1. Essential Paediatric Cardiology for Primary Care
Dr J Cyriac
Consultant Paediatrician
Special Interests: Cardiology, Nephrology
Mid Essex Hospitals NHS Trust
Chelmsford
Ramsay Springfield Hospital
03/05/2017
GPSTP

2. Vast Topic Cyanotic heart disease Acquired heart disease
Tachyarrhythmia
Acyanotic heart disease
Asked to present cardiovascular disease
Vast
Present a textbook in 1 hour with 10 minutes of discussion
Familial Late onset heart disease
Brady arrhythmia
03/05/2017
GPSTP

3. Classification Cardiac Problems Children Structural →Functional
Congenital
Acquired
Pure Functional
Electrical →Functional
Another way is to divide into structural, functional and electrical
Purely functional: Dilated cardiomyopathy
Again classify into congenital and acquired
27/10/2012
GP Update

4. Risk Factor and Genotype Heart Disease
“You have the potential for heart disease, but currently you are okay !”
Risk Factor and Genotype Heart Disease

5. Scope of this presentation
General Overview
Based on type, severity and age of presentation
GP perspective :Common referrals
Red flag signs
My approach to cardiac diseases
Illustrations of common CHD
03/05/2017
GPSTP

6. Presentations Cong Structural Heart Disease
Antenatal Scanning
Newborn check
Six week check
Cardiorespiratory collapse
Cyanosis
Congestive cardiac Failure
Associated Symptoms
Incidental murmur

7. Structural Acquired Heart Disease
Hypertrophic Cardiomyopathy: Intrinsic and extrinsic
Dilated Cardiomyopathy: Intrinsic and extrinsic
Infective heart disease
Immune mediated heart disease
Consequential Heart Disease: chemotherapy, injury, radiation, metabolic etc.

8. My classification of CHD based on severity
Critical: Sudden death, Collapse, Shock
Emergency Intervention: Prostaglandin, Catheter, cardiac operation
Major: Significant symptoms: Device intervention or operation
Moderate: Some symptoms: Medical or device intervention
Mild: minimal consequence
From a clinical response point of view I divide CHD into critical, major etc
27/10/2012
GP Update

9. Presentations based on age groups
Talk about presentations of CHD based on age groups
27/10/2012
GP Update

10. Pre-Antenatal Scan Era ----------------------------------- Post Antenatal Scan Era
I divide the last 20 years into pre-ante and post antenatal
Evolving technique
Doing since early 1990s
Driver dependent and pick up rate is extremely variable.
Pick up rate of CHD is between 25% to <85%
27/10/2012
GP Update

11. Heart Disease in Infancy
Critical and Serious
1-4 months
Serious and Significant
4-8months
Significant and Important
8-12months

12. Timing of Presentation
Remember I mentioned about the classification of CHD based on severity
Red column signifies the critical CHD.
Quite a few are detected in the antenatal scans and appropriate management plans are made before delivery
Some are delivered in tertiary centre
Significant number of these are not picked in the antenatal scan and present in the neonatal period either in the post natal ward or after discharge.
I will take about this later.
As you can most of the critical, major CHD present in the first year of life.
Once present later always minor ones
These include small VSD, PS, ASD etc Unlikely to cause any problems but anything with heart gives a lots of anxiety
Occasional major ones present after infancy and early childhood. These are mostly Coarctation of aorta. Please check femoral
03/05/2017
GPSTP

13. Types of Presentation Antenatal Diagnosis Postnatal Ward
Cyanotic episodes
Incidental murmur
Absent Femoral pulse
Collapse/Shock/Sudden Death( Critical Heart Lesion)
Incidental detection of tachycardia (SVT)
Incidental Detection of Bradycardia (Complete Heart Block)
Breathlessness, Poor feeding etc. (CCF)
As I told depending your antenatal sonographers roughly less than half of CHD are diagnosed antenatally. Referred to foetal cardiologists and detailed plan is made before delivery
Most critical ones are even delivered in tertiary centre.
Other presentations as above cyanosis,
Symptoms are signs of CCF etc
Only time I am going to mention Bradycardia
03/05/2017
GPSTP

14. Types of Presentation Neonatal period following discharge 8 week check
Cyanotic episodes
Poor feeding, weight faltering, breathlessness (CCF)
Collapse/ Sudden Death (Critical heart lesion)
Funny Turn (SVT)
8 week check
Weight Faltering, Poor feeding, breathlessness (CCF)
Incidental Murmur
Cyanotic Episodes
Absent or feeble femoral pulses
Funny Turn
Referred by parents or HV going blue
Symptoms and signs of CCF
Ireland: six week check picked up child with Coarctation of aorta
27/10/2012
GP Update

15. Presentation in Infancy
Weight faltering, Poor Feeding, Breathlessness (CCF)
Recurrent respiratory infections
Delayed recovery with chest infection
Incidental detection of murmur
Funny Turn (SVT)
Incidental detection of absent femoral pulse
Cyanotic episodes (infrequent)
Funny turn: goes pale, bit listless etc parents say feel the heart thumping away.
27/10/2012
GP Update

16. Presentation in Toddler and Preschool period
Recurrent chest infections
Delayed recovery from chest infection
Incidental detection of murmur
Blue episodes
Funny turn/Palpitation (SVT)
Breathlessness on exertion
These are time normal children start to get respiratory infections
When maternal antibody wears off and going to nursery etc.
One need to watch out for underlying CHD like undiagnosed ASD, PDA etc
I did not mention VSD as the murmur is fairly loud and is unlikely to miss.
Talk about breathless on exertion later
Starts to become aware of their own heart beat so they might heart thumping away etc
27/10/2012
GP Update

17. Presentation in school age children
Breathlessness on exertion
Incidental detection of murmur
Palpitations
Chest Pain
Blue Episodes
Most of the breathlessness on exertion is respiratory.
Older child with a new onset of breathing problems without any evidence of respiratory infections need to think about dilated cardiomyopathy
Talk about chest pain in the next slide
27/10/2012
GP Update

18. Presentation in Teenagers
Syncope
Chest Pain
Exertional Breathlessness
Palpitations
Sudden Collapse/Death
We talked about breathlessness and palpitation
Sudden collapse/death: rare but happens: Ventricular arrhythmia: VF or pulseless VT related QT problems, Myocarditis or undiagnosed HOCM
Lots of discussion about screening everybody to pick these genetic mutations.
There is clinic in Brompton called sudden death clinic
27/10/2012
GP Update

19. Essential Clinical Evaluation
Signs of respiratory distress
Oxygen saturation lower limb
Peripheral pulses
Precordial activity
Murmur
Heart Sounds
Liver size

20. Questions?
27/10/2012
GP Update

21. Conclusion and take home messages
Antenatal diagnosis is not foolproof
Critical CHD presents in the first few weeks of life
Don’t diagnose innocent heart murmurs in infancy!
In infancy significant heart disease can be present even without significant murmurs
27/10/2012
GP Update

22. Conclusion and take home messages
In each patient at least once feel femoral pulse
Invest in a paediatric probe for oxygen saturation monitor
Watch out for exertional chest pain and exertional syncope
Family history of sudden death (especially if <30 years of age), prolonged QT syndrome or HOCM.
27/10/2012
GP Update