When to Refer to Pediatric Cardiology

When to Refer to Pediatric Cardiology
Priscila Phillips Reid, MS, RN, NP-C, PNP-AC Cardiology Nurse Practitioner Texas Children’s Hospital Faculty, Baylor College of Medicine Text xxx00.#####.ppt 12/5/2018 2:16:00 PM

Objectives Background of congenital heart disease
Common referrals made to pediatric cardiology Understand red flags for common referrals Be able to differentiate pathologic murmurs from innocent, non cardiac chest pain from cardiac chest pain Review common causes for syncope, palpitations Abnormal ECG findings Review common cardiology screening tools Text xxx00.#####.ppt 12/5/2018 2:16:00 PM

Congenital Heart Disease (CHD)
Incidence of 4-5/1,000 live births Defined as gross structural abnormality of the heart or major vessels Excludes congenital arrhythmias and cardiomyopathies xxx00.#####.ppt 12/5/2018 2:16:00 PM

CHD Categories 2 major types Further divided into
Cyanotic defects Acyanotic defects Further divided into Obstructive defects Hypoplasia Septal defects Ventricular septal defect (VSD) – most common, 20-30% CHD is divided into 2 major categories: Cyanotic and acyanotic. They can further be divided into obstructive lesions, hyoplastic lesions (HLHS, hypoplastic right), and septal defects. I have also seen the categories listed as L to R shunts, R to L shunts, complex shunts (TGA, TA, TAPVR, HLHS, DORV), and obstructive lesions (CoA, IAA, AS, PS) xxx00.#####.ppt 12/5/2018

Common referrals to pediatric cardiology
Murmur - Chest pain, shortness of breath Syncope, near syncope - Kawasaki Disease Palpitations, arrhythmias - Genetic syndrome Abnormal ECG -ADHD medication clearance Hypertension -Sports clearance

June 2012-July 2012 Most common referrals to my clinic. Majority being L-R shunts and Chest pain. Abnormal ECGs 23, Arrythmias (palpitations, bradycardia, tachycardia) = 33, Obstructive lesions (AS, PS, CoA) = 14, L-R shunts (PDAs, ASDs, VSDs) = 60 (40 of those were VSDs). Few others: HTN, KD, Williams syndrome, Trisomy 21

Texas Children’s Houston Area PCP Survey
Murmurs Chest pain 61 responders to Houston PCP survey: 2 most common reasons for referral. Other common referrals included syncope, arrhythmias xxx00.#####.ppt 12/5/2018

Survey, Con’t Difficult to manage or resolve Hypertension Syncope
Palpitations/arrhythmias Murmurs in the newborn/infant Cyanotic CHD Exercise restrictions for cardiac patients 62 responders, at least 60% of the responders found the above conditions/situations difficult to manage or resolve At least 67% of the responders were not at all comfortable with treating palpitations or arrhythmias. xxx00.#####.ppt 12/5/2018

Barriers to Care Time delay in appointments (82.5%)
Difficulty with referral process/paperwork for referral (39.7%) Patient Compliance (17.5%) Potential barriers foreseen in diagnosing, treating, or managing cardiac related issues. 63 responders xxx00.#####.ppt 12/5/2018

Heart Murmurs “You have a heart murmur and I’m starting to hear your liver and kidneys complain, too”. xxx00.#####.ppt 12/5/2018

Heart Murmurs, con’t Usually our patients can understand when we say “we want to listen to their heart”. However, there are a few boys that would find this pretty funny! xxx00.#####.ppt 12/5/2018

Murmurs – Pre Test Which of the following is NOT included in the definition of a heart murmur? A sound related to the cardiac cycle that originates in the chest of a child or adult. A hole in the heart. The turbulence sound of blood moving through the normal structures of the heart. The turbulence sound of blood moving through an abnormal structure of the heart. The following questions were adapted from Texas Health Steps May seem like a silly question, but many assume a murmur means there is a hole in the hearts. A murmur is simply turbulence of blood flow. xxx00.#####.ppt 12/5/2018

