Pediatric cardiology JFK pediatric core curriculum

1. Pediatric cardiologyJFK pediatric core curriculum MGH Center for Global Health Pediatric Global Health Leadership Fellowship Credits: Brett Nelson, MD, MPH

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

3. 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…)

4. Auscultation • Rate & regularity • Heart sounds • 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)

5. Auscultation

6. 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)

8. 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)

9. 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

10. Murmurs: timing

11. 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

12. Distinguishing pathologic from innocent murmurs

13. 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

14. 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

15. 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)

16. Common innocent murmurs

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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.