William F' Waltz, Ph'D', M'D'

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Pediatric Cardiology Problems Facing the Primary
Care Provider
Nurse Practitioner Association of South Dakota
Fall Conference 5 November 2009

• William F. Waltz, Ph.D., M.D.

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Objectives

• Discuss recognizing cardiac disease in the
  primary care setting
• Describe cardiac evaluation by the primary care
  provider
• Explain when to refer to Pediatric Cardiology

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Common Cardiac Problems

• Chest pain
• Syncope
• Hypertension
• Murmur
• Family history

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The Plan

• Discuss common pediatric cardiology referrals for
  non-cardiac problems
• Compare non-cardiac complaints with serious
  cardiac issues

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• Chest pain
• Syncope

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Case -Chest Pain

• A 13 year old boy complains of sharp chest pain
  at the mid left sternal border that came on
  during cross country running.
• Stopped running because of the pain. He was short
  of breath, had tingling hands and feet.
• Pain was worse with a deep breath.
• Physical Exam- BP 110/60 P 90 R 16- Pulses
  strong and equal- 2/6 ejection murmur at LUSB-
  Discrete tenderness at site of pain

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Chest Pain

• Common reason for referral
• Do not equate adult CP with childhood CP
• If benign reassure, dont refer
• If suspect cardiac-dont echo-please refer

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Chest Pain Breakdown

• Idiopathic 12-85
• Chest wall/musculoskeletal 15-95
• Psychogenic 20-29
• Respiratory 12-21
• Gastrointestinal 4-7
• Cardiac 1-6
• Organic and functional causes can coexist
• Non-cardiac chest pain typically occurs at
  rest-can be worse with movement/exercise, deep
  inspiration, palpation

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Chest Pain Breakdown

• Chest wall pain-precordial catch
  syndrome sharp pain at rest worse with deep
  breath localized over precordium lasts
  seconds to minutes-costochondritis-pleuritis-tr
  auma
• Other non-cardiac SS crisis, Asthma, Zoster,
  Pneumonia, GI reflux, Pneumothorax

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Chest Wall Pain

• Common in teen athletes
• Frequently seen in association with handsprings,
  shooting baskets, volleyball, weight lifting,
  martial arts
• Often comes on as new activity starts
• Frequently worse with deep breathing
• Discrete tenderness over site (sometimes)
• Acute at first, can last for weeks, migrate

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Therapy for Chest Wall Pain

• Reassurance
• NSAIDs scheduled dose for two weeks
• Avoid offending activity
• Referral for reassurance?

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Counseling About Chest Wall Pain

• Time well spent in evaluation
• Discuss mechanism for pain
• Pain is real, but not a threat
• Pain not due to heart!

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Chest Pain Of Concern

• cardiac cause in 1-6
• patients c/o having a heart attack (44), heart
  disease (12), cancer (12).
• adolescents more likely to have psychogenic chest
  pain with stress
• younger children more likely to have true
  cardiorespiratory cause

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Chest Pain Of Concern

• Myocarditis/Cardiomyopathy-associated with
  GI/Respiratory symptoms-associated with fever,
  or recent history of fever-appear ill,
  tachycardia, weak
• Chest pain with exercise should be evaluated
  before activity continues
• React quickly if patient has known or suspected
  Marfans and tearing chest pain or back pain

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Chest Pain Of Concern

• Pericarditis lean forward for comfort, friction
  rub, distended neck veins, hepatomegaly, pulsus
  paradoxus, low voltage EKG, diffuse ST changes
• Arrhythmias-May be felt as or described as chest
  pain
• -eg. SVT sudden on/off, gt200/min at
  rest pallor, hypotension, syncope narrow
  complex tachycardia on EKG
• -eg. VT chest pain and syncope 120-240/min

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Chest Pain Of Concern

• Respiratory-asthma-pneumonia/effusion-spontaneo
  us pneumothorax
• Cancer-primary-metastasis/infiltration
• Trauma

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Taking a Chest Pain Historydescribing the pain

• frequency
• duration seconds, minutes, hours
• location sternum, apex, subxiphoid, right, left,
  diffuse, point with one finger, epigastric
• quality burning, stabbing, sharp, dull,
  crushing, tearing
• clustering
• setting

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Taking a Chest Pain Historydescribing the pain

• time of day
• relation to meals
• precipitating factors
• exacerbating factors
• relieving factors
• association with rest, body position, deep
  inspiration
• recent trauma

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Taking a Chest Pain Historyassociated symptoms

• Palpitations fast, slow, irregular, skips, hard
• headaches
• shortness of breath/dyspnea-wheeze/ cough
  -prolonged expiration-cant get air
  out-response to bronchodilators
• paresthesias

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Taking a Chest Pain Historyassociated symptoms

