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Flashcards in Cardiology Deck (58):

On a neonatal cxr, a narrowed mediastinum is an indication of what pathology?



What is the classic triad of aortic stenosis?

1. Chest pain

2. Breathlessness

3. Syncope


When do you expect the T wave in V1 to be upright?

  • Can be upright until day 4 (RVH is the norm)
  • After day 4 until age 4 yrs upright T=pathological RVH
  • Severe RVH - T wave goes down again due to "strain"


How do you work out QT interval?

Measure the interval from the start of the Q to the end of the T, and then divide by the square root of the preceding R-R interval.

QTc=QT(ms)/sq root R-R interval(ms)

Measured in leads 2 and V5 (particularly not in V2-V4)



What is normal for ST elevation?

  • Up to 1mm is normal.
  • Up to 2mm is normal in V2-V4.


A well 4 year old presents with a murmur.

Pulses are normal, BP 95/60.

RV lift

2-3/6 ESM at LSE

CXR shows cardiomegaly, plethora and prominent PA

ECG below


What is the diagnosis and what is another physical sign to expect?

Atrial Septal Defect

ECG - normal axis Incomplete RBBB

Fixed splitting of the second heart sound may be heard


A well 4 year old presents with a murmur.

Pulses are normal, BP 95/60.

Precordium is normal.

2-3/6 vibratory ESM at upper and lower LSE.

ECG shows normal axis IRBBB.

CXR is normal.

Murmur disappears with the manouvre from the image below.

What is the diagnosis?

Stills murmur (aka vibratory murmur).

A functional murmur most common in the 2-5 year age group.



A well 4 year old presents with a murmur.

There is a 4/6 pansystolic murmur at the LSE.

ECG shown below.

What is the diagnosis?

Ventricular septal defect


Describe this ECG.

Rate ~150bpm

Axis - + in I and AVF = normal

P waves - Sinus, normal

PR - normal

QRS - narrow

V1 - RSR

III and AVF - Q waves in III and AVF -ok

V5 and V6 - Q waves - usual finding

Incomplete RBBB without RV hypertrophy



A well 4 year old presents with a murmur.

The child is slim with a history of regular chest infections.

The pulses are normal, BP 95/60

Overactive precordium

2/6 low pitched PSM at lower LSE, 2/4 mid diastolic murmur at apex

ECG below.

Describe the ECG.

What is the diagnosis?

ECG- Dominant R waves in V1 and V2 with no S waves. Hints at RV hypertrophy.

N/2 at V5 indicate half voltage. Tall R and deep S waves indicate biventricular hypertrophy.

Diagnosis - Large VSD

Flow murmur at apex indicates large left to right shunt.


A 2 year old presents with a loud systolic murmur, cyanosis (SpO2 88%) and the ECG below.

Describe the ECG

What is the diagnosis?

Tetralogy of Fallot

Right axis deviation at approx +150 degrees

QRS - narrow

S waves - deep in V5 and V6 (RVH)

T waves - upright in V1 and V2




What are the cyanotic heart defects?

Tetralogy of Fallot



Truncus arteriosis

Tricuspid atresia


Looking at leads II and V1, what do you expect the P wave to look like in:

A normal heart?

Right atrial hypertrophy?

Left atrial hypertrophy?

Combined atrial hypertrophy?

The first half of the P wave reflects the right atrium, and the second half the left atrium.


In lead II, what changes do you see in the P wave that would assist in diagnosing

1. RAH

2. LAH

3. CAH


What are causes of LAD on ECG?

  • LVH esp with volume overload (eg big VSD)
  • LBBB (QRS Broad)
  • Left anterior hemiblock ("superior axis", QRS narrow)
    • tricuspic atresia
    • AV canal defect
    • LTGA


On ECG, what is the criteria for right atrial chamber enlargement?

p wave amplitude >3mm


On ECG, what is the criteria for LA chamber enlargement?

Bifid p wave and prolonged >.10 secs

ie. 2.5 small squares  (0.08 secs in infants)


What is the criteria for RV chamber enlargement on ECG?

  • R in V1 >20mm, >25mm in neonates
  • S in V6 >7mm


  • upright T wave in V1 after 72 hours and up to 5 years

Severe RVH

  • ST and T wave invert with ST depression, and small Q wave in lead V1


What is the criteria for LV chamber enlargement on ECG?

R in V6 >25mm

Severe - ST depression and T wave inversion V6


When are Q waves normal on a paediatric ECG?

1,2,3, AVF, V5, and V6.

