Cardiology Flashcards
(221 cards)
1
Q
What % of kids will have a murmur at some point in their lives?
A
90%
2
Q
What % of murmurs in children actually represent pathology?
A
<5%
3
Q
What are some buzz words for describing an innocent murmur?
A
V’s: Very Good
Vibratory
Venous hum
Vascular (Carotid bruit)
4
Q
What in the history should make you think of a pathological murmur?
A
Any associated physiological problem
5
Q
Name some findings on history that would point away from an innocent murmur
A
- Tachypnea
- Exercise intolerance
- Feeding difficulties
- Dyspnea
- Cyanosis
- Syncope
- Wheezing/Cough
6
Q
What are some descriptions of a murmur that should make you think pathological?
A
- Harsh sounding
- Intensity >3/6
- Pansystolic or late systolic
- Diastolic
- 4th heart sound or S4 gallop
- Ejection and/or mid-systolic clicks
7
Q
What is the first thing to do if they describe a 3rd heart sound?
A
Check the position of the child
8
Q
If you hear a 3rd heart sound in what position is it normal versus not?
A
If laying down, can be normal- Should disappear when sitting- if not, could be abnormal
9
Q
Fixed split S2?
A
ASD
10
Q
Patient with decreased exercise tolerance and a fixed split S2?
A
ASD
11
Q
Where is the VSD murmur best heard?
A
Left lower sternal border
12
Q
Blowing/Holosystolic murmur?
A
VSD
13
Q
True or False: Infants with VSDs typically do not have a murmur in the immediate newborn period?
A
True
14
Q
Why doesn’t an infant with a VSD have an audible murmur?
A
Right/left ventricular pressures are roughly equal in newborn period so no interventricular flow to create a murmur
15
Q
When is a VSD murmur louder- with a smaller opening or larger one?
A
Smaller (more turbulance)
16
Q
Baby with tachypnea, sweating with feeds, hyperdynamic precordium…?
A
Watch out for VSD (may not have murmur)
17
Q
Systolic click and normal splitting of S2?
A
Pulmonary stenosis
18
Q
What changes to the heart happen with pulmonary stenosis?
A
RVH
19
Q
Systolic (ejection) click, regardless of position?
A
Aortic stenosis
20
Q
Murmur best heard at the upper right sternal border and radiating into the neck?
A
Aortic stenosis
21
Q
What changes to the heart happen with aortic stenosis?
A
LVH
22
Q
To-and-fro machinery-type murmur?
A
PDA
23
Q
What condition should you think of with an AV canal defect?
A
Down Syndrome
24
Q
What axis is seen in an AV canal defect?
A
Superior QRS axis (30-90degrees)
25
Why does an AV canal defect have a superior QRS axis?
Conduction system has to go around the large defect in the middle of the heart
26
What axis deviation is seen in AV canal defect?
LAD
27
What should a right-sided aortic arch make you think of?
22q11 deletion
28
What axis deviation on EKG does LVH lead to?
LAD
29
Does hypertrophic cardiomyopathy that results in LVH lead to left axis deviation on EKG?
No
30
What are 2 scenarios where you can see left axis deviation without left ventricular hypertrophy?
1. Tricuspid atresia
2. AV canal defects
Due to effect on conducting system's orientation
31
True or False: CHF presents the same in infants and older children
False
32
How does CHF in infancy present?
Difficulty feeding, weight loss or failure to gain weight, tachypnea, tachycardia, hepatomegaly
33
What should you think with an infant that is small, sweaty, surly, and sick?
CHF
34
How does CHF present in older children?
Fatigue (especially with exertion or exercise), poor appetite, coughing, shortness of breath, diaphoresis
35
What are clinical scenarios where you would see systemic arteriovenous shunting of blood?
AV malformation in brain or liver
36
What does systemic arteriovenous shunting of blood result in?
Left to right extracardiac shunting which leads to right sided congestion
- Blood goes from high pressure (arterial) to low pressure (venous)
- Causes volume overload on right side of heart leading to jugular vein distension and hepatomegaly
37
What are some physical exam findings of CHF?
1. Gallop rhythm
2. Distended jugular veins
3. Peripheral edema
38
What treatments are preferred for CHF?
