Pediatric Cardiology

The Essential Pocket Guide

Walter H. Johnson, James H. Moller

• Publisher: Wiley-Blackwell
• Year: 2014
• ISBN:
  9781118503393
• Edition: 3
• Topic: Medicina
• Subtopic: Cardiología

Caring for children with heart disease is extremely complex, requiring a different and often tailor-made approach compared with adults with similar cardiac problems.

Built on the success of previous editions and brought to you by a stellar author team, Pediatric Cardiology: The Essential Pocket Guide provides a unique, concise and extremely practical overview of heart disease in children.

From history-taking, physical examination, ECG, and chest X-ray – the basics that enable clinicians to uncover possible problems and eliminate areas of false concern – it goes on to examine the range of more complex topics in the diagnosis and treatment/management of childhood cardiovascular disease.

New to this edition you'll find:

• An enhanced section on imaging including recent advances in cardiac MRI and fetal echocardiography.
• New techniques in genetic testing for heart disease in special populations.
• Much more emphasis on the importance of echocardiography in understanding the pathophysiology of congenital cardiac malformations.
• Expanded section on cardiac conditions in the neonate, specifically on prenatal diagnosis and management, neonatal screening for congenital heart disease, and hypoplastic left heart syndrome.
• Expanded and updated congestive cardiac failure section, including the latest in genetic and metabolic causes of heart failure, and medical/surgical treatment options; discussion of bridging therapies; essentials of transplantation, including common drug treatment regimens, clinical recognition of treatment complications and rejection, outcomes, morbidity and survival.

In addition, every chapter is fully updated with the very latest clinical guidelines and management options from the AHA, ACC and ESC.

Pediatric Cardiology: The Essential Pocket Guide, 3 rd edition, is quite simply a must-have guide for all members of the multidisciplinary team managing children suffering from heart disease.

Chapter 1

Tools to diagnose cardiac conditions in children

History

General principles of the cardiovascular history

Chief complaint and/or presenting sign

Physical examination

Vital signs

Cardiac examination

Laboratory examination

Electrocardiography

Chest X-ray

Pulse oximetry

Blood counts

Echocardiography

Magnetic resonance imaging (MRI and MRA)

Computed tomography

Exercise testing

Cardiac catheterization

Additional reading

Much of the information presented in this chapter relates best to older infants and children. Diagnosis in newborn infants is more difficult, because the patient may be very ill and in need of an urgent diagnosis for prompt treatment. In this age group, echocardiography is often the initial diagnostic method. The unique challenges in newborns are discussed in Chapter 8.

The history and physical examination are the keystones for diagnosis of cardiac problems. A variety of other diagnostic techniques can be employed beyond the history and physical examination. With each technique, different aspects of the cardiovascular system are viewed, and by combining the data derived, an accurate assessment of the patient's condition can be obtained.

History

General principles of the cardiovascular history

The suspicion of a cardiovascular abnormality may be raised initially by specific symptoms, but more commonly the presenting feature is the discovery of a cardiac murmur. Many children with a cardiac abnormality are asymptomatic because the malformation does not result in major hemodynamic alterations. Even with a significant cardiac problem, the child may be asymptomatic because the myocardium is capable of responding normally to the stresses placed upon it by the altered hemodynamics. A comparable lesion in an adult might produce symptoms because of coexistent coronary arterial disease or myocardial fibrosis.

In obtaining the history of a child suspected of cardiac disease, the physician seeks three types of data: those suggesting a diagnosis, assessment of severity, and indicating the etiology of the condition.

Diagnostic clues

Diagnostic clues and other more general factors include the following.

Gender

Certain cardiac malformations have a definite gender predominance. Atrial septal defect (ASD) and patent ductus arteriosus (PDA) are two to three times more likely in female than in male children. Coarctation of the aorta, aortic stenosis, and transposition of the great arteries occur more commonly in male children.

Age

The age at which a cardiac murmur or a symptom develops may give a diagnostic clue. The murmurs of congenital aortic stenosis and pulmonary stenosis are often heard on the first examination after birth. Ventricular septal defect (VSD) is usually first recognized because of symptoms and murmur at 2 weeks of age. The murmur of an ASD may not be discovered until the preschool examination. A functional (innocent) murmur is found in half of school-age children.

