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

2. SUBJECTS History Physical examination Innocent murmurs
Inspection
Palpation
Oscultation
Innocent murmurs
Electrocardiogram
Telecardiogram

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

4. 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)

5. PHYSICAL EXAMINATION

6. INSPECTION General appearance
Chromosomal, hereditary, nonhereditary syndroms
Pallor
Cyanosis
Clubbing
Neck vein distension
Left precordial bulge

7. 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

8. 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

9. 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 mmHg higher than that obtained in the arm.

10. OSCULTATION
Heart rate and rhythm
Heart sounds
Other sounds
Murmurs

11. 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).

12. 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

13. 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

14. 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.

15. 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

16. CHARACTERISTICS OF HEART MURMURS

17. TIMING OF HEART MURMURS

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

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

20. Early diastolic murmurs (Decrescendo)
Aortic regurgitation
Pulmonary regurgitation 20

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

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

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

24. 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

25. LOCATION OF HEART MURMURS
Aortic area: right parasternal 2. intercostal space
Pulmonary area: left parasternal 2. intercostal space
Tricuspid area: left parasternal intercostal space
Mitral area (cardiac apex): 5.-6.intercostal space/ midclavicular line
Mezocardiyak area (second aortic area, Erb): left parasternal intercostal space
Aorta
Pulmonary
Mitral
Tricuspid

26. 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.

27. INNOCENT MURMURS
Innocent murmurs are heard in up to % 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.

28. TELECARDIOGRAM

29. 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

30. Thymus

31. 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

35. 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.

36. 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.

37. 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

40. NORMAL PULMONARY VASCULARITY
Obstructive lesions such as pulmonary or aortic stenosis
Small left-to right shunt lesions

41. 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

44. 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

46. 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).

47. 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.

49. ELECTROCARDIOGRAPHY

52. 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

53. Frontal reference system

54. Horizontal reference system

55. 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

57. 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.

58. TRANSITION TO ADULT ECG (R and S waves)

59. 23

60. 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

61. 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.

62. Frontal reference system

63. 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

64. Frontal reference system

65. QRS AXİS
Axis is calculated on frontal reference system (DI, DII, DIII, aVR, aVL, aVF)
DI and aVF (angle between them 90) are used

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

74. 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)

75. 303

76. 261

77. 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)

79. 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

80. 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

81. 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