Murmurs – Pre Test A comprehensive history and physical
Which test is necessary for evaluation of all patients with a heart murmur? A comprehensive history and physical An echocardiogram An ECG A chest X-ray

Murmurs – Pre Test Which of the following is true about grading heart murmurs? Grading heart murmurs is somewhat provider dependent Grade IV/VI is always associated with a palpable thrill Grade IV/VI and above can frequently indicate true pathology All of the above are true All the above xxx00.#####.ppt 12/5/2018

Murmurs – Pre Test Which of the following is a feature of an innocent heart murmur? Increases with change of position The murmur can appear and disappear Radiates to back or neck Continues through adulthood B xxx00.#####.ppt 12/5/2018

Cardiac Murmurs Murmurs occur in 50 percent of children
Only 2 to 7 percent of murmurs in children represent heart disease Pediatric Health-Care Providers are generally accurate in determining whether a murmur is innocent or pathologic 61 percent of murmurs referred to cardiologists were found to be normal or innocent murmurs Murmur – turbulence of blood flow that is sufficient enough to produce a sound Physiologic or pathologic One set of investigators found that physicians were generally accurate in determining whether a murmur was benign or pathologic. Nonetheless, 61% of the murmur referred for cardiology evaluation were found to be functional, or innocent. (AFP) xxx00.#####.ppt 12/5/2018

Cardiac Murmurs, con’t Characteristics
Point of maximal intensity/location Timing Shape Radiation Intensity/loudness Pitch Quality Location – where is the murmur best heard Timing – systolic, diastole, continuous, early, mid, late, long, short Shape – crescendo, decrescendo, ejection, regurgitant Radiation – not transmission, where does the murmur radiate to. Track the inflow and outflow of the heart (direction of blood flow) Intensity – loudnss of the murmur. Grade 1-6. Will review further Pitch – low, medium, high Quality – blowing, harsh, rumbling, musical xxx00.#####.ppt 12/5/2018

Red Flags – Infants Clicks and snaps Short, high pitched sound
Failure to thrive Poor feeding/Inability to feed Diaphoresis with feeding Unexplained respiratory symptoms, tachypnea Cyanosis Grade IV/VI or higher murmur Gallop, click, rub Family history of sudden, unexplained death, cardiomyopathy, early MI You are examining an infant with a murmur. What are the red flags? Refer to cardiology for further evaluation Failure to thrive – those infants who are not gaining weight gain, poor feeding, taking a long time for the baby to finish a bottle. Ask the parent “how long does it take for him/her to complete a bottle”. Infants may take minutes and decrease in time as they get older. If the parent reports it takes “a long time”, get them to give you an estimate. For example if they are telling u 45 minutes, then ask if that is due to taking breaks to burp, distractions, or is it truly fatigue related. Diaphoresis with feeds – feeding is the activity or exercise for newborns and infants. If the parents are verbalizing sweating, clarify if the sweating is all the time or just with feeds. Clicks and snaps Short, high pitched sound Clicks may originate from any valve in the heart Rubs Scratching, high pitched sound Loudest in systolic, but can be heard in diastole Dependent on body position and can change from hour to hour xxx00.#####.ppt 12/5/2018

Red Flags – Older Children
Chest pain (especially with exercise) Syncope Exercise intolerance High grade murmur, thrill Gallop, click, rub Family history of sudden, unexplained death, cardiomyopathy, early MI Older child with a murmur. Red flags xxx00.#####.ppt 12/5/2018

