CARDIOLOGIC DIAGNOSIS

I.U. Cerrahpaşa Medical Faculty

Department of Pediatrics

Division of Pediatric Cardiology

Prof. Dr. Ayşe Güler EROĞLU

SUBJECTS

History Physical examination

Inspection Palpation Oscultation

Innocent murmurs Electrocardiogram Telecardiogram

HISTORY

Sweating Exercise intolerance Common respiratory tract infections Growth retardation Feeding difficulties Palpitation Dyspne Cyanosis Chest pain Syncope

HISTORY

Medical history (ilnesses, medications) Prenatal history (ilnesses, medications) Natal history (asphyxia, prematurity, birth

weight) Family history (CHD, sudden death, ARF) Mother’s health (DM,SLE)

PHYSICAL EXAMINATION

INSPECTION

General appearance Chromosomal, hereditary, nonhereditary

syndroms Pallor Cyanosis Clubbing Neck vein distension Left precordial bulge

PALPATION

Pulses Volume Rate Rhythm Character

Chest Apical impulse

In newborn and infants 4. intercostal space/midclavicular line In older children and adults 5. intercostal space/midclavicular line

Precordial activity Thrills

VOLUME OF PULSES

Increase in pulse volume: pyrexia, fever, anemia, exercise and thyrotoxicosis

Weak pulses: low cardiac output (left heart obstructive lesions: aortic valve atresia or stenosis

Bounding pulses: patent ductus arteriosus, aortic regurgitation, large systemic arteriovenous fistula

Differences in pulse volume between extremities: coarctation of the aorta

BLOOD PRESSURE MEASUREMENT

The width of the cuff’s bladder should be 125%-155% of the diameter of the extremity.

The air bladder should be long enough to completely or almost encircle the limb.

The point of first appearance of Korotkoff sounds (phase I) shows the systolic blood pressure. The point of muffling is closer to the true diastolic pressure than the point of disappearance in children.

Even when a wider cuff is selected for the thigh, the systolic pressure in the thigh is 10-20 mmHg higher than that obtained in the arm.

OSCULTATION

Heart rate and rhythm Heart sounds Other sounds Murmurs

HEART SOUNDS First heart sound (S1): The S1 is associated with

closure of the atrioventricular valves (mitral and tricuspid) It corresponds to the beginning of systole. Abnormally wide splitting: right bundle branch

block, Ebstein’s anomaly Increased S1: pyrexia, anemia, excitement,

thyrotoxicosis, short PR interval, mitral stenosis

Decreased S1: long PR interval and mitral regurgitation

Second heart sound (S2): The S2 is associated with closure of semilunar valves (aortic and pulmonary). It corresponds to the beginning of diastole. In every normal child, the s2 is split during inspiration and single during expiration (normal splitting of the S2).

HEART SOUNDS Widely split S2

Right ventricle volume overload: ASD, partial anomalous pulmonary venous return)

Right ventricle pressure overload: pulmonary stenosis

Delay in electrical activation of right ventricle: right bundle branch block

Early aortic valve closure: mitral regurgitation Narrowly split S2

Pulmonary hypertension Aortic stenosis

Paradoxically split S2

Severe aortic stenosis Left bundle branch block

HEART SOUNDS

Single S2

Only one semilunar valve is present: aortic or pulmonary atresia, persistent truncus arteriosus

P2 is not audible: transposition of the great arteries, tetralogy of Fallot, severe pulmonary stenosis

Aortic closure is delayed: severe aortic stenosis

P2 occurs early: pulmonary hypertension P2 increases in pulmonary hypertension and

decreases in severe pulmonary stenosis, tetralogy of Fallot and tricuspid stenosis

HEART SOUNDS Third heart sound (S3): The S3 is a low-frequency

sound in early diastole and is related to rapid filling of the ventricle. It is commonly heard in normal children and

young adults. A loud S3 is abnormal and is audible in large

shunt VSD, congestive heart failure. Fourth heart sound (S4): The S4 is a low-frequency

of late diastole and is rare in infants and children. It is always pathologic. It is seen in conditions with decreased

ventricular compliance.

