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Cardiology Flashcards

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1
Q

What congenital heart diseases present in the first few hours of life?

A
  • AVSD
  • Tricuspid Atresia
  • Hypoplastic left heart syndrome
  • Peripheral transient cyanosis is very common in the first 24 hours of life → assess them regularly
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2
Q

What congenital heart diseases present in the first few days of life?

A
  • Transposition of the Great Arteries (day 2-4)
  • Tetralogy of Fallot
  • Large PDA in premature contraction
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3
Q

What congenital heart diseases present in the first few weeks of life?

A
  • Aortic stenosis
  • Coarctation of the aorta
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4
Q

What congenital heart diseases present in the first few months of life?

A

Any L to R shunt → occurs as pulmonary resistance falls

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5
Q

What is the significance of the majority of paediatric murmurs?

A
  • Majority of murmurs in paediatrics are innocent - Still’s, Venous hum
    • Characteristics
      • Soft
      • Systolic
      • Asymptomatic
      • Left sternal edge
      • Sitting/Standing variation
      • Short
    • Can be due to ↑CO in illness or anaemia
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6
Q

What investigation can determining the presence of heart disease in a cyanosed neonate?

A

Hyperoxia - Nitrogen washout test

  • 1) 100% O2 for 10mins
  • 2) If right radial artery PaO2 from blood gas stays low (<15kPa, 113mmHg) = diagnose of cyanotic CHD
    • If PaO2 >20kPa then it is not cyanotic HD
  • Must have excluded persistent pulmonary HTN of the newborn
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7
Q

What are the risk factors for congenital heart disease?

A
  • Maternal
    • Rubella
    • DM
    • SLE
    • Warfarin
    • FAS
  • Chromosomal
    • Down’s
    • DiGeorge
    • Edwards
    • Patau’s
    • Turner’s
    • William’s
    • Noonan’s
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8
Q

What are the types of congenital heart disease?

A
  • Left to right shunts = Breathless Baby
    • ASD
    • VSD
    • PDA
    • CoA
    • Aortic valve stenosis
  • Right to left shunts = Blue Baby
    • Tetralogy of fallot
    • TGA
    • Tricuspid atresia
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9
Q

What are the types of atrial septal defects?

A
  • Secundum ASD – defect in atrial septum → foramen ovale does not close
    • 80% of ASDs
  • Partial AVSD – defect of AV septum
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10
Q

What are the signs and symptoms of atrial septal defects?

A
  • Asymptomatic
  • Recurrent chest infections / wheeze
  • Arrhythmias (from 40yo+)
  • Murmur:
    • Ejection-Systolic Murmur at ULSE
    • Fixed wide splitting of S2 → pulmonary valve closure occurs after aortic
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11
Q

What are the appropriate investigations for suspected atrial septal defects?

A
  • CXR
  • ECG
    • Secundum = RBBB and RAD
    • Partial AVSD = ‘superior’ QRS axis
  • Echocardiography = diagnostic
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12
Q

What is the management of atrial septal defects?

A
  • Secundum ASD = cardiac catheterisation + insertion of occlusive device (percutaneous/endovascular closure)
  • Partial AVSD = surgical correction
  • Usually at 3yo
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13
Q

How are ventricular septal defects classified?

A

Size

  • Small = <3mm → higher risk of endocarditis
  • Large = >3mm
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14
Q

What are the signs and symptoms of a small ventricular septal defect?

A
  • Asymptomatic
  • Loud Pan-Systolic Murmur at (LLSE) - louder = smaller defect
  • Soft pulmonary 2nd sound
  • Breathless 3m-old baby with normal sats, poor feeding with tiredness
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15
Q

What are the appropriate investigations for suspected small ventricular septal defects?

A

ECHO = diagnostic

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16
Q

What is the management of a small ventricular septal defect?

A
  • Self-limiting → close by themselves
    • After these close, they are no longer at a high risk of infective endocarditis
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17
Q

What are the signs and symptoms of a large ventricular septal defect?

A
  • Heart failure → SOB
  • Recurrent chest infections
  • Hepatomegaly
  • Soft Pan-Systolic Murmur with Mid-diastolic murmur (apical)
  • Loud pulmonary 2nd sound
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18
Q

What are the appropriate investigations for suspected large ventricular septal defects?