Clinic Scenario: Murmurs
Scenario 1: 6-month-old well-child check. No concerning medical history. Vigorous, pink and well perfused, and has normal vital signs. A heart murmur was noted for the 1st time. Scenario 2: 6-month-old well-child check, non-specific dysmorphic features. Poorly nourished, "always had difficulty feeding.” Tachypneic, O2 sats 98%. A heart murmur was noted for 1st time; remainder of exam was unremarkable. Scenario 3: 6-month-old well-child check. No concerning past medical history. Pink and well perfused, adequate growth. Vital signs are stable. BPs could not be obtained because of agitations. Lower extremity pulses were diminished. A murmur was noted for the 1st time. Adapted from Texas Health Steps Now you have all the tools you need to listen to murmurs. What is your answer? Answer: Scenario 2. Red flag – difficulty feeding, poorly nourished. xxx00.#####.ppt 12/5/2018

Chest Pain We never have CP related to work 
xxx00.#####.ppt 12/5/2018

Chest Pain – Pre Test Which of the following is FALSE regarding chest pain in children and adolescents? It is rarely caused by a heart condition It is frequently secondary to a heart attack or cardiac issue It can be caused by systems other than cardiovascular It can originate from any structure in the chest Answer - B xxx00.#####.ppt 12/5/2018

Chest Pain – Pre Test While taking a patient's history, which of the following is a “RED FLAG" that may require referral to a pediatric cardiologist? History of trauma to the chest that causes musculoskeletal pain Contributory medical problems, such as asthma or reflux History of unexplained sudden death in a family member All of the above Answer - C xxx00.#####.ppt 12/5/2018

Chest Pain – Pre Test Which of the following signals worrisome chest pain? Dizziness Palpitations Syncope All of the above. Answer - D xxx00.#####.ppt 12/5/2018

Chest Pain Etiology is benign in most cases Can be acute or chronic
Causes considerable anxiety for patients and families Causes important functional consequences Very common referral to pediatric cardiology Causes anxiety b/c of the fatal disease in adults. CP is viewed as foreshadowing serious cardiac disease Functional consequences of CP - Restriction of activities, no sports participation, and school absences – consequences Studies have shown CP to be associated with cardiac disease in 1-4% of cases. Very rare. xxx00.#####.ppt 12/5/2018

Chest Pain - Red Flags Occurred at peak exercise, exertion
Lasted until activity stopped Tightness, crushing pain during exercise No relationship to time of day or mealtime Dizziness, nausea, syncope Known family history of sudden death, early MI, HCM

Chest Pain – Non Cardiac Causes
Musculoskeletal conditions 15-31% of cases (most common) Trauma: fracture, bruise, injury Non-traumatic (more common): costochondritis, myalgia, chest wall syndrome, precordial catch Psychogenic causes More common in older children Anxiety, stressful event Respiratory Pneumonia, bronchitis, reactive airway disease, asthma Precordial catch – uncommon and benign. Known as Texidor’s twinge. Consists of brief episodes (seconds to few minutes) of sharp pain that can be localized with the fingertip to one interspace at the LSB or cardiac apex. Sudden onset, typically at rest or during mild activity, and increases with inspiration. Unknown cause ?poor posture. Psychogenic causes: death, illness, accident in the family, separations, school changes. Important to gather from history. xxx00.#####.ppt 12/5/2018

Chest Pain – Non Cardiac Causes
Gastrointestinal GERD Any GI disorder that affect the esophagus (most common), stomach, bowel, biliary tract, and pancreas Occurs after meals, awakens them from sleep, cough Idiopathic without cough, stressful event, previous trauma, meal-related pain, fever, dyspnea Pain is sharp, as occurring, or not, with exercise, and as episodes that are short in duration and occasional. Physical exam is normal and the pain is not reproducible. Non cardiac causes of CP is reproducible and explainable xxx00.#####.ppt 12/5/2018

Chest Pain – Cardiac Causes
Rare, but potentially serious More likely if the chest pain occurs during exertion and is recurrent Most conditions will be associated with an abnormal cardiac examination or coexisting symptoms You can be reassured if the chest pain is: Reproducible through palpation, cough, or movement. Explainable. xxx00.#####.ppt 12/5/2018

