2. Approach to CHD
â—†Common clinical clues that help in diagnosis of CHD
â—†Nadas's criteria of diagnosis of CHD
â—†Diagnostic implication of Second heart sound
Objectives
3. Approach to CHD
â—†Common clinical clues that help in diagnosis of CHD
1. Cyanosis
2. Difficult feeding and poor growth
3. Difficult breathing
4.Frequent respiratory infections
5. Specific syndromes
â—†Nadas' criteria of diagnosis of CHD
â—†Diagnostic implication of Second heart sound
Objectives
4. Approach to CHD
Parents seldom report cyanosis unless, it is relatively severe
(saturation <80%).
It is often easier for them to notice episodic cyanosis (when the child
cries or exerts).
Cyanosis
5. Approach to CHD
â—†The parent may complain of difficulty in feeding.
â—†Usually a feature of congestive heart failure resulting from CHD.
â—†History may be of
â—† Slow feeding,
â—† Small volumes consumed par feed,
â—† Tiring easily following feeds and
â—† Need of periods of rest during feeds.
â—†Excessive sweating of forehead or occiput
â—†Sometimes history of feeding difficulty is not found
â—† Examination of the growth charts will reveal recent decline in growth rate
â—†Characteristically,growth failure affects weight more that height
Difficult feeding and poor growth
6. â—†Tachypnea is a characteristic feature of heart failure in newborns
â—†Respiratory rates
â—†Up to 1 month : > 60 / Min
◆2 – 12 months : > 50 / Min
◆1 – 5 years : > 40 / Min
â—†For infants, subcostal or intercostal retractions together with flaring
of nostrils are frequently associated with tachypnea.
Approach to CHD
Difficult breathing
7. â—†The association of respiratory infections that are
â—†Frequent,
â—†Severe and
â—†Difficult to treat
◆With large L – R shunts
â—†Not a specific feature
Frequent respiratory infections
Approach to CHD
9. Approach to CHD
â—†Common clinical clues that help in diagnosis of CHD
1. Cyanosis
2. Difficult feeding and poor growth
3. Difficult breathing
4.Frequent respiratory infections
5. Specific syndromes
â—†Nadas' criteria of diagnosis of CHD
â—†Diagnostic implication of Second heart sound
Objectives
10. â—†The assessment for presence of heart disease can be
done using the Nadas' criteria.
â—†Congenital heart disease is indicated by presence of
ONE MAJOR OR TWO MINOR
â—†These criteria are of limited use in newborns, where
clinical signs are subtle
Nadas' Criteria
11. Nadas' criteria for clinical diagnosis of CHD
Major Minor
Systolic murmur grade III or more Systolic murmur grade I or II
Diastolic murmur Abnormal second sound
Cyanosis Abnormal electrocardiogram
Congestive cardiac failure Abnormal blood pressure
Nadas' Criteria
12. A murmur should be interpreted by analysing many factors.
Main factors are
Area of Maximum intensity
Timing in cardiac cycle
Intensity
Radiation
Relation with respiration
Relation with posture etc
Systolic murmur grade III or more in intensity.