Ones that rest the heart:
1. Diuretics
2. Vasodilators
3. Beta-blockers
Over inotropes (Dignoxin) that overexert the heart
39
What is the murmur with coarctation?
Systolic murmur with radiation to the back and an early diastolic component
40
Name 3 classic findings of coarctation
1. Murmur (systolic, radiates to back, early diastolic)
2. Systolic HTN
3. Decreased perfusion/pulses in lower extremities
41
What is the classic description for BP with coarctation?
>10mmHg difference in BP between arms and leg (brachial/femoral pulse delay)
42
What are some findings you might be presented with for coarctation?
1. Classic signs of CHF
2. Shock
3. Acidosis
4. Lethargic infant not feeding well
5. Non-specific gallop
6. Nasal flaring
7. Sweating while feeding
43
What is the main goal of treatment of coarctation?
Maintain PDA with a prostaglandin drip (increases blood flow to descending aorta)
44
How is coarctation ultimately treated?
Surgery
45
True or False: After coarctation correction, re-occurance and HTN can occur
True
46
Does coarctation in newborns present with right or left ventricular hpertropy?
Right (RV is dominant pumping chamber in fetus)
47
When do infants with hypoplastic left heart present?
When PDA closes
48
How does hypoplastic left heart present?
Severe CHF (after PDA closes), cardiomegaly, precordial hyperactivity, loud S2
49
10 day old newborn, tachypneic, thready pulses, enlarged liver, ABG with metabolic acidosis.... what medication do you start?
Prostaglandin E1 (hypoplastic left heart)
-Presents with picture of cardiogenic shock
50
Describe the murmur with hypoplastic left heart
There isn't one- PDA is open, but pulmonary and aortic pressures are equal so no turbulance across the patent ductus
51
What are 2 important tests to get in a child with cardiogenic shock?
EKG and ECHO
52
What should you think with a newborn with hypoxemia whose O2 sat doesn't improve with 100% O2?
Cardiac disease (vs. pulmonary)
53
What are infants with cyanotic heart disease and polycythemia at risk for?
CVA
54
What are the 3 causes of severe cyanosis in the immediate newborn period?
1. Transposition
2. Pulmonary atresia
3. Ebstein malformation
55
Which 3 conditions will presents with central cyanosis, no respiratory distress, no significant murmur, and fail to correct with 100% O2?
1. Transposition
2. Pulmonary atresia
3. Ebstein malformation
56
What is the first thing to do for an infant with transposition, pulmonary atresia, or Ebstein malformation?
PGE1 (maintain PDA)
57
What can present similarly to transposition/pulmonary atresia/Ebstein, but will improve with O2 administration?
Persistent pulmonary HTN of the newborn
58
True or False: If an infant is anemic, they may not show signs of cyanosis on PE?
True (even with O2 sats around 88%)
59
Why might you not see cyanosis in an infant until O2 sats are quite low?
Because infants have high fetal Hbg levels
60
5 T's of cyanotic congenital heart disease?
1. Truncus Arteriosus
2. Transposition of the Great Arteries
3. Tricuspid Atresia
4. Tetrology of Fallot
5. Total Anomalous Pulmonary Venous Return
61
Of the 5 T' which presents with severe cyanosis in the first few hours of life?
Transposition (the others turn blue after PDA closes
62
Infant with good APGARs, pink/well-perfused initially. Day 1-2 of life becomes cyanotic, tachypneic. CXR has no increased vascular markings?
Ductal Dependent Lesions
- Cyanotic with closing PDA (decreased mixing at level of PDA)
- Lack of increased vascular markings rules out pulmonary disease
63
How are ductal dependent lesions treated?
Prostaglanding- Maintain PDA
64
None of the 4 pulmonary veins is attached to the left atrium?
TAPVR
-Oxygenated blood leaving lungs returns to RA and then back to lungs
65
What must be presents for TAPVR to be compatible with life?
Connection from R heart to L (ASD/VSD/PDA)
66
How does TAPVR present?
Full term infant
1. Increased right ventricular activity
2. Cyanosis
3. Hypoxia
4. Hypercarbia
5. Pulmonary edema
67
What are findings on CXR consistent with TAPVR?
- Pulmonary congestion (increased venous return)
| - Normal to small heart
68
What is seen on ABG with TAPVR?
Increase PCO2
69
What pulmonary problem can TAPVR present similarly to?