Chest Pain – Cardiac Causes
Severe left ventricular outflow tract obstruction (decreased coronary blood flow and angina) Aortic root dissection associated with Marfan’s syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome, chronic systemic hypertension Pericarditis (often idiopathic) Myocarditis Coronary artery abnormalities (congenital and acquired) Tachyarrhythmias (SVT, WPW, VT) if sustained Mitral valve prolapse? Severe LVOTO – AS, obstructive CM, CoA Coronary anomalies: congenital ALCAPA (although usually presents in infancy), acquired: KD Conflicting studies whether MVP causes CP Studies have shown that CP associated with cardiac disease is just 1-4% of cases. xxx00.#####.ppt 12/5/2018

Chest Pain – Description
Costochondritis midsternal, sharp with minimal radiation. Rest and lasts for few seconds to minutes. May increase in intensity with deep respiration (stretching of the muscle fibers) Pericarditis retrosternal, sharp, radiation to the left shoulder. More severe in supine position or with deep inspiration (because of pericardial distention). Ischemic Squeezing, tightness, pressure, constriction, burning, or fullness in chest. Caused by aortic root dissection is extremely severe and described as tearing in quality, and typically radiates to the back. May be helpful in determining cause xxx00.#####.ppt 12/5/2018

Clinic Scenario: Chest Pain
14-year-old SVT Complaining of chest pain, sharp and sudden in onset Occurs at rest Deep breathing intensifies the pain Yesterday, he had a similar pain during exercise Fell to the ground, briefly unconscious. FH: great uncle died of a heart attack at age 80. Exam: heart rate 75 bpm This patient presents to your clinic with the following concerns xxx00.#####.ppt 12/5/2018

Clinic Scenario – Concerning finding
Chest pain occurred at rest and made it difficult to breathe. A great uncle recently died of a heart attack at age 80 The patient had a syncopal episode during exercise The heart rate during the evaluation measured 75 beats per minute Which of the following is the concerning finding in his history? Syncopal episode during exercise. Cause for further pedi cardiology evaluation xxx00.#####.ppt 12/5/2018

Clinic Scenario: Chest Pain
11-year old boy complaining of chest pain during PE. No intercurrent illnesses. No previous episodes. occurred during peak exercise. tightening of his chest with a grabbing/crushing sensation over the left side of the chest. No change with changing position, although he felt a bit better with rest. Nauseated and lightheaded. It did not hurt to breathe. No recent meal. Family history - an uncle who died suddenly and another uncle who had abnormal thickening of his heart. Did you refer to pediatric cardiology? Red flags – CP during activity, during peak exercise. Tightening of the chest. Better with rest. Nauseated and lightheaded. No change with respiration. No recent meal. Significant FH. xxx00.#####.ppt 12/5/2018

Clinic Scenario: Chest Pain (Cardiac or Non Cardiac)
11-year old boy with chest pain during PE at school. History Several years’ history of intermittent chest pain not requiring evaluation (but family now is concerned because the patient will be playing football). First episode occurred yesterday at peak exercise, and patient had to stop to recover. Timing Before exercise when he was stretching/preparing for PE Occurred during peak exercise

Duration - How long did the chest pain last? He had continuous chest pain for hours and sometimes days. In fact, he has chest pain right now. He had episode that lasted until the activity ceased. Quality - Can he describe the chest pain? How did it feel? Short-sharp pains that occur when sitting and at rest. Tightness/crushing pain during exercise. Associated symptoms? Hurts when I take a deep breath I have dizziness and nausea with chest pain.