A
  • Echocardiography = diagnostic
  • CXR → heart failure ‘ABCDE’
  • ECG → heart hypertrophy R wave height >8mm
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19
Q

What is the management of large ventricular septal defects?

A
  • CDC
    • Captopril
    • Diuretics
    • Calories - additional calorie input
  • Surgery at 3-6 months to prevent permanent lung damage from pulmonary hypertension and high blood flow → prevent Eisenmenger syndrome
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20
Q

At what age should the ductus arteriosus close?

A

1 month → by 2-4 at the very latest

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21
Q

What are the signs and symptoms of a patent ductus arteriosus?

A
  • Gibson’s murmur at ULSE = continuous ‘machine-like’
  • Left sub-clavicular thrill
  • Heaving apex beat
  • Wide pulse pressure
  • Large volume, bounding, collapsing pulses
  • Respiratory symptoms → apnoea, bradycardia, high O2 need
  • Ventilatory wean difficulty if on one
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22
Q

What is the management of a patent ductus arteriosus?

A
  • Medical → indomethacin (NSAID) - will promote duct closure
  • Surgical → coil/device closure via cardiac catheter at 1yo
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23
Q

What are the signs and symptoms of an atrioventricular septal defect?

A
  • Cyanosis at weeks 2-3 of life
  • No murmur → found on routine echocardiography of Down’s
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24
Q

Which condition is associated with atrioventricular septal defects?