RDS- With a full term baby, consider TAPVR first (even though RDS can occur in full term infants)
70
What is the valve between RA and RV?
Tricuspid
71
What is Ebsteins' anomaly?
Abnormality of the Tricuspid valve leaflets
72
What 2 drugs can cause Ebsteins' anomaly?
Lithium or Benzos
73
4 components of TOF?
1. Pulmonary stenosis
2. Overriding aorta
3. VSD
4. RVH with RAD on EKG
74
What is the overall most common cyanotic heart condition?
TOF
75
What is the most common cyanotic heart condition in newborns?
Transposition of the great arteries
| TOF most common overall, but not usually present in the newborn period
76
How do kids with TOF present?
Palpable right ventricular impulse
| Single 2nd heart sound (pulmonary component absent)
77
What does EKG demonstrate in TOF?
RVH
78
What is seen on CXR for TOF?
"Boot-Shaped" heart with decreased pulmonary vascularity
79
When does TOF typically present?
Infant 3-5 months
*Often asymptomatic in early infancy*
80
What 2 things are kids at risk for after surgery for TOF?
1. Arrhythmias
| 2. Episodes of syncope
81
What happens during a tet spell?
Increased right to left shunting causes hypercyanosis and hypoxia
82
What are common triggers for tet spells?
Anemia and dehydration
83
Describe what the child does during a tet spell?
Turn blue, deep rapid respiratory pattern (hyperpnea)
84
What is found on cardiac exam during a tet spell?
Murmur disappears... Usually they have a systolic murmur
85
What are 4 factors that worsen cognitive prognosis in children with cyanotic heart disease?
1. Decreased neurological baseline before surgery
2. Seizures occurring after surgery (especially early)
3. Coexistent problems (chromosomal abnormality)
4. Duration of intraoperative circulatory arrest (>75 min makes for worse prognosis)
86
What is a clue you will see when describing a classic tet spell?
Acute onset
87
What is treatment for a tet spell?
1. Squatting position or knee to chest (increase peripheral vascular resistance)
2. Morphine
3. Phenylephrine
4. IV propranolol
5. Volume expansion
88
When should elective repair of TOF be completed?
In the first postnatal year
89
What is transposition?
Aorta connected to right ventricle and pulmonary artery to the left ventricle
Two circulations in parallel
90
What is the most common congenital heart defect presenting with severe cyanosis in the first week of life?
Transposition of the great arteries
91
Where does blood have to mix in transposition to be compatible with life?
Either at the foramen ovale (atrial level) or PDA
"Ductal Dependent"
92
What should you think with a cyanotic newborn?
Transposition
93
How do infants with transposition present?
Cyanosis, tachypnea, single 2nd heart sound
94
What is seen on CXR with transposition?
- Egg-shaped heart (this can be absent in 1st week of life)
| - Increased pulmonary vascularity
95
What does S2 represent on heart exam?
Closure of the aortic and pulmonic valve
96
Can you have a normal split S2 with cyanotic heart disease?
Not really- this essentially rules this out
97
What do you think if they mention a single S2?
Concern for cyanotic heart disease
Need prostaglandin
98
When do you see a fixed split S2?
ASD
99
True or False: TOF and transposition both present with a single 2nd heart sound?
True
100
Which presents with increased pulmonary vascularity, TOF or transposition?
Transposition
101
How is transposition treated?
1. IV prostaglandin E1- Maintain PDA
2. Balloon septostomy (to maintain ASD- if above doesn't work)
3. Ultimately surgical correction
102
When is a differential O2 saturation seen between arms and legs?
Transposition
103
Which saturation is higher in transposition, legs or arms?
Legs
- Upper extremities dependent on RV
- Lower extremities dependent on LV (via duct)
104
What cardiac findings are seen in DiGeorge?
Aortic arch defects
105
What cardiac findings are seen in Downs?
AV canal defects
106
What cardiac findings are seen in Marfans?
Aortic root dissection
| MVP
107
What cardiac findings are seen in Williams?
Supravalvular aortic stenosis
108
What cardiac findings are seen in Noonans?
Supravalvular pulmonic stenosis
109
What cardiac findings are seen in Turners?
Coarctation of the aorta
110
Anxious patient with tachycardia which has occurred on more than one occasion?
