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Flashcards in Cardiology Deck (46):
1

What can be attributed Chest pain in pediatrics?

most pediatric chest pain is musculoskeletal in origin
chest pain leads to many school absences
older children are more likely to have psychogenic reasons
younger children are more likely to have a cause related to respiratory disease
cough
asthma
pneumonia

2

Approach to chest pain herald signs of serious causes

chest pain with exertion
acute pain that is acutely worsening
acute onset of fever with chest pain
findings on history or exam referable to cardiac or respiratory systems
rule out severe distress
chest tenderness is very reassurring against a cardiac source
initial workup typically starts with EKG and chest plain film

distinguish pleuritic from non-pleuritic
"Does it hurt when you breath"

3

Musculoskeletal source chest pain features.

chest tenderness with or without movement

overuse injury or strain of chest wall muscle
direct trauma
rib fracture
contusion of chest wall
slipping rib syndrome
involves 8th, 9th, 10th ribs slipping and impinging on intercostal nerve
precordial catch (Texidor’s twinge)
sharp pain at the left sternal border, lasts less than 3 minutes
costochondritis
pain at sites of costal cartilage reproduced by eliciting tenderness over the costochondral junctions or with AP compression of the chest(crazy common with teenagers=give motrin.)

4

Respiratory source chest pain features?

illnesses with persistent or forceful cough
pneumonia +/- pleural effusion
asthma +/- pneumomediastinum
spontaneous pneumothorax
asthma
cystic fibrosis
Marfan’s syndrome
Pleurisy(involves inhaled chest pain)

5

Pulmonary vascular disorder source chest pain(if teenager female think OCP)

pulmonary embolism
rare in children but can occur in those with risk factors
oral contraceptives
termination of pregnancy
trauma, particularly of lower extremities
classic presentation
acute onset of pleuritic chest pain, dyspnea, hypoxia
presentation is not always classic

6

pulmonary hypertension
features

pain typically related to underlying heart or lung disease

7

acute chest syndrome
features

chest source crisis in patients with sickle cell disease

8

Psychogenic source chest pain features

anxiety disorder or conversion disorder
relative or friend with cardiac disease
family history of depression, somatization
triggered by stress
hyperventilation

9

GI source chest pain features? causes?

reflux esophagitis
burning, substernal pain
worse with reclining or certain foods
may be associated with esophageal spasm (mimicks angina)
severe cases complicated by esophageal candidiasis
intrathoracic foreign body
pill esophagitis(pill is not swallowed all of the way)reflux from the acid that is produced

10

Mammary source chest pain features?

females
mastitis
thelarche
pregnancy
fibrocystic disease
males
gynecomastia

11

Cardiac source chest pain features?

Rare cause of chest pain in children
Co-morbid risk factors raise likelihood of cardiac-source chest pain
diabetes mellitus
Kawasaki’s disease
chronic anemia
stimulant use
cocaine
amphetamines

12

All of the other causes of chest pain?

cardiac ischemia
may result from
anomalous coronary arteries
left ventricular outflow tract obstruction (LVOTO)
coarctation of the aorta
aortic dissection
cardiac infection
embolic phenomena
endocarditis
aneurysm due to Kawasaki disease
medium vessel vasculitis
pulmonary hypertension
valvular disease (congenital or acquired)
cardiomyopathy
subaortic stenosis
arrhythmia
myocardial infarction
rare in children
herald sign – pain with exertion
mitral valve prolaspe
pericarditis and myocarditis may cause chest pain without ischemia

13

hypertrophic obstructive cardiomyopathy (HOCM)
genetic feature?
what is it?
The manuvure?

autosomal dominant inheritance
systolic murmur worsening with change from lying to standing or with squat/Valsalva
procedures that reduce blood return to ventricles (reduce preload)
pain with exertion
listen to murmur while pt is standing and ask them to squat while you squat with them and listen for the murmur to see if it gets louder or softer.