Relationship, if any, between the pain and eating or time of day. Happened after a big lunch. No relationship to time of day or mealtime. Family history Negative for cardiac disease in first-degree relatives Sudden death, known HCM, early heart attacks

Exam Chest wall deformity, tenderness on palpation vs no tenderness Normal cardiac examination including findings like innocent murmurs vs tachycardia, gallop Tender epigastric, palpation of the stomach reproduces the “chest pain” vs hepatomegaly was appreciated What did you find in your exam? xxx00.#####.ppt 12/5/2018

Syncope

Syncope Most often the etiology is benign
Majority of causes are related to alterations in vasomotor tone Life-threatening cardiac conditions cause syncope as a result of an abrupt decrease in cardiac output, either from an arrhythmia or related to a structural heart disease Remember that syncope was thought of being difficult to treat, manage, work-up. xxx00.#####.ppt 12/5/2018

Syncope – Red Flags With exercise In a driving patient
With emotional trigger Not consistent with vasovagal syncope Abnormal ECG findings Family history of sudden death, unexplained death, cardiomyopathy Recurrent syncope Referral to pediatric cardiology xxx00.#####.ppt 12/5/2018

Syncope – Life Threatening
Primary electrical disturbances Long QT syndrome Brugada syndrome Catechohlaminergic polymorphic ventricular tachycardia (CPVT) Preexcitation syndrome, Wolff-Parkinson-White (WPW) Congenital short QT syndrome (QT <300) Long QT – prolongation of QT interval. Will discuss further Brugada – have a characteristic pattern in ECG and increased risk of sudden death. ECG notes a psuedo-RBBB and persistent ST segment elevation in leads V1 to V3. CPVT – produces syncope or sudden death. Estimated to cause 15% of all unexplained sudden cardiac deaths in young people. Symptoms are most prevalent when the body is exposed to intense emotional or physical stress. Colleague of mine had a young teenage boy who was in detention and would become angry and pass out, collapse. His evaluation noted CPVT. DX: gene testing, reproducing VT during exercise stress testing, syncope with acute emotion, physical activity, history of symptoms xxx00.#####.ppt 12/5/2018

Syncope – Life Threatening
Structural abnormalities Hypertrophic cardiomyopathy Coronary artery anomalies Arrhythmogenic right ventricular cardiomyopathy (ARVC) Valvar aortic stenosis Dilated cardiomyopathy Pulmonary hypertension Acute myocarditis HCM – incidence of 1 in 500. Patients experience exertional syncope. Most common cause of sudden death during exercise. LVOTO lead to inadequate CO, ischemia, and arrhythmia CA anomalies – an abnormally located CA (ex: between the aorta and pulmonary artery) may become compressed during exercise, resulting in ischemia, syncope, or sudden death. ARVC – arrhythmias of the RV; the condition causes part of the myocardium to break down over time, increasing the risk of an arrhythmia. Presentations between the ages of 10 and 50. Valvar aortic stenosis – majority of children with AS are asymptomatic; sudden death can occur. Majority of deaths were in children over the age of 10 and had significant obstruction and/or AI. DCM – usually develop syncope as the result of an arrhythmia. PHTN – children with PHTN with a systemic to pulmonary shunt may experience syncope. Most initially develop exertional dyspnea. Syncope is an indication RV failure. Acute myocarditis – syncope as a result of ventricular dysfunction or an arrhythmia. xxx00.#####.ppt 12/5/2018

Syncope: Long QT Syndrome
Suggested Bazett-Corrected QTc Values for Diagnosing QT Prolongation Rating 1-15yrs Adult Male Adult Female Normal <440 <430 <450 Borderline Prolonged >460 >450 >470 JACC 2008 vol 51 (24) 2293 Obtain ECG's of 1st degree relatives Thorough family history for patterns of syncope, sudden cardiac death, congenital deafness R/o acquired factors that can cause long QTc including: MI, cardiomyopathies, hypokalemia, hypocalcemia, hypomagnesemia, autonomic influences, drug effects, and hypothermia Measurement of QT interval by the square root of the preceding R-R interval in which the QT is being measured. Always must be calculated DO NOT RELY ON EKG COMPUTER VALUE Measure in lead II (V5 if unable to use lead II) Varies with heart rate, so must be corrected xxx00.#####.ppt 12/5/2018