Sinus tachycardia
111
When can sinus tachycardia be appropriate?
When it is secondary in cases of infection and dehydration
112
What are 2 examples of when sinus tachycardia is pathologic?
1. Hyperthyroidism
| 2. Pheochromoytoma
113
True or False: A cardiac echo is routinely done in infants with atypical physical features even with a normal initial cardiac exam.
True
114
True or False: Most of the time, PACs are benign?
True
115
What are 3 things that can cause PACs?
1. Caffeine
2. Drug use
3. Electrolyte imbalances
116
What 2 situations should you worry about PACs progressing to Atrial Flutter?
1. Digoxin
| 2. Children under 1
117
Saw tooth waves
Atrial flutter or Atrial fibrillation
118
What is a sinus arrhythmia?
Normal variation in the heart rhythm caused by breathing
Common in healthy, normal children
119
Shortened PR interval and/or delta wave (distorts QRS upstroke)?
WPW
120
What arrhythmia are kids with WPW at risk for?
SVT
SVT can be a presenting sign of WPW on exam
121
What does the QT interval represent?
The time it takes the heart muscle to recover between beats
122
Why is a prolonged QT so dangerous?
When a new beat starts before the old beat as had time to end can lead to serious arrhythmias
123
What should family history of sudden death make you think of?
Prolonged QT syndrome
124
Previously healthy person who has unexplained syncope?
Prolonged QT syndrome
125
Syncope associated with emotions (sudden fright) or surprise (alarm clock going off)?
Vs. Exercise
Prolonged QT syndrome
126
Syncope that is followed by a seizure (syncope happens first then the seizure)?
Prolonged QT syndrome
127
Child collapses/is resuscitated after passing out in a pool. Family member with history of epilepsy and sudden death. What test do you do?
EKG- Long QT
Congenital long QT syndrome is caused by a variant of V-tach and can result in brief generalized seizures
128
Recurrent episodes of syncope usually with standing for prolonged periods of time. No family history of sudden death in anyone under 50 or other premature cardiac disease. Diagnosis?
Neurocardiogenic syncope
Not prolonged QT- no family history
129
Athletic teenage boy, 2 episodes syncope during practice. Not dehydrated, drug screen negative, no known family history of cardiac arrhythmia, no known history of sudden death in anyone under 50. Management?
Cardiology consult, no sports until cleared by cards, get more family history (no "known" history)
Could be congenital long QT syndrome.. key is history of syncope during exercise (as opposed to occurring with prolonged standing)
130
What is the most common symptomatic arrhythmia in children?
SVT
131
How might infants present with SVT?
Fussy and tachypneic
132
What might an older child with SVT complain of?
Chest pain
133
What is considered SVT?
Narrow complex tachycardia over 200-220
134
What is the first thing you do in a stable patient with SVT (HR over 220)?
Get a 12 lead EKG
135
What can be done to correct SVT in a stable patient?
Vasovagal maneuvers: Brief facial stimulation (cold, wet cloth, ice bag), want to induce the diving reflex that normally slows down the heart
136
What is the drug to use for SVT?
Adenosine
137
What type of pacing can be used in SVT?
Atrial overdrive pacing
138
If you give adenosine for SVT and it works, but the SVT returns right after adenosine is given, what do you use?
IV diltiazem
139
What do you do for an unstable patient with SVT?
Adenosine immediately... if IV adenosine isn't available, use cardioversion
140
When medication is sometimes used in the long term management of children with SVT?
Digoxin
141
What syndrome is the use of Digoxin contradicted in?
WPW
142
What drug is not indicated for SVT in children (especially younger than 1) because it can cause cardiac arrest?
Verapamil
143
What is it called when the P waves and the QRS complexes are working independently of each other?
AV block
144
In AV block which is more concerning... a widened QRS complex or narrow one?
Widened... blood flow to brain can be compromised resulting in risk for seizure and syncope
145
What is often seen in Mom's of kids with a 3rd degree heart block?
SLE
146
What can AV block be associated with?
Viral myocarditis
147
What is 3 or more continuous wide QRS complexes with abnormal or absent P waves?
Ventricular tachycardia
148
What is the rate in V-tach?
120-150 bpm
149
What are 3 symptoms of V-tach?
1. Pallor
2. Fatigue
3. Palpitation
150
True or False: Majority of patients with VT have underlying heart disease?
