Transcript Reasons to Call a Pediatric Cardiologist

Reasons to Call a Pediatric Cardiologist
Premchand Anne, MD, MPH, FACC
Pediatric and Adult Congenital Cardiology
Pediatric Lipid Clinic
St. John Providence Children’s Hospital
April 1, 2015
Disclosures
• I have nothing to disclose!
Objectives
• Understand signs and symptoms of shock and
heart failure due to congenital heart disease
• Management of absent pulses with associated
hypertension
• Differentiate between benign and pathologic
causes of syncope
• Recognize chest pain that is of concern
• Understand what to do with an elevated total
cholesterol
Case
• A 2.5 month old girl is brought to you for a
well-visit. Parents have noticed over the past
two weeks that she has diaphoresis with
feedings, along with persistent tachypnea.
Her PO intake decreased over the past one to
two weeks. She has decreased wet diapers.
She is more tired after feeding and, in general,
fussy. There is poor weight gain. Physical
exam reveals a harsh 3/6 murmur at the apex
with radiation to the left axilla. There are
diminished pulses. Tachypnea; Liver size inc.
Differential Diagnoses
• Cardiogenic shock
– Pump function
• Structural
• Hypoxemia and acidosis
• Arrhythmia
– Obstruction
• LVOT obstruction
• Arch obstruction
• Tamponade
Differential Diagnoses
• Hypovolemic shock
– Inadequate fluid intake
– Intravascular volume loss
– Fluid loss
• Distributive shock
– Septic
– Anaphylaxis
– Drugs/toxins
– Endocrine-Addisonian
Diagnosis
• Anomalous origin of the left coronary artery
from the pulmonary artery
Typical Signs and Symptoms
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Tachypnea and/or retractions
Tachycardia
Decreased PO intake
Poor weight gain
Diaphoresis with feeds
Decreased activity and fatigue
• Abdominal pain in older children
Management
• Treat underlying condition or provide
supportive, including medications.
• High calorie nutrition
• Minimize energy expenditure
• Noninvasive testing
– ECG
– ECHO
– CXR
• Surgical repair, if amenable
Case
• A fussy, six-month old girl is seen for a well visit
in your office. Per mother, she is active, has good
appetite and healthy. Examination shows a
comfortable child without significant respiratory
distress. There is a 3/6 harsh systolic ejection
murmur noted in right upper sternal region, with
radiation to the midscapular area. There are no
bruits noted in the abdomen. There are
diminished pulses in the lower extremities and BP
in left arm 54/42.
Question
• What are the next steps?
A. Calm the baby down and check the baby’s
femoral pulses
B. Obtain four limb blood pressures with
appropriate size cuff
C. Obtain an echocardiogram
D. Consider getting a chest XRAY.
E. All of the above
Differential Diagnoses
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Coarctation of the Aorta
Coarctation of the Aorta
Coarctation of the Aorta
Everything else!
– Possible sepsis
– Possible shock and heart failure
Case
• A 15-year old boy is seen in your office for a wellvisit. Child’s BP has been elevated one year ago.
They were lost to follow-up since last visit even
though the PCP mentioned rechecking the blood
pressure in 1-2 weeks. He reports intermittent
headaches and exertional chest discomfort when
he does sprints. No other symptoms. Physical
exam: Comfortably chatting with mother. Rt arm
BP: 154/92; Rt. Leg BP: 102/67. Harsh 3/6 SEM at
LUSB with radiation to the back. Diminished
femoral pulses. Saturation in right arm: 100%
Most likely diagnosis?
A.
B.
C.
D.
Hypoplastic left heart syndrome
Pulmonary stenosis
Unrepaired AVCD
L-Transposition of the great arteries with
coarctation of the aorta
E. D-Transposition of the great arteries.
A Note on Checking Blood Pressure
• The patient should be resting for 5 minutes
while sitting upright
• Feet must be flat on the ground and quiet.
• Appropriate sized cuff (width >40% of the arm
circumference halfway between the olecranon
and acromion and length >80% of the arm
circumference)
Case
• A 15-year old girl had a brief syncopal episode
after stepping out of a hot shower. The
episode lasted 3-5 seconds and was preceded
by visual scintilla, auditory disturbances, and
dizziness. There was no drowsiness or
confusion after the episode. She reports
having dizziness with acute positional
changes. Work-up in the local ER with an ECG
was normal; IV fluids given and discharged
home.
Diagnosis
• Neurocardiogenic syncope
– Neurally-mediated hypotension
– Vasovagal syncope
– “Fainting reflex”
– Vasodepressor syncope
– Autonomic dysfunction
Differential Diagnoses
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Orthostatic hypotension
Prolonged QT syndrome
Tachydysrhythmias or Bradycardias
Obstructive cardiac disease
High grade atrioventricular block
Myocardial structural disease
Medication toxicity
Predispositions to Neurocardiogenic
syncope
• Prolonged periods of upright posture
– Lines at amusement park rides
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Being in a warm environment
Immediately after exercise
Emotionally stressful events
Painful hair brushing/plaiting
Syncope-Concerned?