OTHER SOUNDS Ejection clic: It follows the S1 very closely,

therefore it sounds like a splitting of the S1 Valvular aortic and pulmonary stenosis, dilated

great arteries Midsystolic click with or without late systolic

murmur Mitral or tricuspid valve prolapse

Opening snup: It occurs earlier than the S3 during diastole Mitral or tricuspid stenosis

Pericardial friction rub (frotman) Pericarditis

Pericardial knock Constrictive pericarditis

CHARACTERISTICS OF HEART MURMURS

Location

Intensity Quality

Radiation

Timing

Murmur

TIMING OF HEART MURMURS

Murmurs

Systolic Continuous Diastolic

Ejection(Diamond Crescendo-

decrescendo)

EarlyRegurgitant(HolosistolicPansistolic)

Late Early Middiastolic Late

Sistolic ejektion murmurs(Diamond shaped,

crescendo-decrescendo)

Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery

Sistolic regurgitant murmurs(Holosistolic, pansistolic)

Ventricular septal defect Mitral regurgitation Tricuspid regurgitation

Early diastolic murmurs(Decrescendo)

Aortic regurgitation Pulmonary regurgitation

Middiastolic murmurs(Flow murmurs)

Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA

Late diastolic murmurs(Presistolik)

Mitral valve stenosis Tricuspid valve stenosis

Continuous murmurs

Arterial PDA Coronary artery

fistula Pulmonary AV fistula Sistemic AV fistula

Venous Venous ham

Venous hum

A common innocent murmur is heard in healthy chidren at 2-8 years old

It is audible in the upright position The infraclavicular region, unilaterally or bilaterally The murmurs intensity changes with the position of

the neck and compression of cervical veins

LOCATION OF HEART MURMURS

Aortic area: right parasternal 2. intercostal space

Pulmonary area: left parasternal 2. intercostal space

Tricuspid area: left parasternal 4.-5. intercostal space

Mitral area (cardiac apex): 5.-6.intercostal space/ midclavicular line

Mezocardiyak area (second aortic area, Erb): left parasternal 3.-4. intercostal space

Aorta Pulmonary

TricuspidMitral

INTENSITY OF HEART MURMURS

Graded from 1 to 6. Grade 1: Barely audible. Grade 2: Soft, but easily audible. Grade 3: Moderately loud, but no accompanied

with a thrill. Grade 4: Louder and associated with a thrill. Grade 5: Audible with the stethescope barely on

the chest. Grade 6: Audible with the stethoscope off the

chest.

INNOCENT MURMURS

Innocent murmurs are heard in up to 70-85 % of normal children at some time or another. They are musical, low- frequency, systolic ejection and a lower grade than 3/6 in intensity. The intensity of the murmur increases during febrile ilness or excitement, after exercise or in anemic states. 1. Still murmur: It is heard best with the patient supine and at the mid-point

between the left sternal border and the apex. This murmur may be confused with the murmur of VSD or mild mitral regurgitation.

2. Pulmonary flow murmur of children: It is common in children and adolescents. It is heard maximally at upper left sternal border. This murmur may be confused with the murmur of pulmonary valvular stenosis or ASD.

3. Pulmonary flow murmur of newborn: This murmur is commonly present in newborns, especially in premature infants. It is heard best at the upper left sternal border and transmits to the right and left chest, both axilla and the back. Theories of its origin include the relative small size of the branch pulmonary arteries after birth. It usually disappears by six months of age.

TELECARDIOGRAM

IS THE ROENTGENOGRAPHY APPROPRIATE

IS TELECARDIOGRAM OR NOT 1)The distance between the patient and the tube

should be 180 cm. 2)Postero-anterior 3)Standing.

HOW IS QUALITY 1)X-ray dosing Inspiration Symmetry

Thymus

INTERPRETING THE CHEST ROENTGENOGRAM

1)Heart size 2)Heart silhouette 3)Pulmonary vascularity 4)Location of the liver and stomach 5)Skin and subcutaneous tissue 6)Bones 7)Diaphragm and pleura

INDIVIDUAL CHAMBER ENLARGEMENT

Left atrial enlargement Double-density on the right lower heart border Smooth left heart border Elevated left main-stem broncus

Left ventricular enlargement The apex of the heart is to the left and downward

Right atrial enlargement An increased prominence of the right lower

cardiac silhouette may be seen. Right ventricular enlargement

A lateral and upward displacement of the roentgenographic apex may be seen.

