Paediatric Cardiology for General Paediatricians     Dr Varsha Atul Shah
Essentials in looking at an ECGRhythm (sinus….nonsinus)Rate, Atrial and ventricular rates.QRS axis, T axis, QRS-T angleInt...
ECG tips   How do you determine Sinus rhythm?   What is T axis?   What is QRS/T angle?
Rhythm   P before every QRS   P axis (0-90). P inverted in aVR
P wave axis   The location of the P-wave axis determines the origin of    an atrial-derived rhythm:           •   0 to 90...
T wave   In most leads, the T wave is positive.   A negative T wave is normal in lead aVR.   Lead V1 may have a positiv...
Inverted (or negative) T waves can be a sign of   Coronary ischemia   Left ventricular hypertrophy
T axis   Determined by the same methods as QRS   0 to + 90 is normal   T Axis out side the normal quadrant could sugges...
QRS-T Angle   Formed by the QRS axis and the T axis   QRS-T angle >60 degrees is unusual but if > 90    degrees, it is a...
Top Tip For ECG Read   more ECGs
Do not forget, nothing replaces good traditional   clinical examination and detailed history                     teaching ...
Syncope   How often related to the heart?   What are the related cardiac conditions?   How do we approach it?
Definition   Syncope is a transient loss of consciousness and muscle    tone.   Near syncope:    premonitory signs and s...
Cause   Brain function depends on Oxygen and glucose.   Circulatory, metabolic, or neuropsychiatric causes.   Adults sy...
Causes of Syncope in Children   Extra cardiac causes            Vasovagal            Orthostatic            Failure of...
1- Vasovagal Syncope                       Neurocardiogenic                       Common Syncope   Predrome for few secon...
Vasovagal Syncope   Anxiety   Fright   Pain   Blood   Fasting   Hot and humid conditions   Crowded places   Prolon...
Vasovagal Syncope                      Pathophysiology   Standing posture without movement shifts blood to the    lower e...
Vasovagal Syncope Patients   Decreased venous return produces large increase in    ventricular contraction force   Activ...
   Paradoxical withdrawal of sympathetic activity,    vasodilatation, hypotension and bradycardia   Reduction of brain p...
Diagnoses   ECG, Holter, EEG, glucose tolerance test all are    normally negative in V V E   Tilt test
Management   Supine +/- feet up   Prevention      Pseudoephedrine      Metoprolol      Fludrocortisone      Disopyra...
2- Orthostatic Hypotension   What happen when we stand up?     HR, vasoconstriction    Absent or inadequate upright posit...
Diagnoses   BP and HR supine and standing up.   BP drop after 5-10 minutes up still by 10-15 mmHG   Positive tilt test ...
Management   Elastic stockings   High salt diet   Corticosteroids   Slow upright position
Micturition Syncope   Rare form of orthostatic   Rapid bladder decompression associated with    degreased total peripher...
3- Failure of systemic venous return   Increased intrathoracic pressure   Decreased venous tone (drugs; nitroglycerin) ...
4- Cerebrovascular occlusive disease   Mainly adult
Cardiac causes of Syncope   Structural heart disease   Arrhythmia
Why Cardiac ?   Syncope at rest   Provoked by exercise   Chest pain   Heart disease   FH of sudden death
What Cardiac   Obstructive lesions   Myocardial dysfunction   Arrhythmias
Obstructive lesions   AS, PS, HOCM, PHTX   Precipitated by exercise, no increase in cardiac output to    accommodate inc...
Myocardial Dysfunction   Ischemia, infarction secondary to CHD, Kawasaki’s..   Myocarditis
Arrhythmia             Arrhythmia               Lack of output             (Fast or slow heart)              SVT, VT, SSS,...
Long QT   Syncope, seizures, palpitation during exercise or with    emotion    ECG   Ventricular arrhythmias (Tachy) wi...
Long QT                 Defective ion                   channels     CongenitalOver 50 mutations in                       ...
clinically   FH 60%   Deafness 5%   Presentation with Syncope 26%, seizure 10%, cardiac arrest 9%,    presyncope palpit...
   Syncope in adrenergic arousal, exercise (swimming is a    particular trigger)   Abrupt noises (Alarm, doorbell, phone...
Tests   ECG with QTc >0.46 seconds      Frequently finding abnormal T wave      Bradycardia (20%)   Exercise test, max...
Diagnoses Criteria   Electrophysiological society     - QTc >0.44 with no other causes (0.46 sec)     - Positive family h...
Treatment   Discuss with cardiologist   Avoid drugs associated with long QT   Avoid swimming, competitive sports   Bet...
Prognoses   Untreated 75-80% mortality   Beta blockers reduce mortality to some extent   The adjusted annual mortality ...
Advise related to CHD   If one child has CHD, what are the chances of the    second?   One parent has CHD, can offspring...