Syncope: Common Conditions
Vasovagal syncope Breath holding spells Orthostatic hypotension Toxic exposure Hypoglycemia Non threatening arrhythmias (SVT, bradycardia) Vasovagal syncope – (neurocardiogenic, situational, and fainting), most common cause. Precipitating events include standing or stress, reflex (swallowing, hair grooming have been reported). Patients describe a prodrome, lightheadedness, dizziness, visual changes (decreased acuity, tunnel vision, double vision), nausea, pallor, diaphoresis. Underlying mechanism is an exaggeration of reflex-mediated alterations in vasomotor tone and heart rate normally responsible for maintaining blood pressure. Breath holding – occur in children 6 months to 2 years of age. Triggered by an emotional insult, such as pain, fear, anger. May be cyanotic or pallid. Begins with breath holding, followed by cyanosis, and then loss of consciousness. Clinical course is benign and spells usually resolve by 5 years of age. Orthostatic hypotension – syncope that occurs with postion changes – likely related to an abrupt drop in BP. Results from volume depletion, pregnancy, anemia, and medications Toxic exposure – Intoxication may present as syncope. Caution some agents (cocaine, tricyclic antidepressants) may also cause life threatening syncope. xxx00.#####.ppt 12/5/2018

Syncope: Common Conditions
Mimic syncope Seizures Migraine syndromes Hysteria/conversion disorder Hyperventilation Choking game (strangulation activity) Conditions that mimic syncope xxx00.#####.ppt 12/5/2018

Clinic Scenario: Syncope
16 year old athletic female Syncope x 1 after playing in a volleyball game. Started feeling dizzy and legs felt wobbly. Saw spots and had tunnel vision prior to passing out. Reports weekly episodes of dizziness, ringing in her ears, and seeing spots when working out. No chest pain or shortness of breath. Negative family history. Drinks 2 water bottles per day and denies caffeine or alcohol. Likely cardiac or non cardiac? Likely vasovagal syncope related to dehydration. Classic for teenage females especially to present with near syncope and have a history of poor hydration. Push ounces of water and/or sports beverages. Have them eat a salty snack. Re-evaluate symptoms in a 2-4 weeks. xxx00.#####.ppt 12/5/2018

Palpitations Etiologies include physiologic stimuli, such as fever, exercise, anxiety, or anemia Rarely life threatening causes (such as cardiac arrhythmias) Those with serious arrhythmias may never report palpitations Palpitations describes the heartbeat that is usually concerning to the patient. xxx00.#####.ppt 12/5/2018

Palpitations: Life threatening
Arrhythmias Tachyarrhythmia or bradyarrhythmia Myocarditis Hypertrophic cardiomyopathy Hypoglycemia Poisoning Pheochromocytoma Arrhythmias – very uncommon cause of palpitations in children with structurally normal hearts; however, frequently seen in children with surgically corrected structural heart disease. Can have tachy or bradyarrhythmias. SVT is the most common non-sinus tachyarrhythmia of childhood and often presents with palpitations in verbal children. Infants with SVT are usually asympomtatic. Myocarditis – usually viral (Coxsacki virus B and other enteroviruses). Clinical findings of tachycardia out of proportion to fever, poor perfusion, and signs of heart failure. May develop arrhythmias. HCM – May present with palpitations or syncope during strenuous exercise caused by atrial fibrillation or ventricular arrhythmia. Remember those with syncope are at a higher risk for CSD. Hypoglycemia – tachycardia with palpitations, diaphoresis, weakness, tremor, feelings of nervousness and/or hunger. Poisoning – have the potential to cause life threatening tachy and bradyarrhythmias. Depends on the agent. Pheochromocytoma – rare neoplasms in children. Tumors that arise from the adrenal medulla. xxx00.#####.ppt 12/5/2018