14

Cardiac infections features.

pericarditis

pericarditis
fever
respiratory distress
sharp, stabbing substernal chest pain
often unable to lie flat
pain improves with sitting up or leaning forward
friction rub, distant heart sounds
jugular venous distension
pulsus paradoxus

15

myocarditis
features
labs

myocarditis
pain develops over a few days
fever
systemic symptoms
vomiting, lightheadedness, etc.
gallop rhythm (S3, S4 sounds)
tachycardia
orthostatic hypotension
CXR - cardiomegaly
abnormal EKG

16

sinus arrhythmia

faster when you inhale and slower when you exhale

17

Pediatric arrhythmias features?

sinus arrhythmia can be very pronounced in children
HR slows with expiration
most common pediatric dysrhythmia is supraventricular tachycardia
mechanisms include
intra-atrial reentry
AV nodal reentrant tachycardia
AV accessory conduction
Wolff-Parkinson-White syndrome
slurred upstroke of the QRS (delta wave)

18

describe murmurs

description
intensity (grade I-VI)I=cant hear it
II=can barely hear it(soft/hard murmur)
III=definetly hear it
IV=
quality
timing
-relationship to cardiac cycle (S2 heart sounds)
-duration
location
variation with position
increase in intensity with standing or Valsalva is generally concerning for HOCM

19

Diastolic murmur

no such thing as normal diastolic murmur

20

Innocent murmurs

“innocent” is synonymous with terms functional, benign, & flow
newborn murmur
peripheral pulmonic stenosis
Still’s (vibratory) murmur(sounds like someone plucking a string from an instrument)
adolescent ejection murmur
venous hum
carotid bruit
all innocent murmurs are systolic ejection murmurs
all vibratory murmurs are innocent
"Like when you turn the sink on and you hear that shhhhhh sound"

21

Innocent newborn murmur

heard during first few days of life (neonate)
grade I-II
soft, short, vibratory (“newborn Still’s”)
LLSB (lower or upper easy to distinguish in neonate)
without radiation

22

Innocent murmurs

peripheral pulmonic stenosis (PPS)

caused by the change in direction of the branches of the pulmonary artery
grade I-II
soft, short, high-pitched
loudest over LUSB
radiates to back & axillae

23

Innocent murmurs

Still’s (vibratory) murmur

heard from age 2 and up
grade I-III
musical, vibratory, short
LLSB to apex
loudest when patient is in the supine position; diminishes when the patient sits or stands

24

Innocent murmurs

adolescent ejection murmur

heard from age 8 and up
grade I-II in intensity
soft
well localized to the LUSB
louder when patient is supine

25

Innocent murmurs

venous hum

heard after age 2
continuous musical hum
located at the upper right and left sternal borders
usually louder on the right
intensity changes with turning of the neck

26

What are Shunts

systemic (left) and pulmonary (right) circuits generally operate in series
a shunt implies a connection that allows communication between the two systems
shunting proceeds down gradient in pressure
newborns have high pulmonary pressures (high pulmonary resistance) until 2-8 weeks of life
left-to-right shunts commonly become evident in this period
right-to-left shunts cause cyanosis
mixing lesions may have either (or both) directions of shunt present

26

Acyanotic CHD types

VSD accounts for about 25% of all CHD
ASD or PFO (patent foramen ovale) places patients at risk for systemic embolism and altitude sickness
PDA covered long ago
aortic stenosis and pulmonic stenosis are uncommon
AS 5% of all CHD, PS 10% of all CHD
both at risk for endocarditis

27

Ventricular septal defect features?
small ones

small VSD
80-85% of VSDs
asymptomatic
generally close on their own without surgery

27

Ventricular septal defect features
moderated VSD

moderate VSD
may shunt left-to-right
or pressures equal on right and left creates situation of no flow across the VSD
no pulmonary hypertension
no congestive heart failure
serially monitored by cardiologists

28

Ventricular septal defect features
larrge VSD

large VSD with normal pulmonary vascular resistance
left-to-right shunting as pulmonary vascular resistance naturally decreases (2-8 weeks of life)
infant develops congestive heart failure
failure to thrive
difficulty feeding
labored breathing/pulmonary edema

29

Eisenmenger’s syndrome

an untreated large VSD will cause pulmonary overcirculation
overcirculation of pulmonary system causes pulmonary hypertension
normal left-to-right shunt reverses to right-to-left shunt as pulmonary system pressures surpass systemic pressures
prolonged cyanosis
causes organ and vascular damage
platelet dysfunction
treatable only with heart transplant
"when pt doesnt get PE until their 20s-30s hen that VSD is so prolonged that there is clubbing

30

Coarctation of the aorta features

main artery to body stenotic or interrupted
causes upper extremity hypertension and reduced flow to abdominal organs and lower extremities
newborns screened for femoral pulses
suspicion prompts four-extremity blood pressure & oxygen saturation measurements
mild cases may have long-term growth problems,
often have aortic valve abnormalities audible on exam
may have chronic leg discomfort or lower extremity wasting
in non-mild cases, PDA needs to be kept open to ensure survival
if PDA closes, shock and acidosis ensue rapidly