A

Down’s

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25
What is the management of atrioventricular septal defects?
* Medical management of heart failure * Surgery at 3 months
26
What is the most common cause of cyanotic heart disease in a neonate?
Tetralogy of Fallot
27
What are the 4 features of tetralogy of fallot?
* **VSD** * **Overriding aorta** → compresses pulmonary outflow → **pulmonic stenosis** → **RVH**
28
What are the signs and symptoms of tetralogy of fallot?
* Clubbing * **Loud Ejection Systolic Murmur at LLSE - pulmonary stenosis** * Tet spells = crying → increased pulmonary resistance → R-L shunt → cyanosis
29
What are the appropriate investigations for suspected tetralogy of fallot?
* CXR → small boot-shaped heart - due to RVH * Echocardiography
30
What is the management of tetralogy of fallot?
* 1st = **Prostaglandin or Alprostadil** - maintain PDA * **Reverses severe cyanosis** * Severe/prolonged = BT shunt from subclavian-pulmonary artery OR balloon dilation of RV outflow * **Morphine** (sedation and pain relief) * **IV propranolol** * **IV fluids + bicarbonate** - correct acidosis * **Muscle paralysis** * **Artificial ventilation** * Mild cyanosis = self-limiting (\<15 minutes cyanosis) * 2nd = **Surgery at 6 months**
31
Define Eisenmenger Syndrome.
Irreversibly raised pulmonary vascular resistance from chronically raised pulmonary arterial pressure and flow leading to a right to left shunt forming * High pulmonary flow from large L-to-R shunt untreated → arteries thick walled → resistance increases → shunt decreases → child becomes less symptomatic * At 10-15y, **shunt reverses** → **blue + cyanotic** with Eisenmenger syndrome → death by right-sided heart failure (40-50yo)
32
What are the main causes of Eisenmenger syndrome?
* Large VSD * Chronic PDA
33
What is the management of Eisenmenger syndrome?
* **Early intervention for pulmonary blood flow → surgical correction** * Heart transplantation not easy but can be done
34
What is the cause of rheumatic fever?
**Group A β-haemolytic streptococcus (GAS)**
35
What is the long term consequence of rheumatic fever?
Mitral stenosis → opening snap is followed by a low-pitched diastolic rumble and presystolic accentuation with loud S1
36
What are the signs and symptoms of rheumatic fever?
* Latent interval of 2-6 weeks after pharyngeal infection = PPE * **Polyarthritis** → tender joints, swelling * **Pericarditis →** endocarditis, myocarditis, pericarditis * **Erythema marginatum** → map-like outlines * Sydenham’s chorea 2-6 months later – involuntary movements
37
What is the diagnostic criteria for rheumatic fever?
* Diagnosis = **Jone's Criteria** * Evidence of recent strep throat and 2 majors or 1 major + 2 minors * Evidence of recent strep throat: * ↑ ISO titre * Other streptococcal Abs * Group A strep on throat culture * Majors - CASES * Carditis * Arthritis * Subcutaneous nodules * Erythema marginatum * Sydenham's chorea * Minor - FRAPP * Fever * Raised ESR/CRP * Arthralgia * Prolonged PR interval * Previous rheumatic fever
38
What is the management of rheumatic fever?
* Acutely * **Bed rest** * **Anti-inflammatory agents** * **High-dose Aspirin** - *suppresses the inflammatory response of the joints and heart* * **Antibiotics - Amoxicillin** - *if persistent infection* * **Corticosteroids** - *if the fever and inflammation doesn't resolve rapidly* * **Prophylaxis → monthly injections of benzathine penicillin** * Until 10 years after the last episode or until the age of 21 years or lifelong if severe valve disease * **Surgical valve repair or replacement** may be required
39
What are the signs and symptoms of cardiac failure in a child?
* **SoB** * Poor feeding / Poor weight gain * Recurrent chest infections * Fatigue * **Increased RR** * Increased HR * Murmur / Gallop rhythm * Signs of venous congestion * Enlarged heart * **Hepatomegaly** * Cool peripheries * Insufficient cardiac output * Respiratory distress * Pallor * FTT
40
What are the causes of cardiac failure in a neonate?
* **Duct dependent or Obstructed systemic circulation** * Hypoplastic L-heart * Aortic stenosis * Severe coarctation of the aorta * Interruption of aortic arch * *Do not close the ductus arteriosus* * Volume overload → anaemia, sepsis * Pressure overload → hypertension
41
What are the causes of cardiac failure in an infant?
* **Defect causing high pulmonary blood flow** * L-to-R shunt → persistent VSA, ASD, PDA * Volume overload → anaemia, sepsis * Pressure overload → hypertension
42
What are the causes of cardiac failure in an older child?
* R- or L-HF * Eisenmenger (RHF) * Rheumatic HD * Cardiomyopathy * Volume overload → anaemia, sepsis * Pressure overload → hypertension
43
What are the appropriate investigations for suspected cardiac failure in a child?
* Obs → O2 sats, BP, * Bloods → FBC, U&Es, Ca2+, BNP/ANP * CXR * ECG * Echocardiography
44
What are the appropriate investigations for suspected cardiac failure in a child?
* Obs → O2 sats, BP, * Bloods → FBC, U&Es, Ca2+, BNP/ANP * CXR * ECG * Echocardiography
45
What is the management of cardiac failure in a child?
* Reduce preload → **Diuretics** or **GTN** * Enhance cardiac contractility → **Dopamine** or **Digoxin, Dobutamine, Adrenaline, Milrinone** * Reduce afterload → **ACE inhibitors** or **Hydralazine, Nitroprusside, Alprostadil** * Improving oxygen delivery → **Beta-blockers** * **Enhance nutrition** * If cyanotic → **Prostaglandin infusion** *(alprostadil)*
46
What is the most common complex cyanotic heart disease?
Tricuspid Atresia
47
What are the signs and symptoms of tricuspid atresia?