• syncope
• near syncope
• dizziness
• sensation of impending doom
• Anginal chest pain cardiac ischemia in a child
  produces pain similar to that in adults
• History of Kawasaki with abnormal coronaries

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Taking a Chest Pain History

• Family history
• Social History/Social Dynamic

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Physical Exam For Chest Pain

• Full Examination
• FOCUSED ON
• Vital signs
• murmurs, rubs, clicks, rhythm, abnormal pulses,
  abnormal heart sounds
• Lung exam
• Palpation of chest, gentle sternum compression
• Reproducing the chest pain by compression or
  palpation is very reassuring

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Testing/Labs For Chest Pain

• Laboratory studies non-contributory
• EKG if indicated normal is reassuringalmost all
  HCM have abnormal EKG (LVH)almost all coronary
  anomalies have abnormal EKG (LVH, ST changes,
  precordial T wave changes)
• Chest radiograph if indicated-cardiomegaly,
  abnormal aortic root
• Consider referral
• Echocardiogram
• Holter Monitor
• Event monitor
• Exercise test if symptoms with exercise

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SYNCOPE
True or False
All syncope is cardiac until proven otherwise
False
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Case -Syncope

• A 13 year old girl passed out in the shower the
  morning after a basketball game
• Felt dizzy, vision went black
• Woke up on shower floor
• She says she drinks enough fluid
• Physical Exam- sitting BP 115/70 P 60 R 16-
  standing BP 95/65 P 90 R 16- Pulses strong
  and equal- 2/6 ejection murmur at LUSB- lean,
  healthy looking

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SYNCOPE

• Definition temporary loss of consciousness due
  to lack of cerebral perfusion
• Most frequent cause is vasovagalvasodepressor
  neurocardiogenic

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VASODEPRESSOR SYNCOPE

• Bezold-Jarisch reflex

vigorous contractions
mechanoreceptors C fibers
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SYNCOPE

• The possibility of serious injury during a faint
  precludes considering recurrent syncopal episodes
  of any cause as benign.
• (Gutgesell, AFP, 1997)

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Causes of Syncope

• Abnormalities of blood pressure control
  (common)
• Cardiac abnormalities (uncommon)
• Metabolic abnormalities (rare)
• Seizure disorders (rare with just syncope)
• Psychiatric conditions (rare)
• Drugs (rare)

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Typical Vasovagal SyncopeThe Setup

• Usually teenagers (13 years /- 3)
• 2.3 female 1 male (Balaji, ACC, 1994)-may be
  associated with menstrual cycle
• Usually some precipitating factor-dehydration/und
  erhydration illness, heat (shower)-poor
  physical condition-more common in morning
• -fasting
• -prolonged standing/position change to more
  upright-can occur standing or sitting-fright/ang
  er/stress/sight of blood/smells/injury-cough,
  voiding, hair grooming

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Typical Vasovagal SyncopeThe Event

• Disorientation/feeling of warmth/dizziness
• Nausea
• Visual changes field narrowing, blurring, spots,
  dark
• Loss of hearing/rushing noise
• Weakness
• Pallor/clammy skin/sweating
• Going to ground
• May be followed by tonic-clonic movement
• No incontinence
• Resolves within a minute
• Wake up may be groggy, not post-ictal
• May feel tired for hours

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Typical Vasovagal Syncope

• If the history is typical for simple vasovagal
  syncope, a careful physical examination is
  generally the only evaluation required.(Gutgesel
  l, AFP, 1997)
• Recurrence rate 7 at one year, 15 at two years
  (Ruiz, Am Heart J, 1995)

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Treatment of Vasovagal Syncope

• Reassurance
• Hydration 90 effective (Younoszai, Arch Ped
  Adol Med, 1998)-Eight 8 ounces glasses/day /-
  two gallons-Urine should look like water-Never
  thirsty
• Salt
• Avoid caffeine
• Activity restrictions?
• G-maneuvers
• Medications fludrocortisone, SSRI,
  beta-blockers, alpha agonists (pseudoephedrine)
• Pacing?

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Evaluation of Syncope

• Complete history
• Complete physical examination
• Careful attention to heart rhythm
• Orthostatic blood pressures?
• EKG

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When is syncope concerning?

