Pediatric cardiology JFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: Brett Nelson, MD, MPH

Discussion Cardiac evaluation Auscultation Distinguishing pathologic from innocent murmurs Common innocent pediatric murmurs Further work-up of a concerning murmur

Initial cardiac evaluation History: poor feeding, diaphoresis, FTT, family hx Vital signs: height, weight, HR, RR Inspection: dysmorphism, cyanosis, clubbing Palpation: presence and quality of distal pulses; precordium for PMI and thrills; liver Auscultation (further cardiac evaluation to follow…)

Auscultation Rate & regularity Heart sounds Murmurs… Clicks Rub Focus particularly on intensity and quality of S2 and for presence of extra heart sounds (S3, S4) Murmurs… Clicks Abnormal valvular sounds (e.g. ejection clicks in early systole, MVP in mid/late systole) Rub Associated with pericarditis; scratchy sound best heard at apex (may diminish if pericardial effusion becomes large)

Auscultation

Heart sounds S1: closing of the AV valves mitral then tricuspid S2: closing of the semilunar valves aortic then pulmonary S3: ventricular overload “TEN-NE-see”: S1, S2, s3 <40yrs, pregnancy, MR/TR, CHF S4: decreased LV compliance “ken-TUCK-Y”: s4, S1, S2 more likely than S3 to be pathologic (HTN, CAD, cardiomyopathy), although can be normal (athletes)

Murmurs Secondary to turbulent blood flow Assess: Intensity / loudness Timing (systolic, diastolic, continuous) Location of maximal intensity Transmission / radiation Quality (high-pitched, blowing, vibratory, harsh, soft)

Murmurs: grading of intensity I barely audible II soft, but easily audible III moderately loud without thrill; roughly as loud as S1/S2 IV loud with a thrill V audible with stethoscope barely on chest VI audible with stethoscope off chest

Murmurs: timing

Maneuvers to dynamically evaluate murmurs Inspiration typically increases murmurs originating from the right heart Negative pressure temporarily increases venous return Expiration typically increases murmurs originating from the left heart Less LV restriction due to lower RV volumes Increasing overall venous return (supine, squatting, leg-raise) can accentuate flow-type murmurs Can also delay MVP click due to “tighter” chordae tendinae Standing increases the murmur of hypertrophic cardiomyopathy (HOCM/IHSS) Decreased venous return  smaller LV volume  closer apposition of LV walls

Distinguishing pathologic from innocent murmurs

Innocent murmurs The prevalence of innocent murmurs in infants is as high as 60% Versus: the incidence of congenital heart defect is 6 in 1000 (0.6%) Innocent murmurs are usually… early systolic Grade I or II poorly transmitted Not associated with other findings

Pathologic murmurs (1) Murmurs that are… Loud (Grade III+) Diastolic Abnormal heart sounds (e.g. S3/S4 gallop) Long in duration Systolic and associated with clicks Louder upon standing

Pathologic murmurs (2) Murmurs that are associated with… Abnormal or absent pulses Unequal blood pressures Cyanosis Symptoms (e.g. syncope, chest pain) Abnormal EKG / CXR Syndromes, dysmorphism, other birth defects (e.g. CHARGE syndrome, DiGeorge, trisomy 21)

Common innocent murmurs

Still’s murmur Most common innocent murmur, usually found between the ages of 3 and 6 Thought to be due to turbulence in LV outflow or to vibration of fibrous tissue bands crossing LV lumen Typically grade II-III, midsystolic, LLSB, and classically described as “vibratory” Decreases with standing Increases with fever, exercise, anemia

Pulmonary flow murmur Accounts for 15% of all innocent murmurs Heard in infants and school-aged children Due to turbulent flow at the origin of the right and left pulmonary arteries Grade I-III, midsystolic ejection, heard at the ULSB, higher pitched than a Still’s murmur Like Still’s, increases with fever, exercise, and anemia

Peripheral pulmonary stenosis (PPS) of the newborn Due to the physiologic relative stenosis of the right and left pulmonary arteries Usually disappears by 1 year of age Grade I-II, midsystolic ejection, heard at the ULSB with radiation to the axillae and back

Venous hum Seen in preschool-aged children Due to turbulence in the jugular venous system Continuous supraclavicular murmur heard throughout the cardiac cycle (usually right side > left side) Disappears when the patient is supine, when the head is rotated, or with manual compression of the neck veins

Supraclavicular arterial bruit Due to turbulence in the major brachiocephalic arteries as these vessels arise from the aorta High-pitched, systolic ejection murmur heard best in the right supraclavicular fossa Decreases with raising of the chin, throwing back the shoulders, or firm pressure on the subclavian artery Increases with slight pressure on the subclavian artery

Further cardiac evaluation (as available) Four-extremity blood pressures Pre- and post-ductal pulse oximetry O2 saturation <93% in the lower extremities is abnormal Clinical cyanosis is not seen until saturation <88% EKG CXR Cardiology referral and echocardiogram (definitive test)

Resources ** Online audio of heart sounds and murmurs ** http://depts.washington.edu/~physdx/heart/demo.html Patel J. “Evaluation of Pediatric Murmurs.” San Antonio, TX. http://www.texasnp.org/resources/2006_conference/PediatricMurmurs%5B1%5D.ppt. McConnell ME, Adkins SB, Hannon DW. “Heart murmurs in pediatric patients: when do you refer?” American Family Physician. November 1999. http://www.aafp.org/afp/990800ap/558.html. How to distinguish between innocent and pathologic murmurs in childhood. Pediatric Clinics of North America. 1984 Park MK. Pediatric Cardiology For Practitioners. Bricker T. The Science and Practice of Pediatric Cardiology. Allen H. Moss & Adams: Heart Disease in Infants and Children.