Palpitations: Common Causes
Increased metabolic rate Catecholamine release Hyperventilation Drug-induced Postural orthostatic tachycardia syndrome (POTs) Premature atrial contractions Premature ventricular contractions Other causes: hyperthyroidism, acute rheumatic fever, mitral valve prolapse Increased metabolic rate – fever, anemia Catecholamine release – catecholamine release assoc with exercise, emotional arousal, and psychiatric distress (anxiety, panic attack). Hyperventilation – often described as having a “racing” heart. Assoc symptoms include dyspnea, chest tightness, chest pain, paresthesias. Appear anxious. Drug induced – opposed to toxic exposures involve medications and substances with sympathomimetic or anticholinergic properties that increase heart rate with routine dosing. Albuterol, caffeine, tobacco, cough and cold medications, dietary supplements, herbal medications, energy drinks, recreational drugs POTS – form of orthostatic intolerance characterized by an excessive increase in HR (>30 bpm over baseline) that occurs without arterial hypotension. Common in teenage girls (palpitations, anxiety, dizziness) PACs – most common arrhythmia. Report their heart “stopping” or “flip-flopping”. PACs are benign. PVCs – Can also be considered benign (once structural heart disease and ventricular dysfunction are excluded). xxx00.#####.ppt 12/5/2018

Abnormal Electrocardiograms
Sinus arrhythmia Bradycardia, tachycardia Right and/or left ventricular hypertrophy Biventricular hypertrophy Nonspecific ST segment abnormality T wave inversion 1st degree AV block Sinus arrhythmia – normal physiologic variant that is characterized by an increased heart rate during inspiration and a decreased heart rate during expiration. Benign. Brady – Usually asymptomatic. When evaluating for ventricular hypertrophy on ECG, you must remember developmental changes as well as clinical parameters. For example, a 2 day old NB with TOF who has RVH on ECG, is considered a normal finding. LVH – There are several criteria used for defining LVH on ECG. More often than not, the ECG interprets LVH and when further evaluated by echocardiogram, this is not demonstrated. Also, AA tend to have higher voltages, which will likely meet criteria for LVH although it is highly unlikely. The only definitive test to rule out RVH and/or LVH is an echocardiogram. 1st degree AV Block - Prolongation of PR interval on ECG (>0.2secs; but age dependent). Conduction delay predominantly within the AV node proper. Usually a benign finding (0.5-1% of population). If asymptomatic and H&P inconsequential, no further evaluation necessary xxx00.#####.ppt 12/5/2018

Sinus Arrhythmia Most common reason for auscultation of “irregular heartbeats” in outpatient setting An irregularity in sinus rate that occurs during breathing Accentuated in children Normal physiologic response (speeds up with inhalation and slows down with exhalation) xxx00.#####.ppt 12/5/2018

Sinus Arrhythmia

What is this? 2 month old boy who presented to Pediatrician’s office for poor feeding and “being tired”. HR = 260bpm. Parents state nobody examined his heart (no vitals, no exam) sent home with instructions to “watch him”. Returned the next day for continued concerns and some lethargy. xxx00.#####.ppt 12/5/2018

Supraventricular Tachycardia
Rapid heart rhythm originating from above the ventricles. Conventionally excludes atrial flutter / fibrillation, or ectopic atrial tachycardia. Usually narrow complex. Rates typically 220–280bpm in infants bpm in older children and adolescents Most common symptomatic arrhythmia in children. Prevalence: 1 in 500 children xxx00.#####.ppt 12/5/2018

Straighten themselves out ….
All Arrhythmias Straighten themselves out …. The main concept about arrhythmias…. They all straighten themselves out…in the end! Doesn’t that give you comfort? in The End xxx00.#####.ppt 12/5/2018

