resp Sx = apnoea, WOB
Mx
- IV Indomethacin (NSAID) to close duct
- Surgical, if medical failed^: surgical ligation or percutaneous catheter
device closure may be used 6m-1yo