Narrow and up to 7mm deep in 2 and 3


When is a Q wave pathological?

In V1 (except occasionl newborns) and indicate L-TGA, single ventricle, severe RVH or anterior MI (deep and wide)


ESM at upper right sternal edge with carotid thrill = ?

Aortic stenosis


ESM at upper left sternal edge with no carotid thrill =?

Pulmonary stenosis or ASD


ESM at mid/lower LSE =?

Innocent murmur


Long harsh systolic murmur + cyanosis =?

Tetralogy of Fallot


Pansystolic murmur at LLSE +/- thrill +/- mid diastolic apical murmur =?


Mid diastolic murmur due to increased mitral flow if large defect.

If assoc with pulmonary hypertension, loud P2.


Pansystolic murmur at apex =?

Mitral regurgitation


Pansystolic murmur at LLSE (rare) +/- cyanosis =?

Tricuspid regurgitation


Diastolic murmur at LSE/apex (+/- carotid thrill) =?

Aortic regurgitation


In a child with a duct-dependent circulation such TGA or pulmonary atresia, what medication is used to keep the duct patent?

Prostaglandins E1 or E2


If a child has a shunt, when will there be cyanosis?

Desaturated blood shunting from right to left.


What is Ebsteins anomaly?

A congenital heart defect of the tricuspid valve.

The valve is displaced toward the apex of the right ventricle essentially causing a larger right atrium and smaller right ventricle.


Describe the four innocent cardiac murmurs.

Stills murmur

Short mid-systolic murmur heard best at LSE or b/w apex and LSE. Medium frequency with vibratory or slightly musical quality.

Pulmonary Flow Murmur

Soft, blowing ejection murmur, maximal in pulmonary area. May radiate softly to axillae. Frequently heard in early infancy.

Carotid Bruit

Medium frequency, rough ESM heard over carotid artery at root of the neck. Very common in children. Softer or inaudible below the clavicle.

Venous Hum

High pitched, blowing, variable, continuous murmur, heard over sternoclavicular junctions or over the neck and changing with position of the head. Almost always disappears when lying flat.


What are the common defects with a left to right shunt?






Describe the fetal circulation.

Main blood flow

Placenta → umbilical vein → ductus venosus → inferior vena cava → right atrium → foramen ovale → left atrium → left ventricle → aorta → hypogastric arteries → umbilical arteries → placenta.

From the right ventricle:

Right ventricle → pulmonary trunk → ductus arteriosus → aorta


2008A Q33

A six-month-old child undergoes cardiac catheterisation. The oxygen saturations obtained in room air during the procedure are as follows:
Superior vena cava 75% 
Right atrium 75%
Inferior vena cava 75%
Right ventricle 87%
Main pulmonary artery 87%
Left ventricle 99%
Aorta 99%

These findings are most consistent with a diagnosis of:

A. atrial septal defect.
B. atrioventricular septal defect.
C. patent ductus arteriosus.
D. tetralogy of Fallot.
E. ventricular septal defect.

E. ventricular septal defect.
The rise in saturations from 75% at RA to 87% at RV indicates a left to right at the ventricles.

ASD - RA shows no change from IVC and SVC
AVSD - RA shows no change
PDA - Doesn’t explain change in RV saturation because it is communication between aorta and pulmonary artery.
TOF - Pt will initially have a L to R shunt as blood follows the path of least resistance. As RV obstruction increases, blood will move R to L as it becomes the easiest path.
VSD - Left to right shunt


2008A Q4

A six-month-old child with cardiac failure secondary to severe dilated cardiomyopathy is initially treated with Frusemide and Spironolactone. The addition of which of the following drugs to the child’s medical therapy is most likely to result in hyperkalaemia if no changes are made to the existing therapy?
A. Amiodarone.
B. Captopril.
C. Digoxin.
D. Metoprolol.
E. Warfarin.

B. Captopril.


2008A Q7

An 11-year-old boy is seen in clinic for review of congenital cardiac disease, for which he underwent surgery as a neonate. You notice asymmetry of his face, as demonstrated in the photograph below.
These findings are consistent with:
A. Duane syndrome.
B. Horner syndrome.
C. Mobius syndrome.
D. Waardenburg syndrome.
E. Williams syndrome.

B. Horner syndrome


2008A Q14

The most significant change in auscultatory findings during a cyanotic spell in an infant with tetralogy of Fallot is that the:
A. ejection systolic murmur becomes louder.
B. ejection systolic murmur becomes softer.
C. pansystolic murmur becomes louder.
D. pansystolic murmur becomes softer.
E. second heart sound becomes more widely split.