Cardiology Studies Electrophysiology studies
Electrocardiogram (ECG), 12 lead Holter monitor Event monitor Imaging Echocardiogram CT, CT angiography MRI Cardiac catheterization Cardiac stress testing ECG – defines the electrical activity of the heart Holter – continuous ECG recording for 24 hours. Used for suspected frequent rhythm abnormalities. Event monitor – records shorts ECG rhythm patterns when initiated by the user. Looping and non looping. Transmissions are sent via land line to a monitoring service. Used when symptoms are infrequent Echo – most commonly used tool in diagnosing heart disease. Andrew Bensky and colleagues surveyed PCPs to understand their reasons for using echos to screen for CHD and to assess their understanding of the costs associated with the service. 876 participated and 494 (57%) responded and 466 were used for analysis. The results noted the majority of pediatricians and family physicians did not know the relative costs assoc with cardiology consultation and echocardiography. They believed the cardiologist would routinely obtain an echo as part of their evaluation of a child with a murmur. Other reasons for obtaining the echo included the time for a subspecialty appointment was lengthy, family pressure for a quick diagnosis, and lack of understanding. Family physicians were more likely to order an echo compared to pediatricians. xxx00.#####.ppt 12/5/2018

Cardiology studies Infants
ECG, 4 extremity blood pressure, pulse oximetry, weight, height, +/- CXR Toddlers Children-young adults ECG, blood pressure, weight, height Studies ordered by providers vary xxx00.#####.ppt 12/5/2018

Early ECG Einthoven’s early ECG machine – William Einthoven was a Dutch MD and physiologist. Invented the first ECG in Rec’d the Nobel Prize in medicine in 1924. xxx00.#####.ppt 12/5/2018

Early ECG Einthoven’s early ECG machine xxx00.#####.ppt 12/5/2018

Everything looks like the heart

What cardiology needs to know
Are there any RED FLAGS (newborns, infants, older children)? Failure to thrive Unexplained respiratory symptoms Cyanosis Poor feeding/Inability to feed/Diaphoresis with feeds Is there any family history of congenital heart disease, sudden, unexplained death, cardiomyopathy, early MI? Were there any cardiac issues during pregnancy? Infants xxx00.#####.ppt 12/5/2018

What cardiology needs to know
Vital signs height/weight percentile O2 saturation Overall appearance of patient distressed, tachypneic, wasted, cyanotic Lower extremity pulses

When do you refer? Murmurs that are pathologic Red flags
Syncope with exertion Chest pain with exertion Palpitations causing symptoms Review of when to refer… xxx00.#####.ppt 12/5/2018

When do you refer? Sudden onset of tachycardia that seems out of portion to situation Abnormal ECG, CXR, and/or echocardiogram Family history (sudden death, unexplained death, cardiomyopathy, early MI, significant arrhythmias) Known genetic disorder Most importantly, refer when you do not feel comfortable!

Thank you!

The Reid Family

References Bensky, A. S, Covitz, W., & DuRant, R. H. (1999). Primary care physicians’ use of echocardiography. Pediatrics, 103 (4). Geggel, R. L., & Endom, E. E. (2011). Approach to chest pain in children. UpToDate. Hoffman, J. E., & Kaplan, S. (2002). The incidence of congenital heart disease. Journal of the American College of Cardiology, 39 (12), Lewis, D. A., & Dhala A. (1999), Syncope in children and adolescents. The cardiologist perspective. Pediatric Clinics of North America, 46 (2), 205. Mazor R., & Mazor, S. (2011). Approach to the child with palpitations. UpToDate.

References, Con’t McConnell, M. E., Adkins, S. B., & Hannon, D. W. (1999). Heart murmurs in pediatric patients: When do you refer? American Family Physician, 60 (2), Pelliccia, A., Maron, M. S., & Maron B. J. (2012). Assessment of left ventricular hypertrophy in a trained athlete: Differential diagnosis of physiologic athlete’s heart from pathologic hypertrophy. Progress in Cardiovascular Diseases, 54, Printz, B. F. (2012). Noninvasive imaging modalities and sudden cardiac arrest in the young: Can they help distinguish subjects with a potentially life-threatening abnormality from normals? Pediatric Cardiology, 33, Rudolph AM. Congenital Diseases of the Heart: Clinical-Physiological Considerations. Second Edition. Futura Publishing Company, Inc. Copyright 2001. Texas Department of State Health Services, Texas Health Steps, 2012

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