CARDIOLOGIC DIAGNOSIS I.U. Cerrahpaşa Medical Faculty Department of Pediatrics Division of Pediatric Cardiology Prof. Dr. Ayşe Güler EROĞLU

SUBJECTS History Physical examination Innocent murmurs 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 Chest Volume Rate Rhythm Character 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 Paradoxically split S2 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

TIMING OF HEART MURMURS

Sistolic ejektion murmurs (Diamond shaped, crescendo-decrescendo) Aortic stenosis Pulmonary stenosis Increased flow in aorta Increased flow in pulmonary artery 18

Sistolic regurgitant murmurs (Holosistolic, pansistolic) Ventricular septal defect Mitral regurgitation Tricuspid regurgitation 19

Early diastolic murmurs (Decrescendo) Aortic regurgitation Pulmonary regurgitation 20

Middiastolic murmurs (Flow murmurs) Increased flow across the atrioventricular valves in patients with ASD, VSD, PDA 21

Late diastolic murmurs (Presistolik) Mitral valve stenosis Tricuspid valve stenosis 22

Continuous murmurs Arterial Venous PDA Coronary artery fistula Pulmonary AV fistula Sistemic AV fistula Venous Venous ham 23

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 Mitral Tricuspid

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 Bones Diaphragm and pleura 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

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=1500/RR small boxes 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 Flat, low or inverted 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 Pericarditis Myocarditis Normal newborn