• Palpitations/heart rate irregularities
• Syncope with no prodrome
• Frequent syncope
• Exercise-induced syncope
• Family history of recurrent syncope
• Family history of sudden death
• Outflow tract obstruction HCM
• Myocardial dysfunction myocarditis, dilated
  cardiomyopathy, ARVD
• Coronary ischemia
• Cardiac arrhythmias

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Other Causes of Syncope

• Breath Holding Spell
• Respiratory Syncope
• Hyperventilation Syndrome
• Neurologic/Seizures/Migraines
• Emotional/Psychiatric

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Hypertension
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Definition of Pediatric Hypertension

• blood pressure gt95 on three separate occasions

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Its Out There

• Based upon the Framingham study, pediatric
  patients with hypertension are at risk for
  catastrophic events later in life
• 10,641 Dallas children 1.6 HTN on 3 screens
• 6,622 Muscatine children1 HTN on 4 screens
• 3,537 Harlem children 1 HTN
• Overall Prevelance 0.5-2 children have
  significant HTN

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Its Out There

• Primary HTN -most common cause-usually no
  symptoms
• Secondary HTN 74 renal/renal-vascular
  19 coarctation 7 others
  endocrine-many are in medical care for other
  issues-BP usually more elevated than in primary
  HTN

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Blood Pressure Control
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Influences on Blood PressureChildhood Risk
Factors for Later-Life Hypertension

• HTN as child
• Heredity
• Obesity
• Race
• Dietary cations
• Exercise, stress, anxiety
• Smoking
• Alcohol and drugs
• Pregnancy-induced HTN
• Diabetes
• Uric acid
• LV mass

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Influences on Blood PressureChildhood Risk
Factors for Later-Life Hypertension

• Obesity prevalence of all forms of HTN in adults
  correlated with tip quintile for fatness 15 years
  earlier
• Race Prevalance of HTN in black adults (27)
  is twice that of white adults-Kids not as
  clear
• Dietary sodium trend to higher
  BP potassium trend to lower BP calcium
  trend to lower BP
• Exercise, stress, anxiety -regular exercise
  decreases blood pressure-stress/anxiety raise
  blood pressure-difficult arithmetic, reaction
  time tasks, video games

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Influences on Blood PressureChildhood Risk
Factors for Later-Life Hypertension

• Smoking duh
• Alcohol and Medsalcohol heavy (gt3 drinks/day)
  intake increases BP light (1-2
  drinks/day) might be beneficial not
  recommended for kidsseveral medications can
  increase BP sympathomimetics, anticonvulsants,
  OCP, cyclosporine, steroidscaffeine, illicit
  drugs
• Pregnancy-induced HTN predictor of later HTN in
  the pregnant one and her baby

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Influences on Blood PressureChildhood Risk
Factors for Later-Life Hypertension

• DiabetesHTN in pediatric diabetes unusual, but
  happens ie. coexisting conditionsstrong
  predictor for adult HTN
• Uric Acid elevated levels correlate with
  increased risk of HTN in kids and adults -marker
  for HTN, not a cause -correlates with plasma
  renin activity
• Increased left ventricular mass end organ damage

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Cardiac Hypertension

• Coarctation of the aorta

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Coarctation of the Aorta
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Coarctation of the Aorta
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Balloon Angioplasty for Coarctation
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Stenting for Coarctation
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Coarctation - Surgery
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Coarctation
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HTN in Coarctation

• Kidneys downstream from obstruction-increased
  renin-angiotensin-aldosterone activity
• Baroreceptors upstream from coarctation-reset to
  higher pressures
• Intrinsic abnormality of aortic tissue
• lifelong issues

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Picking up a Coarctation

• EXAM!
• elevated blood pressure
• decreased femoral pulses
• upper to lower extremity BP gradient
• non-innocent murmur

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Renal Disorders Causing HypertensionRenal
Parenchyma Renovascular

• Acute glomerulonephrtitis renal artery
  thrombosis pyelonephritis sickle cell
  crisisHUS vasculitisrenal traumaureteral
  obstruction
• Chronicglomerulonephrtitis fibromuscular
  dysplasia pyelonephritis renal artery aneurysm
  HUS arteriovenous fistula reflux
  nephropathy vasculitisobstructive
  uropathypolycystic diseasesrenal
  dysplasiarenal tumors

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Vital Signs Measuring Blood Pressure

• Patient sitting or supine-be consistent
• Right arm
• Arm flexed
• Relaxed (if possible)
• Right arm right leg pressures can help

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Vital Signs Measuring Blood Pressure

• Method 1 Dynamap random number generator
• Method 2 Sphygmomanometer Inflate cuff to
  30mmHg above expected BP Deflate 3mmHg/sec
• Method 3 Sphygmomanometer Inflate cuff until
  radial pulse disappears Deflate 3mmHg/sec
• Method 4 Direct catheter measurement

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Vital Signs Measuring Blood Pressure
Best Method

• Method 3 Sphygmomanometer
• Inflate cuff until radial pulse disappears
• Deflate 3mmHg/sec

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Vital SignsKorotkoff Sounds
Korotkoff sounds sounds produced by blood
flowing past deflating cuff
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Blood Pressure Assessment