True
151
What is the most likely cause of VT with loss of consciousness?
Torsades de pointes VT
152
What is the treatment of choice for sustained VT longer than 30 seconds?
Synchronized cardioversion
153
What is seen in history for rheumatic fever?
1. Pharyngitis
| 2. URI
154
What labs are seen with rheumatic fever?
1. Elevated ESR
2. Elevated CRP
3. Elevated ASO titer
155
What is found on physical exam for rheumatic fever?
Migratory arthritis of large joints, emotional lability, purposeless rapid movements of extremities, muscle weakness (Syndenham's chorea)
-Joint pain and a new heart murmur
156
What are 2 two most common murmurs in rheumatic fever?
1. Mitral insufficiency
| 2. Aortic insufficiency
157
What are the requirements to meet Jones criteria for Rheumatic fever?
1. Proof of recent group A strep infection
| 2. 2 major symptoms or 1 major/2 minor symptoms
158
New murmur with mild congestive heart failure?
Aortic regurgitation (think rheumatic fever)
159
What is the most common murmur in rheumatic fever?
Mitral valve regurgitation
160
What is the description of a mitral valve regurgitation murmur?
Murmur heard best at the apex
161
True or False: A positive throat culture distinguishes chronic carrier state from a recent infection?
False
162
True or False: A negative rapid strep doesn't rule out a recent infection?
True
163
What test can provide definitive documentation of a recent strep infection when trying to diagnose rheumatic fever?
ASO titers and positive streptozyme (these correlate very well with a recent strep infection)
164
What are the major Jones criteria?
1. Joints: Polyarthritis
2. Heart: Carditis (CHF, new murmur, cardiomegaly)
3. Nodules (subcutaneous)
4. Erythema marginatum
5. Sydenham chorea
165
What % of cases of rheumatic fever have polyarthritis?
75%
166
Describe the nodules seen in rheumatic fever.
Firm, painless, extensor surfaces of wrists, elbows, and knees
167
What is sydenham chorea?
Rapid, purposeless movements of the face and upper extremities
168
What are minor Jones criteria?
1. Fever
2. Arthralgia
3. Elevated acute phase reactants (ESR, CRP)
4. Prolonged PR interval
*Help*- Hot (fever), Elevated (CRP/ESR), arthraLgia, Prolonged (PR)
169
True or False: Asthralgia is a major Jones critera?
False: Arthritis is major, arthralgia is minor
170
Describe the arthritis seen in rheumatic fever.
Migratory
171
Which joints are involved in arthritis seen in rheumatic fever?
Larger joints: Knee, ankle, elbow, wrist
172
How long do episodes of arthritis with rheumatic fever typically last?
From a week up to a month
173
What is the rash seen in rheumatic fever?
Erythema marginatum
*Don't mix up with erythema migrans (Lyme)*
174
What are the 3 treatment goals for rheumatic fever?
1. Eliminate Group A strep infection
2. Alleviate symptoms
3. Prophylaxis to prevent recurrence
175
What do you use to eliminate strep infection in rheumatic fever?
Penicillin
This does alter disease course, this is empiric
176
What is used for prophylaxis for rheumatic fever?
Penicillin
177
What is used to treat migratory arthritis and somewhat fevers seen in rheumatic fever?
ASA
178
What treats carditis seen in rheumatic fever?
Steroids (controversial for mild carditis)
179
What is used to help with chorea in rheumatic fever?
Haldol
180
What is used to treat heart failure seen with rheumatic fever?
Digoxin
181
What is an infection of the endocardial surface of the heart, usually involving the valves called?
Infective endocarditis
182
What are 2 major risk factors for infective endocarditis?
1. Congenital heart disease (repaired or not)
| 2. Dental work
183
What are some factors in the history that you would see with infective endocarditis?
1. Unexplained fever
2. Hepatosplenomegaly
3. Petechiae
4. New or changing murmur
5. Myalgias
6. Arthalgias
7. Headaches
8. Generalized malaise
184
What are Osler nodes?
Tender nodules on the pads of fingers and toes
185
What are non-tender red nodules on the palms or soles?
Janeway lesions
186
What is the best study to confirm diagnosis of infective endocarditis?