TO BE…
NOT TO BE…
Exercise-related
History of fluid losses
Positive ECG changes
Situational
Positive echo changes
Absence of cardiac disease
Documented dysrhythmias
Strickberger, S. A. et al. Circulation 2006;113:316-327
Non-Invasive Testing
• ECG
– QT interval
– Hypertrophy
– Blocks
– Brugada changes
– ARVD changes
• ECHO
• Tilt test
• Exercise stress test
• Monitor (Event versus Holter)
• MRI (ARVD, hypertrophy, ischemia)
Testing for Syncope
Brignole, M. et al, Heart. 93: 130-136
Management
• Depends on the cause
• Consider increasing fluids and salt intake
– Hypovolemia
– Neurocardiogenic syncope
• Postural Orthostatic Tachycardia Syndrome (POTS)
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Sit if dizziness is present
Avoid caffeinated products
Mineralocorticoids, beta-blockers, midodrine…
Although uncommon, consider pulmonary
embolism.
Case
• A five-year-old girl reports that her “heart
hurts.” She has had a few episodes, which
occurred at rest and physical activity. When
her mother palpated her anterior chest all,
she noted rapid heart rate that was “too hard
to count.” The pain usually resolves after a
few minutes, and is associated with resolution
of the sensed tachycardia. There is no
reproducible chest pain. She denied dizziness,
syncope, and difficulty breathing.
Case
• A 15-year old football player presents for a
well visit. He reports having exertional
discomfort only when sprinting during football
practice. He denies similar discomfort when
lifting weights. He describes the discomfort as
a pressure below the sternum. There is no
nausea, vomiting, or radiation of discomfort to
the neck and arm. ECG and Echo were
abnormal. He was restricted from further
participation in sports to his dismay.
Parental Perception of Chest Pain
Chest Pain Etiology in Reality…
“6 Questions to Ask”
Cincinnati Children’s Hospital Blog
1.
2.
3.
4.
5.
6.
Has the child been sick recently?
Was the child injured recently?
Is the child stressed?
When does it hurt?
How long has it been hurting?
How painful is it?
7. Were there any cardiac deaths in the first two
decades of life?
Madsen, N.
http://cincinnatichildrensblog.org/healthy-living/6-questions-to-ask-when-your-child-complains-of-chest-pain/#authorbox
Chest Pain Characteristics
Likely Benign
Likely Pathologic
Reproducible with palpation
Associated with syncope
Sharp
Tearing
Occurs at rest
Pressure
No tachycardia
Radiation to neck and shoulder
Due to hyperventilation
Angina
Extracardiac
Retrosternal
Sudden onset and offset; worse with deep breathing and position change; several
minutes into activity
Causes of Chest Pain
• Common musculoskeletal causes
– Costochondritis
– Trauma and over-use syndromes
– Slipped rib syndrome-Tietze’s syndrome
– Precordial catch syndrome-Texidor’s Twinge
• Psychological causes
– Hyperventilation
– Anxiety
Causes of Chest Pain
• Respiratory causes
– Exercise-induced asthma
– Pneumonia
– Pleurisy
– Pulmonary embolism, pneumothorax
• Gastrointestinal causes
– Reflux
– Gastritis
– Esophagitis and esophageal spasms
Causes of Chest Pain
• Cardiac Causes
– Tachyarrhythmias
– Pericarditis
– Myocarditis
– Obstructions (pump and pipes)
– Syndromic associations
• Turner’s, Marfan’s, Type IV EDS,
– Ischemia
• Coronary anomalies; HCM or HOCM
Chest Pain Work-up
• Not everyone needs an echocardiogram or
ECG; a thorough history and physical can
guide the level of testing.
• Non-invasive and invasive testing
– ECG
– Echo
– CXR
– CT-Angiogram-myocardial bridges
Chest Pain Management
• Most often: reassurance
• Treat underlying etiology
– Medical management
– Referral to Pediatric Cardiology
• Medical Management
• Surgical management
– Referral to other specialties if suspecting noncardiac etiology
Cases
• Few fasting lipid profiles are listed below:
A
B
C
D
TC
217
217
217
217
HDL-C
77
38
38
65
LDL-C
119
158
105
120
TG
105
105
370
210
Apo B
89
127
120
105
• Which profile(s) are concerning?
Fridewald Equation Vs. Direct measurement
• LDL-C= TC – HDL-C- TG/5
Martin, SS et al. JACC. 2013;62(8):732-739
Lipid Cutoff Values
Expert panel. Pediatrics. 2011; 128: S5
Cases
• Few fasting lipid profiles are listed below:
A
B
C
D
TC
217
217
217
217
HDL-C
77
38
38
65
LDL-C
119
158
105
120
TG
105
105
370
210
Apo B
89
127
120
105
• Which profile(s) are concerning?
AAP Guidelines for Lipid Screening
• Ages 2-8 years: selective screening if at least one risk
factor
• Ages 9-11 years: Universal screening
• Ages 12-17 years: selective screening if at least one
risk factor.
• Risk Factors:
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Unhealthy body weight
Elevated blood pressure
One or both parents with hyperlipidemia
Tobacco use
DM
Expert panel. Pediatrics. 2011; 128: S5
LDL-C Level and Duration
Horton JD, et al. J Lipid Res. 2009; 50 (Suppl):S172-S177
Lipid Management
• Usually lifestyle modification
• Determine whether primary or secondary hyperlipidemia
• Hypercholesterolemia
– Dietary modification with low saturated fat
– BAS
– Statins
– Ezetimibe
• Hypertriglyceridemia
– Decreased intake of carbohydrates, especially refined
carbohydrates (candy, juice, POP, sugar); weight loss; activity
– Omega-3 Fatty Acids (marine type)
Questions?