• Measure blood pressure-if abnormal, -history
  and exam-repeat on another occasion
• Repeat blood pressure-if still high
  (90-95) -talk about lifestyle issues
  -repeat in six months-if still high (gt95),
  work it up

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Detecting HTN in Children

• Measure BP upon admission to the nursery
• Measure BP at every well child check and annual
  physical
• Measure BP at other visits, if possible
• Also, do a good cardiac exam at each check and
  physical
• Also, do a good cardiac exam when guided by
  symptoms
• Pursue evaluation when indicated

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Treatment of HTN in Children

• PREVENTION
• Make accurate measurements
• Make accurate diagnosis
• Treat underlying condition, if possible
• Weight control
• Low fat-high fiber diet
• Sodium restriction
• Exercise
• Relaxation
• Avoid alcohol, medications, drugs, caffeine
• No tobacco

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Meds for HTN in Children

• Goal is normal pressures
• Individualized approach, not stepped-care
• Start with single drug therapy-ACE
  inhibitors-beta blockers-calcium channel
  blockers-diureticslowest effective dose
• Add additional med if needed
• Management is usually long-term

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Summary

• Pediatric hypertension is uncommon but real
• Pediatric hypertension must be diagnosed and
  fully evaluated
• Pediatric hypertension must be treated for short
  and long term gain
• Refer to nephrology, cardiology, endocrinology as
  indicated

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• Murmurs

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AuscultationMurmurs

• Intensity (grade)
• Pitch
• Timing
• Location
• Radiation
• Quality

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AuscultationMurmurs- Intensity

• Grade 1 faint
• Grade 2 soft
• Grade 3 loud
• Grade 4 loud with thrill
• Grade 5 heard with edge of stethoscope
• Grade 6 heard with stethoscope off chest

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AuscultationMurmurs-Pitch

• Pitch frequency
• High
• Medium
• Low
• Reflects velocity of jet
• Reflects pressure gradient driving the jet

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So Much Noise
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AuscultationMurmurs-Timing

• Systolic S1-coincident, early, mid, late
• Diastolic early, mid
• Continuous

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AuscultationMurmurs-Location

• Remember aortic, pulmonary, mitral, tricuspid
  areas for the tests
• Be wary of abnormal anatomy
• Describe location on chest

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NL
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AuscultationMurmurs-Radiation

• Listen everywhere!
• Determine if you hear radiation of one murmur or
  a different murmur
• Some may change pitch as you get further from
  focus

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AuscultationMurmurs-Quality

• Crescendo
• Decrescendo
• Crescendo-decrescendo
• Be creative blowing harsh
• coarse
• honking
• squeak

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ABNORMAL SYSTOLIC MURMURS
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DIASTOLIC MURMURS
eg. Flow Rumble
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Vital Signs

• Weight
• Height
• Blood pressure

• Heart rate-compare with age norms-consider
  patients physiologic state
• Respiratory rate-compare with age norms
• -consider patients physiologic state
• Temperature
• Oxygen saturation

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General

• Well-nourished?
• Well-developed?
• Syndromic?
• Deformities?
• Distress?
• Respiratory effort?
• Level of consciousness?
• Pallor/cyanosis?
• Anxiety?

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Inspection

• Precordium activity
• Neck pulses
• Chest deformity
• Respiratory effort
• Head bobbing

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Inspection

• Skin color/tone/texture
• Scars
• Rashes
• Vein distension
• Jugular venous distension
• Carotid thrill
• Cranial thrill

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Rashes may point to the heart
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Palpation and Percussion

• Precordium activity quiet, active,
  hyperdynamic
• PMI (point of maximal impulse)
• Lifts, heaves, taps
• Palpable heart sounds
• Thrills
• The heart should percuss to the PMI

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AuscultationPrinciples and Technique

• GET A GOOD STETHOSCOPE!!!!!!!!!
• Become one with the stethoscope
• Eliminate extraneous noise

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AuscultationStart with the back

• Breathing normally-breath hold helps
• Listening for heart sounds radiating to the back
• Listening for abnormal vascular sounds
• Listen on sides of chest and axillae

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AuscultationLung Sounds

• Standard lung exam
• Lung findings may not represent primary lung
  pathology
• Crackles may mean pulmonary vascular congestion
• Wheezing may be due to severe pulmonary
  congestion
• Percuss for effusions

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Abdomen

• Inspection distension, veins
• Auscultation bowel sounds bruit
• Palpation liver size breadth, liver edge,
  tender splenomegaly pulsatility
  mass

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Palpating Pulses

• Brachial/radial
• Femoral
• at same time!
• pedal
• popliteal
• axillary

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Extremities

• perfusion
• edema
• clubbing
• deformity

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Clubbing
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Endocarditis
Roth spots
Oslers nodes
Janeway lesions
Splinter hemorrhages
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Family History

• We already talked about itand more to come