31

Cyanotic CHD features

separated into
lesions with obstructive lesions leading to normal pulmonary blood flow
lesions with increased pulmonary blood flow
prolonged cyanosis leads to polycythemia
enables easier visual recognition of cyanosis
five most common cyanotic CHD
tetralogy of Fallot
tricuspid atresia
transposition of the great arteries
truncus arteriosus
total anomalous pulmonary venous return

32

Tetralogy of Fallot (bbot shaped heart)

~10% of all congenital heart disease
misplaced migration of neural crest to form the supracristal septum
four components to defect
ventricular septal defect
pulmonary stenosis
right ventricular hypertrophy
overriding aorta

33

“Tet spells"

where patient grows cyanotic, progressively worse with age
infants become agitated, tachypneic and have difficulty feeding
toddlers may squat to resolve Tet spell

34

Rheumatic fever tx?

10 days penicillin tx PO

35

Rheumatic fever features

follows a previous infection with S. pyogenes (GAβHS) – rate in untreated is approx. 3%
typically beteween ages 5 and 15 years
mortality of 2-5%
pathophysiology
sensitization of B lymphocytes
formation of anti-streptococcal antibodies
formation of Immune complexes
myocardial & valvular inflammatory response

36

name the Jones criteria

major criteria (mnemonic JCNES) – 2 signify disease
joints – migratory polyarthritis
-typically large joints
carditis
-as myocarditis, pericarditis or valvular disease
-indolent carditis can be a single criterion defining disease
nodules (subcutaneous)
-extensor surfaces of extremities
erythema marginatum
-can be locally exacerbated by heat
-pink-red macules grow, then coalesce into serpiginious long patches
Sydenham’s chorea
-with or without psychiatric disease
-may define disease as a single criterion

37

1 major + 2 minor can also signify disease
minor criteria

polyarthralgia
fever
previous rheumatic fever
elevated ESR, CRP, blood WBC
prolonged PR interval
supportive serology of previous infection
anti-streptolysin O is the best test
anti-DNAse B & streptozyme also used

38

name the Jones criteria

major criteria (mnemonic JCNES) – 2 signify disease
joints – migratory polyarthritis
-typically large joints
carditis
-as myocarditis, pericarditis or valvular disease
-indolent carditis can be a single criterion defining disease
nodules (subcutaneous)
-extensor surfaces of extremities
erythema marginatum
-can be locally exacerbated by heat
-pink-red macules grow, then coalesce into serpiginious long patches
Sydenham’s chorea
-with or without psychiatric disease
-may define disease as a single criterion

39

1 major + 2 minor can also signify disease
minor criteria

polyarthralgia
fever
previous rheumatic fever
elevated ESR, CRP, blood WBC
prolonged PR interval
supportive serology of previous infection
anti-streptolysin O is the best test
anti-DNAse B & streptozyme also used

40

Rheumatic fever other tx?

treatment
antibiotics
short-term to treat indolent infection
long-term to prevent recurrence
often ever 3-4 weeks for life
aspirin for anti-inflammatory effects
sometimes requires corticosteroids
supportive
cardiac meds (digoxin, diuretics)
endocarditis prophylaxis for procedures

41

Infective endocarditis features?

greatest risk is to those with preexisting heart disease or cardiac foreign material
may be acute or subacute
viridans streptococci
S. aureus
less common
enterococci
HACEK organisms (fastidious Gram-negative rods)

42

Infective endocarditis sx's

fever
chest pain
symptoms of heart failure
fatigue, tachypnea, dyspnea on exertion
changing murmur
petechiae & embolic phenomena
splenomegaly +/- hepatomegaly
arthritis
weight loss (subacute or chronic illness)
bacteremia
hematuria
markedly elevated inflammatory markers

43

Infective endocarditis treatment

long-term antibiotics
directed therapy (based on cultures)
surgical excision or valve repair sometimes warranted
supportive care for sequelae
congestive heart failure

44

Endocarditis prevention

risk of procedure also important to determine need
dental/oral or upper respiratory tract
amoxicillin
GU/GI procedures
amoxicillin for enterococcal coverage
aminoglycoside - for gram-negative coverage
procedures that involved infected tissues
clindamycin or vancomycin to cover MRSA