Major Criteria
13. Area of Maximum intensity
Major Criteria
1. Aortic area
Systolic – AS, Carotid Bruit
Continuous Flow murmur – venous
hum
2. Pulmonary area
Systolic – PS, ASD
Continuous Flow murmur – PDA,
venous hum
3. Left Upper Sternal Border
Diastolic – AR, PR
Systolic – Hypertrophic
cardiomyopathy, Pulmonary Flow
murmur
4. Left Lower Sternal Border
Systolic – VSD, TR, Still's murmur
Diastolic – ASD, TS
5. Apex
Systolic – MR, MVP
Diastolic -- MS
14. Timing in Cardiac Cycle Systolic
Major Criteria
Pansystolic murmur
VSD, MR, TR
Continuous murmur
PDA
Ejection Systolic murmur
AS, PS, CoA
Late Systolic murmur
MVP
Systolic murmur grade III or more usually indicate organic heart disease
15. Timing in Cardiac Cycle Diastolic
Major Criteria
Early Diastolic murmur
AR, PR
Mid Diastolic murmur
MS
The presence of a diastolic murmur almost always indicates the
presence of organic heart disease
16. Grade I Barely audible
( softer than heart sounds )
Grade II Soft but easily audible
( as loud as heart sound )
Grade III Moderately loud murmur without a thrill
( louder than heart sounds )
Grade IV Loud murmur with a thrill
Grade V Murmur heard with the stethoscope barely touching
the chest
Grade VI Murmur heard with stethoscope off the chest
GRADES of MURMUR by INTENSITY
Major Criteria
18. Relation with
Respiration
Major Criteria
Relation with
Posture
Left sided murmurs accentuate in expiration
Right sided murmurs accentuate in inspiration
MS murmurs better heard in Left lateral
position
Murmurs of base of heart is better heard on
stooping forwards
19. Must meet the following criteria
➢ Child must be asymptomatic from cardiovascular point
➢ Cardiac examination should be normal
➢ Heard only in Systole except venous hum which is continuous
➢ Intensity < III / VI
Innocent Murmur
20. Major Criteria
Central Cyanosis
-------------------------------------------------------------------------------------------------
Features Central Cyanosis Peripheral Cyanosis
--------------------------------------------------------------------------------------------------
Mechanism Desaturation at Heart / Lung Increased O2 extraction by
CCHD or Lung disorder peripheral tissues
Site Skin + Mucosa Skin – Extremity, nose tip
Blue nail, nail bed, ear
lobule
Mucosa – remain pink
Clubbing Present Absent
Extremity Warm Cold
On Warming No change Disappears
O2 inhalation Slight improvement No change
PaO2 Low < 85% Normal > 85%
-------------------------------------------------------------------------------------------------
21. Presence of CHF indicates
heart disease
Except
Major Criteria
Congestive Heart Failure
Neonates and infants
may show CHF due to
extra cardiac causes like
Anemia
Hypoglycemia
22. â—† Electrocardiogram is used to determine the
â—† Mean QRS axis
â—† Atrial hypertrophy -- R or L
◆ Ventricular hypertrophy – R or L.
â—† Criteria for ventricular hypertrophy, based only on voltage criteria are
not diagnostic for the presence of heart disease.
â—† The voltage of the QRS complexes can be affected by
â—† Changes in blood viscosity,
â—† Electrolyte imbalance,
â—† Position of the electrode on the chest wall and
â—† Thickness of the chest wall.
Abnormal electrocardiogram
Minor Criteria
23. â—†Why abnormal X-ray as a minor criterion ?
â—† In infants and smaller children, the heart size varies
considerably in expiration and inspiration. If there is
cardiomegaly on a good inspiratory film, it suggests
presence of heart disease.
â—† Thymus in children in < two years, may mimic
cardiomegaly.
Minor Criteria
Abnormal X - Ray
24. Egg on Side in TGA
Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID:
43062
Minor Criteria
Abnormal X - Ray
Snowman sign or Figure of 8
in TAPVC
Coeur en Sabot in TOF
25. It is difficult to obtain accurate blood pressure in smaller children.
Appropriate sized cuffs should be used for blood pressure
Abnormal Blood Pressure
Minor Criteria
Age group Width Length Max arm circumference
cm (inch) cm (inch) cm (inch)
Newborn 4 (2") 8 (3") 10 (4")
Infant 6 (3") 12 (5") 15 (6")
Child 9 (4") 18(7") 20 (8")
Adult 13 (5") 30(12") 35 (14")
26. It is difficult to obtain accurate blood pressure in smaller children.
Appropriate sized cuffs should be used for blood pressure
Abnormal Blood Pressure
Minor Criteria
Age group Upper Limit Lower Limit
mm (Hg) mm (Hg)
Newborn 90 < 60
1 Year 100 < 70
Child 100 + Age in year*2 <70 + age in year*2
(< 10 years of age) up to 120 mm
Child > 120 < 90
(< 10 years of age)
27. â—† Hypertension is defined as average systolic blood pressure (SBP)
and/ or diastolic blood pressure (DBP) that is > 95th
percentile for age, sex and height on 3 occasions.
â—† Elevated Blood Pressure is defined as SBP or DBP that are > 90th
percentile but <95th percentile.
â—† Stage I Hypertension Children with blood pressure that is between
95th percentile and 95th + 12mm of Hg.
â—† Stage II Hypertension is above 95th percentile+ 12 mm of Hg.