INCREASED PULMONARY VASCULARITY

Enlarged right and left pulmonary arteries Vascular images extend into the lateral third

of the lung field. Increased vascularity to the lung apices.

INCREASED PULMONARY VASCULARITY

Acyanotic child Atrial septal defect Ventricular septal defect Patent ductus arteriosus Atrioventricular septal defect Partial anomalous pulmonary venous return

Cyanotic child Transposition of the great arteries Total anomalous pulmonary venous return Hypoplastic left heart syndrome Truncus arteriosus Single ventricle

NORMAL PULMONARY VASCULARITY

Obstructive lesions such as pulmonary or aortic stenosis

Small left-to right shunt lesions

DECREASED PULMONARY VASCULARITY

Hilum appears small, the remaining lung fields appear black, and the vessels appear small and thin. Tetralogy of Fallot Pulmonary atresia Severe pulmonary stenosis Cyanotic heart diseases with pulmonary

stenosis

PULMONARY VENOUS CONGESTION

The pulmonary veins are straight in their course and directed toward the central portion of the heart, the left atrium.

Pulmonary venous congestion is characterized by a hazy and indistinct margin of the pulmonary vasculature.

Kerley`s B lines Kerley`s A lines

LOCATION OF THE LIVER AND THE STOMACH

Location of the liver and the stomach and the relation of these organs with the cardiac apex should be determined.

In abdominal situs solitus (normal) the liver shadow is on the right and the stomach gas bubble is on the left.

In abdominal situs inversus (mirror image) the liver shadow is on the left and the stomach gas bubble is on the right.

A midline liver is usually associated with complex congenital heart defects (heterotaxia syndromes).

OTHERS

Skin and subcutaneous tissue Amphysema Calcifications

Bones Pectus excavatum Thoracic scoliosis Vertebral abnormalities Rib notching is a specific finding of coarctation of the

aorta in the older child (usually older than 5 years old) and usually found between the fourth and eight ribs.

Diaphragm and pleura The right diaphragm is higher one rib than the left

diaphragm.

ELECTROCARDIOGRAPHY

REFERENCES SYSTEMS İN ECG

Frontal reference system shows right-left, up-down DI, DII, DIII, aVR, aVL, aVF

Horizontal reference system shows right-left, front-back Precordial leads: V1,V2, V3,

V4, V5, V6

Frontal reference system

Horizontal reference system

NORMAL PEDIATRIC ELECTROCARDIOGRAM

ECG of normal newborn shows 1)Right axis deviation 2)Dominant R waves in the right precordial

leads (V1) 3)Deep S waves in the left precordial leads

(V5-V6) 4)Positive T waves in the right precordial

leads

TRANSITION TO ADULT ECG

Pediatric ECG features are age dependent. Right axis deviation decreases with age, Dominant R waves in the right precordial

leads decreases with age, T waves in the right precordial leads

should be upright in the first 2-3 days of life and inverted between 7 days of age and adolescence in normal children,

Heart rate decreases; PR, QRS, and QT interval increase with age.

TRANSITION TO ADULT ECG(R and S waves)

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INTERPRETATION OF ECG

1)Heart rhythm 2)Heart rate 3)The QRS axis 4)PR, QT intervals and QRS duration 5)Atrial dilatation 6)Ventricular hypertrophy 7)ST segment and T wave

RHYTHM

Sinus rhythm is the normal rhythm.

The P axis should be normal (0 to +90) in sinus rhythm. P wave must be positive in both D1

and avF or positive in one and on the isoelectrical line on the other

P waves should precede each QRS complex in sinus rhythm.

Frontal reference system

HEART RATE

The heart rate can be calculated by dividing 1500 in the number of small boxes between RR interval (during the ECG paper moves 25mm/sec). Heart rate=1500/RR small

boxes

Frontal reference system

QRS AXİS

Axis is calculated on frontal reference system (DI, DII, DIII, aVR, aVL, aVF)

DI and aVF (angle between them 90) are used

QRS AXIS

Normal ranges of QRS axis vary with age.