B. ejection systolic murmur becomes softer.


What is the triad of Eisenmenger syndrome?

  1. systemic-to-pulmonary cardiovascular communication,
  2. pulmonary arterial disease and
  3. cyanosis


What signs are useful indicators of pumonary vascular disease in a patient with a VSD?

  1. Early diastolic murmur at mid-left sternal edge indicates pulmonary regurgitation (?raised PVR)
  2. Narrow or single accentuated second heart sound indicates elevated PVR


What are cardiac lesions associated with Williams Syndrome?

Supravalvular aortic stenosis most common.

Also pulmonary valve stenosis


Describe what you would see in the following ECGs:

1. 1st Degree heart block

2. Mobitz I

3. Mobitz II 

4. Complete heart block

1. 1st Degree HB

Prolonged PR interval with no skipped QRS

2. Mobitz I

(Wenkebach) Progressively increasing PR interval preceeds a non-conducted P wave (no QRS).

3. Mobitz II

Unchanged PR intervals before P that suddenly fails to conduct through to the ventricles (no QRS).

4. Complete Heart Block

P waves unrelated to QRS 


What happens to second heart sound in ASD?

Fixed splitting


ECG changes in RBBB

V1 = RSR

V6 = slurring of s wave


ECG changes in LBBB

1. QRS >120ms

2. V1 = QS or rS

3. V6= RsR


What triggers interaction between troponin and myosin in the myocardium?

Release of calcium from the sarcoplasmic reticulum


Ebsteins anomoly

malformed and displaced tricuspid valve leaflets, partly attached to annulus and partly to RV endocardium


What are you at risk of developing in WPW?

Re-entrant tachycardia

Criteria for diagnosis of WPW are:

  • Short PR interval (less than the lower limit of normal for age):
    • Younger than 3 years - 0.08 second
    • 3-16 years - 0.10 second
    • Older than 16 years - 0.12 second
  • Delta Wave (initial slurring of the QRS complex) Wide QRS duration beyond the upper limit of normal.

Patients with Wolff-Parkinson-White Syndrome have an anomalous conduction pathway which bypasses the normal delay of conduction in the AV node making them at risk of a re-entrant supraventricular tachycardia.


What is pulmonary wedge pressure?

Gives an indication of left atrial mean pressure.


The electrocardiogram (ECG) shown below was obtained from a three-year-old girl with a systolic murmur. Which one of the following is the most likely diagnosis?

A) Perimembranous ventricular septal defect.

B) Persistent ductus arteriosus.

C) Primum atrial septal defect.

D) Pulmonary valve stenosis.

E) Subaortic stenosis.

Answer = C = Primum atrial septal defect

The ECG shows sinus rhythm, a partial RBBB and normal ventricular voltages except for slightly larger S voltage in V6 (upper limit 7mm).

These findings are consistent with ostium primum ASD.

In most paediatric cases RBBB reflects a longer pathway through the right bundle branch (rather than anatomical disruption of the RBBB) resulting from RV enlargement. RV enlargement is an indirect sign of the left-right shunt due to ASD. (RBBB also seen in Ebsteins anomaly and CoA)


In what conditions will you see a RBBB in children?

Ostium primum ASD

Coarct of Aorta

Ebsteins Anomoly


What ECG changes would you see with an Ebstein anomaly?

Ebstein anomaly: ECG has tall wide P waves and an rsR'S' pattern


What will you look for on ECG for a Transposition?

Transposition: Develops Right atrial enlargement, right axis deviation and right ventricular hypertrophy


What is the chance of spontaneous closure of a small muscular VSD in the first decade of life?



muscular - 90%

membranous 35%


Most by 4 years of age


In a fetus with a structurally normal heart, what is the percentage of pulmonary arterial blood flow that is directed through the ductus arteriosis?



What are typical ECG changes in pericarditis?

Typical changes include widespread ST elevation (particularly in those leads representing the LV) and T wave inversion.


Management of SVT?

1. Vagal stimulation

  • diving reflex (babies - head and face in basin of ice-cold water for 5 seconds; older child - bag of ice cold water on face for 15 seconds)
  • unilateral carotid massage

2. Adenosine - rapid IV bolus (rx of choice)

3. Synchronised DC cardioversion (after sedation)

  • NB, if pt severely compromised, this is first line management

4. Other drugs include amiodarone, flecainide, digoxin