Pathophysiology of congenital heart lesions
Pathophysiology of left to right shunt lesions ASD
Pathophysiology of left to right shunt           lesions VSD
Pathophysiology of left to right shunt           lesions PDA
Pathophysiology of left to right shunt          lesions AVSD
Pathophysiology of Obstructive and valvular        regurgitation lesions MR
Pathophysiology of Obstructive and valvular        regurgitation lesions AR
Pathophysiology of Obstructive and valvular        regurgitation lesions PR
Pathophysiology Cyanotic lesions         TGA with good mixing        65%                           LA 90%         RV 80%  ...
PathophysiologyTGA with poor mixing      30%      100%45%                      LA 92%      RV 45%          LV 92%       45%
PathophysiologyTGA with poor mixing      30%      100%45%                      LA 92%      RV 45%          LV 92%       45%
Tips   Read ECGs, easy to loose ECG skills.   Ask for help   As all specialties, it is only common sense.
Cardiology for g psaediatrics[1]
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Cardiology for g psaediatrics[1]

  1. 1. Paediatric Cardiology for General Paediatricians Dr Varsha Atul Shah
  2. 2. Essentials in looking at an ECGRhythm (sinus….nonsinus)Rate, Atrial and ventricular rates.QRS axis, T axis, QRS-T angleIntervals: PR. QRS, and QTP wave amplitude and durationQRS amplitude and R/S ratioQ waveSt- Segment and T wave abnormalities
  3. 3. ECG tips How do you determine Sinus rhythm? What is T axis? What is QRS/T angle?
  4. 4. Rhythm P before every QRS P axis (0-90). P inverted in aVR
  5. 5. P wave axis The location of the P-wave axis determines the origin of an atrial-derived rhythm: • 0 to 90 degrees = a high right (normal sinus rhythm) • 90 to 180 degrees = a high left • 180 to 270 degrees = a low left • 270 to 0 degrees = a low right
  6. 6. T wave In most leads, the T wave is positive. A negative T wave is normal in lead aVR. Lead V1 may have a positive, negative, or biphasic T wave. In addition It is not uncommon to have an isolated negative T wave in lead III, aVL, or aVF.
  7. 7. Inverted (or negative) T waves can be a sign of Coronary ischemia Left ventricular hypertrophy
  8. 8. T axis Determined by the same methods as QRS 0 to + 90 is normal T Axis out side the normal quadrant could suggest conditions with Myocardial dysfunction.
  9. 9. QRS-T Angle Formed by the QRS axis and the T axis QRS-T angle >60 degrees is unusual but if > 90 degrees, it is abnormal. Abnormally wide angle, with T axis outside the normal quadrant is seen in - severe ventricular hypertrophy with starin - Ventricular conduction disturbances - Myocardial dysfunction of a metabolic or ischemic nature.
  10. 10. Top Tip For ECG Read more ECGs
  11. 11. Do not forget, nothing replaces good traditional clinical examination and detailed history teaching 1.asx
  12. 12. Syncope How often related to the heart? What are the related cardiac conditions? How do we approach it?
  13. 13. Definition Syncope is a transient loss of consciousness and muscle tone. Near syncope: premonitory signs and symptoms of imminent syncope occur; dizziness with or without blackout, pallor, diaphoresis, thready pulse and low BP
  14. 14. Cause Brain function depends on Oxygen and glucose. Circulatory, metabolic, or neuropsychiatric causes. Adults syncope mostly cardiac. Children’s mostly benign.
  15. 15. Causes of Syncope in Children Extra cardiac causes  Vasovagal  Orthostatic  Failure of systemic venous return  Cerebrovascular occlusive disease  Hyperventilation  Breath holding
  16. 16. 1- Vasovagal Syncope Neurocardiogenic Common Syncope Predrome for few seconds; dizziness, light-headedness, pallor, palpitation, nausea, hyperventilation then Loss of consciousness and muscle tone Falls without injury Lasts about a minute, awake gradually
  17. 17. Vasovagal Syncope Anxiety Fright Pain Blood Fasting Hot and humid conditions Crowded places Prolonged motionless standing
  18. 18. Vasovagal Syncope Pathophysiology Standing posture without movement shifts blood to the lower extremities Decrease venous return, stroke volume, BP Less stretching of vent muscle and mechanoreceptors (mrcpts), decline in neural traffic form mrcpts, decreased arterial pressure, increase sympathetic output with Higher HR, vasoconstriction (higher diastolic pressure)
  19. 19. Vasovagal Syncope Patients Decreased venous return produces large increase in ventricular contraction force Activation of LV mechanoreceptors (normally only responds to stretch) Increase neural traffic mimicking high BP condition
  20. 20.  Paradoxical withdrawal of sympathetic activity, vasodilatation, hypotension and bradycardia Reduction of brain perfusion
  21. 21. Diagnoses ECG, Holter, EEG, glucose tolerance test all are normally negative in V V E Tilt test
  22. 22. Management Supine +/- feet up Prevention  Pseudoephedrine  Metoprolol  Fludrocortisone  Disopyramide  Scopolamine
  23. 23. 2- Orthostatic Hypotension What happen when we stand up? HR, vasoconstriction Absent or inadequate upright position response, Hypotension without increased HR
  24. 24. Diagnoses BP and HR supine and standing up. BP drop after 5-10 minutes up still by 10-15 mmHG Positive tilt test without autonomic signs
  25. 25. Management Elastic stockings High salt diet Corticosteroids Slow upright position
  26. 26. Micturition Syncope Rare form of orthostatic Rapid bladder decompression associated with degreased total peripheral vascular resistance.