Severity of the cardiac condition

A physician should seek information that suggests the condition's severity (e.g. dyspnea or fatigue).

Etiology

A physician should seek information that suggests an etiology of cardiac condition (e.g. maternal lupus).

Chief complaint and/or presenting sign

Certain presenting complaints and signs are more common in particular cardiac disorders and the “index of suspicion” aids the physician in organizing the data to make a differential diagnosis. For many of the signs and symptoms discussed later, noncardiac causes are often more likely than cardiac causes (e.g. acute dyspnea in a previously healthy 4-month-old infant with no murmur is more likely a result of bronchiolitis than of congestive heart failure). Therefore, a complete history must be integrated with the physical examination and other diagnostic studies to arrive at the correct cardiac diagnosis.

The most common symptoms or signs found in an outpatient setting are murmur, chest pain, palpitations, and near-syncope (fainting).

Murmur

Murmur is the most common presenting finding because virtually all children and adults with a normal heart have an innocent (normal) murmur sometime during their lifetime. Certain features are associated with an innocent murmur; the child is asymptomatic and murmurs appearing after infancy tend to be innocent. The murmur of atrial septal defect is one important exception.

Chest pain

Chest pain is a common and benign symptom in older children and adolescents, estimated to occur at some time in 70% of school-aged children. About 1 in 200 visits to a pediatric emergency room is for chest pain.

Chest pain rarely occurs with cardiovascular disease during childhood. Myocardial ischemic syndromes (e.g. Kawasaki disease with coronary artery aneurysms; hypertrophic cardiomyopathy) may lead to true angina. Patients with connective tissue disorders (e.g. Marfan syndrome) may have chest (or back) pain from aortic dissection. Although pericarditis may cause chest pain, it is almost always associated with fever and other signs of inflammation. Occasionally, chest pain accompanies supraventricular tachycardia. Most children with congenital cardiac malformations, including those who are fully recovered from surgery, do not have chest pain, and most children and adolescents who present with chest pain as their chief complaint do not have a cardiac malformation or disease.

Most chest pain is benign. It is usually transient, appearing abruptly, lasting from 30 seconds to 5 minutes and localized to the parasternal area. It is distinguished from angina by the absence of diaphoresis, nausea, emesis, and paresthesias in an ulnar distribution. Benign chest pain is “sharp,” not “crushing” like angina. It may also occur as a result of chest wall tenderness. Benign chest pain is typically well localized, sharp in character, short in duration (seconds to minutes), often aggravated by certain positions or movements, and occasionally can be induced by palpation over the area. These characteristics are strong evidence against cardiac cause for the pain. Some noncardiac conditions (e.g. asthma) may be associated with childhood chest pain. Benign pain is often described as “functional” because an organic cause cannot be found.

Palpitations

Palpitations, the sensation of irregular heartbeats, “skipped beats,” or, more commonly, rapid beats, are also common in the school-aged child and adolescent. They frequently occur in patients with other symptoms, such as chest pain, but often not simultaneously with the other symptoms. Palpitations are often found to be associated with normal sinus rhythm when an electrocardiogram is monitored during the symptom. Palpitations are not usually present in patients with known premature beats. Palpitations of sudden onset (approximately the time span of a single beat) and sudden termination suggest tachyarrhythmia.

Near-syncope

Near-syncope is a complex of symptoms that include vertigo and weakness. It is often induced by a postural change (orthostatic), is found commonly in older children and adolescents, and is almost always benign. The history often reveals little fluid and caloric intake beforehand. True syncope, characterized by complete loss of consciousness and loss of skeletal muscle tone, rarely results from a cardiac abnormality. It is often autonomic (vasovagal) in origin. Benign syncope is usually very brief in duration, often lasting only seconds. Benign syncope may follow a period of physical activity by several minutes; however, syncope during exercise often indicates a serious cardiac problem, such as aortic stenosis, arrhythmia, or myocardial abnormality. Because some life-threatening conditions (e.g. long QT syndrome) may result in syncope after a patient has been startled or has experienced an emotionally stressful situation, similar to benign syncope, an electrocardiogram is advisable for any child with a history of syncope. The family history should be explored for sudden death, syncope, seizures, SIDS, swimming ...