Blood culture (have to isolate pathogen in blood)
187
What are the 2 most common causes of acute bacterial endocarditis in children?
1. Viridans strep
| 2. S. Aureus
188
What is the initial IV antibiotic regimen for infectious endocarditis?
Vancomycin plus gentamicin for minimum 4-6 weeks
189
Who is routine antibiotic prophylaxis for dental work to prevent infectious endocarditis indicated for?
Patients with congenital heart disease and...
1. Incompletely repaired cyanotic heart disease (especially shunts and other hardware)
2. Heart disease surgically corrected with hardware and other devices within previous 6 months
3. Any residual defect near a prosthetic cardiac device
190
What antibiotics are used for dental prophylaxis with concern for infectious endocarditis?
Oral amoxicillin 50mg/kg 30-60 minutes prior to procedure
191
What is given for dental prophylaxis with concern for infectious endocarditis in a child with a penicillin allergy?
Clindamycin or azithromycin
192
What is typically seen in the recent history of myocarditis?
Viral illness (like a recent URI)
193
What is often described on exam for myocarditis?
A new murmur
194
Name some symptoms of myocarditis.
1. Fatigue
2. Lethargy
3. Tachypnea
4. Tachycardia
5. Chest pain
6. Shock
7. CHF
8. Pulmonary edema
9. Arrhythmias
10. Death
195
What is the most common cause of myocarditis?
Coxsackie group B virus
196
What is the treatment for myocarditis?
Supportive
| Steroids are controversial
197
What is inflammation of the pericardial sac, typically involving the epicardium and pericardium?
Pericarditis
198
What are some causes of pericarditis?
Viral (URI) or collagen vascular disease (JIA) are more common. Can also be due to bacteria.
199
When pericarditis is caused by bacteria, what is it usually due to?
Preceding or concurrent bacterial infection somewhere else (like a pneumonia)
200
What is the most common bacterial cause of pericarditis?
S. Aureus
201
How can a definitive cause of pericarditis be obtained?
Cardiocentesis to get a sample for serology and cultures
202
What position do children with pericarditis prefer?
Leaning forward
203
What is heard on auscultation in pericarditis?
Friction rub
204
What is seen on EKG in pericarditis?
ST segment elevation
205
What are some other symptoms of pericarditis?
Non-specific chest pain or epigastric pain
206
What are 2 exam findings besides the friction rub that can be seen in pericarditis?
Low grade fever, jugular venous distention
207
What is an important part of the history to get when concerned for pericarditis?
If there is an underlying rheumatological disorder
208
Chest pain worse when lying down, ST segment elevation, muffled heart sounds?
Pericarditis
209
What is the most important study to order when pericarditis or effusion is suspected?
CXR
210
What is pulsus paradoxus?
Drop of systolic BP more than 10mmHg seen with inspiration
211
What condition is pulsus paradoxus seen in?
Pericardial effusion, tamponade, pericarditis, some cardiomyopathies, severe asthma
212
How might a child with a pericardial effusion present?
Chest pain and general malaise
213
What is the finding on CXR in pericardial effusion?
Enlarged heart
214
Does a child with a pericardial effusion have clinical heart failure?
No... even though they have an enlarged heart on CXR
215
What is seen on ECHO in pericardial effusion?
Pericardial fluid
216
What is called when a pericardial effusion builds up enough pressure to compromise cardiac output?
Cardiac temponade
217
What are signs of cardiac tamponade?
1. Tachypnea
2. Rales
3. Pulsus paradoxus
4. Muffled heart sounds
5. JVD
6. Hepatomegaly
7. Peripheral edema
8. Hypotension
218
What % of chest pain is cardiac in origin?
Less than 1
219
What is chest pain that is cardiac in origin often described as?
Pain that radiates to the neck, back, shoulders, or left arm. Pain that is constant/frequent, dull, pressure-like, associated with exercise.
220
What is the likely cause of chest pain that is infrequent and brief or sharp that increases with a deep breath?
Musculoskeletal or pleuritic pain
221
Name 7 cardiac causes of chest pain in children.
1. Pericarditis/Myocarditis
2. Aortic stenosis and severe pulmonic stenosis
3. Anomalous origin of coronary arteries
4. Mitral valve prolapse
5. Kawasaki disease
6. Arrhythmias (SVT and VT)
7. IHSS