* Cyanosis and SoB * **Presents _very early_ (10mins)** * **Ejection Systolic Murmur** at **left sternal edge** * **Hypoplastic left heart**
48
What is the management of tricuspid atresia?
* 1st = **Maintain a secure supply of blood to the lungs** * *Option 1: Blalock-Taussig (BT) shunt insertion (between subclavian and pulmonary arteries)* * *Option 2: Pulmonary artery banding operation to reduce pulmonary blood flow if breathless* * **Complete corrective surgery not possible in most cases because only one functioning ventricle** * 2nd = Glenn operation → connect SVC to pulmonary artery * 3rd = Fontan operation → connect IVC to pulmonary artery
49
What is Ebstein's Abnormality?
Malformation of TV leading to severe tricuspid regurgitation → cardiomyopathy.
50
What are associated with Ebstein's abnormality?
* **Maternal lithium use in pregnancy** * Down's
51
What are the signs and symptoms of Ebstein's abnormality?
* Split 1st & 2nd heart sounds * Cardiomegaly
52
What are the important investigations for suspected Ebstein's abnormality?
ECHO
53
What is the management of Ebstein's abnormality?
* Prostaglandins * Surgery → Cone repair of tricuspid valve
54
Define Transposition of the Great Arteries..
The pulmonary artery and aorta are switched. * Aorta is connected to the right atrium and the pulmonary artery is connected to the left atrium * Oxygenated blood goes to the lungs and deoxygenated blood is sent to the body * Usually fatal immediately *→ often found alongside VSDs, ASDs, PDAs, etc. which aid mixing in the short-term*
55
What are the signs and symptoms of transposition of the great arteries?
* Cyanosis within a few hours * Loud S2 → No murmur
56
What are the appropriate investigations for transposition of the great arteries?
* CXR * Narrow upper mediastinum (‘egg on side’) * Increased pulmonary markings * Echocardiography
57
What is the management of transposition of the great arteries?
* **Immediate prostaglandin infusion →** PDA patency * **Balloon atrial septoplasty →** tears atrial septum down to allow mixing * **Arterial switch surgery to switch the vessels** * Must act quickly/within hours → fatal if not
58
What are the causes of outflow cardiac obstruction?
* Aortic Stenosis * Pulmonary Stenosis * Coarctation of the Aorta * Hypoplastic Left-Heart Syndrome
59
What conditions often co-exist with aortic stenosis?
Coarctation of aorta ± mitral valve stenosis
60
What are the signs and symptoms of aortic stenosis?
* Ejection Systolic Murmur * No Cyanosis * Carotid thrill
61
What are the signs and symptoms of pulmonary stenosis?
* Ejection Systolic Murmur - particularly harsh murmur * No Cyanosis
62
What is the management of aortic and/or pulmonary stenosis?
Transcatheter balloon dilatation
63
What are the signs and symptoms of coarctation of the aorta?
* Asymptomatic in many * If symptomatic → presents in 3rd day to a few weeks of life * No cyanosis * Ejection systolic murmur * High BP in arms + Low BP in legs * ‘Rib notching’ - *occurs due to large collateral intercostal arteries forming*
64
What are the appropriate investigations for suspected coarctation of the aorta?
* ECHO * Magnetic Resonance Angiography
65
What is the management of coarctation of the aorta?
* Sick infant * ABC * Prostaglandin infusion guidelines * Well child / Stabilised child * Surgical repair OR * Balloon angioplasty ± stenting
66
What is Hypoplastic Left-Heart Syndrome?
Congenital defect in which the mitral valve, **left ventricle**, aortic valve, and aorta fail to develop properly. * Very poorly developed and small left ventricle
67
What is the management of Hypoplastic Left-Heart Syndrome?
* 1st * ABC * Prostaglandin * 2nd * Blalock-Taussig (BK) shunt - *artificial ductus arteriosus* OR * Norwood stage 1 * 3rd * BK shunt removed → Glenn or hemi-Fontan → Fontan or TCPC (Total Cavo-pulmonary Connection)
68
What is the most common arrhythmia in children?
SVT
69
What are the signs and symptoms of SVT?
* **HR 250-300bpm** * Poor CO * Pulmonary oedema * Neonatal = HF, hydrops fetalis * Foetus = Intra-uterine death
70
What are the appropriate investigations for suspected SVT?
* **ECG** * Narrow complex tachycardia - delta wave in WPW * T wave inversion due to ischemia * Echocardiography
71
What is the management of SVT?
1. Circulatory and respiratory support → correct tissue acidosis and positive pressure ventilation if needed 2. **Vagal stimulating manoeuvres** → e.g. carotid sinus massage, cold ice pack to face = 80% success 3. **IV adenosine** → induces AV lock after rapid bolus infusion 4. **Electrical cardioversion** with synchronised DC shock if adenosine fails
72
What are the risk factors for infective endocarditis?
Any congenital heart defect or abnormality which gives rise to a turbulent blood flow - *i.e. VSD*
73
What is the most common cause of infective endocarditis?
Streptococcus viridians
74
What are the signs and symptoms of infective endocarditis?
* Fever * Anaemia / Pallor * Clubbing, **splinter haemorrhages** * **Necrotic skin lesions** (infected emboli) * Changing cardiac signs * Splenomegaly * Neuro signs from cerebral infarct * Retinal infarcts * Arthritis or arthralgia * Microscopic haematuria
75
What are the appropriate investigations for suspected infective endocarditis?
* Multiple **blood cultures** - before Abx * ECHO to identify vegetations
76
What is the management of infective endocarditis?
* **High dose penicillin in combination with aminoglycoside** - (*gentamicin or streptomycin) for 6w IV* * Surgical removal of infected prosthetic material
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