Right axis deviation occurs when the axis is between the upper limit for age and 180

Left axis deviation occurs when the axis is between lower limit for age and -90

Northwest axis is between -90 and 180

PR INTERVAL

Normal PR interval varies with age and heart rate.

Prolongation of PR interval (1 AV block) Atrial septal defect Atrioventricular septal defect Myocarditis Digitalis effect

A short PR interval Preexcitation syndromes (Wolff-Parkinson-

White syndrome) Glicogene storage diseases

QRS DURATION

QRS duration increases with age 0,05- 0,10 second in children Increased QRS duration

Intraventricular block: methabolic or ischemic myocardial disease, hyperkalemia, some antiarrhythmic drugs (e.g., quinidine, procainamide)

Bundle branch block Preexitation syndromes Ventricular rhythm: premature ventricular

contractions, ventricular tavchycardia

QT INTERVAL

The QT interval varies primarily with heart rate.

The heart rate corrected QT (QTc) Bazett’s formula QTc= QT/square root RR.

QTc interval should not exceed 0.44 sec, except in infants

A QTc interval up to 0.49 may be normal for the first 6 months of age

DII, V1 is the best leads to measure QT interval

LONG QT INTERVAL

Long QT syndrome, Myocarditis, Diffuse myocardial disease, Head injury, Cerebrovasküler attack, Hipocalcemia, Drugs

Ampicilline, erythromycine, trimetoprim-sulpha etc antibiotics

Phenothiazines Tricyclic antidepressants Terfenadine

ATRIAL DILATATION

Right atrial dilatation: Tall P waves>2.5 mm Left atrial dilatation:

1) Wide P waves > 0.10 sec (> 3 years old)

Wide P waves > 0.09 sec (< 3 years old) 2) P notching (it is seen in 10% of normal

children) 3) In lead V1, terminal negative portion of P

wave should be less than 0.04 sec and less than 1 mm deep (less than one small box by one small box) in normal children

CRITERIAS FOR RIGHT VENTRICULAR HYPERTROPHY

1)Right QRS axis deviation 2)R wave greater than the upper limits of normal for the

patient`s age in V1, V2 3)S wave greater than the upper limits of normal for the

patient`s age in V6 4)R/S ratio in V1 and V2 greater than the upper limits of

normal for age 5)R/S ratio in V6 less than 1, after newborn period 6)A Q wave in V1 (pressure load: pulmonary stenosis etc) 7)rsR’ pattern in V1 (volume load: ASD etc) 7)Between 1 week and 6 years old, upright T wave in V1 In the presence of right ventricular hypertrophy, a wide

QRS-T angle (strain pattern)

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CRITERIAS FOR LEFT VENTRICULAR HYPERTROPHY

1)Left axis deviation (QRS axis) 2)R wave greater than the upper limits of normal

for the patient`s age in V5, V6, DI, DII,aVL and aVF 3)S wave greater than the upper limits of normal

for the patient`s age in VI and V2 4)R/S ratio in V6 greater than the upper limits of

normal for age 5)R/S ratio in V1 and V2 less than the lower limits

of normal for age 6)Q wave in V5 and V6, 5 mm or more 7)Tall symmetric T waves in V5 and V6 (volume

load: VSD, PDA etc 8)In the presence of left ventricular hypertrophy, a

wide QRS-T angle (strain pattern) (ST depression and inverted T waves in V5 and V6) (pressure load: AS etc)

ST SEGMENT

The normal ST segment is isoelectric. Elevation or depression of the ST segment up to 1 mm in the limb leads and 2 mm in the precordial leads is considered normal.

Abnormal shift of ST segment Pericarditis Myocarditis Myocardial ischemia or infaction Digitalis effect

T WAVES

T wave amplitude is variable in normal children

T waves in leads DI, DII and V6 should be more than 2 mm in all children over 48 hours old

An abnormally tall T wave is generally defined at any age as greater than 7 mm in a limb lead or 10 mm in a precordial lead

T WAVES Tall peaked T waves

Left ventricular hypertrophy of the volume overload type Hyperkalemia Myocardial infaction Exercise Excitement Cerebrovascular attack

Flat, low or inverted T waves Hypoxia Ischemia Tachycardia Hipokalemia Hypotroidism Malnutrition Exercise Excitement Pericarditis Myocarditis Normal newborn