  27. 27. 3- Failure of systemic venous return Increased intrathoracic pressure Decreased venous tone (drugs; nitroglycerin) Decreased volume (bleed…)
  28. 28. 4- Cerebrovascular occlusive disease Mainly adult
  29. 29. Cardiac causes of Syncope Structural heart disease Arrhythmia
  30. 30. Why Cardiac ? Syncope at rest Provoked by exercise Chest pain Heart disease FH of sudden death
  31. 31. What Cardiac Obstructive lesions Myocardial dysfunction Arrhythmias
  32. 32. Obstructive lesions AS, PS, HOCM, PHTX Precipitated by exercise, no increase in cardiac output to accommodate increased demand. Examination, CXR, ECG, Echo
  33. 33. Myocardial Dysfunction Ischemia, infarction secondary to CHD, Kawasaki’s.. Myocarditis
  34. 34. Arrhythmia Arrhythmia Lack of output (Fast or slow heart) SVT, VT, SSS, CHB, Abnormal Heart Structure Normal Ebsteins, MS, MR, heart structure CCTGALong QT, WPW Post op, TOF, TGA MVP VT Cmpthy SVT, VT, s brady
  35. 35. Long QT Syncope, seizures, palpitation during exercise or with emotion ECG Ventricular arrhythmias (Tachy) with risk of sudden death
  36. 36. Long QT Defective ion channels CongenitalOver 50 mutations in Acquired 4 sites Drugs, illnesses,Jarvell-lange-nielson Autoimmune Deafness AR Neurological Romano-ward Nutritional no deafness AD Electrolytes Sporadic no FH no Deafness
  37. 37. clinically FH 60% Deafness 5% Presentation with Syncope 26%, seizure 10%, cardiac arrest 9%, presyncope palpitation 6% Symptoms during exercise or emotion Normally symptoms related to ventricular arrhythmias, mostly end of second decade of life.
  38. 38.  Syncope in adrenergic arousal, exercise (swimming is a particular trigger) Abrupt noises (Alarm, doorbell, phone..)
  39. 39. Tests ECG with QTc >0.46 seconds  Frequently finding abnormal T wave  Bradycardia (20%) Exercise test, maximum prolongation after 2 minutes of recovery, ventricular arrhythmia in 30% during exercise Holter monitoring may show longer QTc
  40. 40. Diagnoses Criteria Electrophysiological society - QTc >0.44 with no other causes (0.46 sec) - Positive family history plus unexplained syncope, seizure or cardiac arrest proceeded by trigger such as exercise, emotion
  41. 41. Treatment Discuss with cardiologist Avoid drugs associated with long QT Avoid swimming, competitive sports Beta blockers Demand cardiac pacing (Pacemaker and defib) Left cardiac sympathetic denervation
  42. 42. Prognoses Untreated 75-80% mortality Beta blockers reduce mortality to some extent The adjusted annual mortality rate on treatment is 4.5% (10 year mortality of 50%)
  43. 43. Advise related to CHD If one child has CHD, what are the chances of the second? One parent has CHD, can offspring be affected? What are the chances? See Handouts, statistical list of potential risks
  44. 44. Pathophysiology of congenital heart lesions
  45. 45. Pathophysiology of left to right shunt lesions ASD
  46. 46. Pathophysiology of left to right shunt lesions VSD
  47. 47. Pathophysiology of left to right shunt lesions PDA
  48. 48. Pathophysiology of left to right shunt lesions AVSD
  49. 49. Pathophysiology of Obstructive and valvular regurgitation lesions MR
  50. 50. Pathophysiology of Obstructive and valvular regurgitation lesions AR
  51. 51. Pathophysiology of Obstructive and valvular regurgitation lesions PR
  52. 52. Pathophysiology Cyanotic lesions TGA with good mixing 65% LA 90% RV 80% LV 90%
  53. 53. PathophysiologyTGA with poor mixing 30% 100%45% LA 92% RV 45% LV 92% 45%
  54. 54. PathophysiologyTGA with poor mixing 30% 100%45% LA 92% RV 45% LV 92% 45%
  55. 55. Tips Read ECGs, easy to loose ECG skills. Ask for help As all specialties, it is only common sense.
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