Abnormal Blood Pressure
Minor Criteria
Adolescents
Elevated blood pressure with 120/80 mm Hg and 129/<80
Hypertension with > 130/80 mm of Hg
28. Approach to CHD
â—†Common clinical clues that help in diagnosis of CHD
1. Cyanosis
2. Difficult feeding and poor growth
3. Difficult breathing
4.Frequent respiratory infections
5. Specific syndromes
â—†Nadas' criteria of diagnosis of CHD
â—†Diagnostic implication of Second heart sound
Objectives
29. â—†Abnormal second sound indicate presence of heart disease.
â—†It has been included as a minor criterion only because
auscultation is an individual and subjective finding.
Diagnostic Implications of the S2
30. Diagnostic Implications of the S2
S2 is said to be NORMAL when
it meets ALL three parts
1. Has two components: A2 and P2.
2. During quiet breathing
➢During expiration S2 is single and
➢During Inspiration A2 – P2 split due to early A2 and delayed
P2.
3. The A2 is louder than the P2 except in infants < 3-6 Mo old.
Abnormalities of the S2 might occur in each of these aspects.
31. â—†The A2 is accentuated
â—†Systemic hypertension from any cause
â—†AR
â—†The A2 is Diminished
â—†Critical AS due to less mobile valve cusps
â—†Absent in aortic valve atresia.
Abnormal Aortic Component (A2)
Diagnostic Implications of the S2
Intensity -- A2 may be accentuated or diminished
Timing –--- A2 may be early or late
32. Abnormal Aortic Component (A2)
Diagnostic Implications of the S2
â—†The A2 is delayed
â—†When Left ventricular ejection is prolonged due to
â—†Pressure overload - AS
â—†Volume overload PDA with a large L - R shunt, AR
â—†Left ventricular electrical activation is delayed -- LBBB and
â—†Left ventricular slow contraction -- left ventricular failure.
â—†The A2 occurs early in VSD, mitral regurgitation
Intensity -- A2 may be accentuated or diminished
Timing –--- A2 may be early or late
33. Diagnostic Implications of the S2
Abnormal Pulmonary Component (P2)
Intensity -- P2 may be accentuated or diminished
Timing –--- P2 may be delayed
Although P2 may occur early in TR, it is not recognized clinically
since TR as an isolated lesion is rare
The P2 is accentuated
Pulmonary hypertension
P2 is diminished
Critical PS due to less mobile valve cusps
Absent in Pulmonary valve atresia.
â—†The P2 is delayed
â—†When Right ventricular ejection is prolonged due to
â—†Pressure overload - PS
â—†Volume overload -- ASD, PAPVC, PR
â—†Right ventricular electrical activation is delayed -- RBBB
34. â—† Wide splitting--
â—†Splitting during expiration due to an early A2 or late P2 or the
A2-P2 interval 0.03 sec or more during expiration
◆Wide and Variable Splitting (WVS) –
â—†Splitting in expiration increases in inspiration
◆Early A2 – VSD, MR.
â—†Late P2 -- PS
◆Wide and Fixed Splitting (WFS) –
â—†Splitting interval same in expiration and inspiration
â—†ASD, TAPVC, RBBB
Abnormal Splitting of S2
Diagnostic Implications of the S2
35. â—†The delay in A2 results in closely split, single or paradoxically split
S2.
â—†Paradoxically split is
â—†P2 - A2 split
â—†Wide in expiration but narrows
in inspiration
Abnormal Splitting of S2
Diagnostic Implications of the S2
â—†When Left ventricular ejection is prolonged due to
â—†Pressure overload - AS
â—†Volume overload PDA with a large L - R shunt, AR
â—†Left ventricular electrical activation is delayed -- LBBB
36. â—†The decision whether it is aortic or pulmonic or a combination, depends on
clinical profile.
â—†It is difficult to differentiate between TOF and Eisenmenger complex on
auscultation alone.
â—†History and CXR can aid in distinguishing between the conditions.
Abnormal Splitting of S2
Diagnostic Implications of the S2
Single S2 means that it is either
A2 only and P2 inaudible – TOF, Critical PS or PA
P2 only and A2 inaudible – Critical AS or AA
A2+P2 in combination – Mod AS, Single Ventricle, VSD + PAH +
Reversal of shunt (Eisenmenger
complex)