Common Cardiac Problemsfor School Age Children

Evaluation and Management for cardiac arrhythmia

• 1) Normal cardiac rhythms

• 2) Abnormal rhythms

SYNCOPE

DefinitionsSyncope transient loss of consciousness

muscle tone most often due to inadequate cerebral perfusion

Pre-syncope the feeling that one is about to pass out but no loss of consciousness

How Common is It?

• Probably more common than reported

• Best estimate is about 15% of children will have syncope

• Often a familial tendency towards syncope is discovered

Why So Much Angst?Fancy word for worry

• Is syncope a harbinger of sudden death?

• Well, it depends on the circumstances of the syncopal episode

• Simple syncope is NOT associated with a higher incidence of sudden death.

HOWEVER . . .

• SYNCOPE DURING EXERTION MAY BE THE ONLY WARNING OF A LETHAL CONDITION

Categories of Syncope

• Neurocardiogenic

• Cardiac

• Non-cardiac

Neurocardiogenic Syncope

• Most common cause of syncope

• Multiple names

• Neurally-mediated syncope

• Vasovagal syncope

• Simple fainting

• Disturbed autonomic control of HR BP in response to emotion, pain or postural change

The Physiology Part(But no biochemical flow

charts!!!) • Surveillance of blood pressure performed by

multiple receptors

• Baroreceptors

• Carotid artery bifurcation (carotid sinus)

• Aortic arch

• Mechanoreceptors

• Atria

• Pulmonary artery

• Left ventricle

Evaluation of the Sinker

• History

• Physical exam

• EKG

History

• Probably the single most important part of the evaluation

• Careful, non-hurried questions detailing entire episode

• Description of circumstances, prodrome, the actual faint and after-effects/appearance from patient and/or observers

Circumstances

• Where did it happen

• Time of day

• ?meals, ?intake

• Body position

• Preceding activity

• Any intercurrent illness

Prodrome

• What was the first sensation?

• Time between 1st warning and the faint?

• Any visual changes?

• Any auditory changes?

• Any nausea, diaphoresis or pain?

• Any palpitations preceding the event?

The Faint

• Any injury?

• Do they remember the fall?

• How long unconscious?

• Any tonic activity ?

• Appearance during?

• Color, diaphoretic?

• Incontinence?

After the Faint

• Whats the first thing they remember?

• Any feelings of nausea, headache, chest sensations, confusion, fatigue

• ?Get up too fast?

• Skin color and ?diaphoretic

• How long until totally back to normal

Typical Sinker Story

• Pre-teen or teen, sitting or standing

• Prodrome of hot feeling, nausea, racing heart, sweaty

• Hearing often dims

• Vision often grays out or tunnel vision

• Falls to floor without serious injury

• May have tonic activity

Typical Sinker Story

• Awakens nearly immediately

• Described as pale, clammy, pasty gray, diaphoretic

• Often feels nauseated and fatigued for a while may not be back to normal for many hours

• Recurs if helped up too quickly

History - Other Aspects

• Voiding history at school

• Prior medical history including cardiac history

• Illicit drugs, behaviors (privately, of course)

• Family history

Family History

• Sudden unexpected death

• HCM, LQTS, arrhythmias, etc

• Syncope

• Seizures

• Migraines

Cardiac Exam

• Palpate

• Displaced PMI - lift/heave

• RV lift/heave

• Thrills

• Murmurs of outflow obstruction

• loud S2 indicative of pulm HTN

NMS Rx - 2nd Step

• Mineralocorticoid fludrocortisone (Florinef)

• Dose range 0.1 mg qd or bid (max 0.4 mg/d)

• Must still maintain good fluid intake

• Warn about tight shoes!

• Takes few days to week for full effect

• Essentially, no side-effects

• Usual treatment course 6-12 mo

Cardiac Causes

• Obstruction to flow

• Myocardial dysfunction

• Arrhythmias

• Obstruction to flow

• Aortic or pulmonary stenosis

• Hypertrophic cardiomyopathy

• Primary pulmonary hypertension

• Eisenmengers syndrome

Cardiac Causes

• Myocardial dysfunction - primary

• Dilated cardiomyopathy

• Neuromuscular disorders

• Duchenne, Becker, Myotonic, etc

• Myocardial dysfunction - secondary

• Inflammatory - myocarditis, Kawasaki

• Ischemia - coronary abnormalities

• Aneurysm/obstr, ALCA, aberrant coronary

Cardiac Causes

• Arrhythmias (nl heart vs CHD pt)

• Tachycardia

• VT or SVT (espec WPW)

• Long QT, Brugada,

• Conduction abnormalities

• Sinus node dysfunction

• AV block

• Arrhythmogenic RV dysplasia

Non-Cardiac Causes

• Seizure disorder

• Often have aura, T-C activity and period of post-ictal confusion and lethargy

• More likely to be confused with simple syncope if complex partial type

• Convulsions occur before LOC

• Usually warm flushed after (not pallid or diaphoretic)

Non-Cardiac Causes

• Migraine (basilar artery migraine)

• Typical presentation is headache aura, then LOC and awake w/ severe occipital HA

• Some dont have headache

• More in adolescent girls

Non-Cardiac Causes

• Drugs

• Espec illicit ones

• Huffing volatile agents

• Metabolic

• Hypoglycemia VERY RARE (maybe never!) cause unless diabetic

Non-Cardiac Causes

• Hyperventilation

• Usually assoc w/ anxiety, c/o dyspnea, chest discomfort, dizziness, numbness sensation.

• More common in adolescents

• Low carbon dioxide level causes decreased cerebral blood flow

• Associated with coversion disorders.Alwaysaudience present.

• LOC for long period.

Non-Cardiac Causes - Situational Syncope

• Cough syncope

• More often in pt w/ lung disease

• High thoracic press gt decr return

• Swallow syncope.

• Rare in peds more in adults

• Esoph receptors initiates the reflex.

Non-Cardiac Causes - Situational Syncope

• Micturition syncope

• Usually female before, during or after voiding (often fatigue, alcohol hx)

• Unknown causes

• Proposed due to combo of postural hypotension, visceral stretch receptors, vagal stim, etc

• Benign usually an isolated episode

Non-Cardiac Causes - Situational Syncope

• Hair-grooming / neck stretch syncope

• Nearly always in adolescents

• Possible mechanisms include trigeminal nerve stim, carotid sinus hypersensitivity, vertebrobasilar circulation changes

• Benign

When To Worry

• Circumstance

• Syncope during exertion

• Known cardiac patient

• Malignant family history

• Prodrome

• Angina

• True palpitations

When To Worry

• The Faint is associated with exercise.

• True sudden arrest even for few seconds.

• Prolonged LOC.

• Serious bodily injury during fall.

• After event tachyarrhythemia or

• Tachy-bradyarrhythmia present.

When To Worry

• Abnormal physical exam

• Abnormal EKG

Syncope During Exertion

• Careful history about details

•

• Must exclude 3 potentially lethal conditions in ostensibly normal person

Must Exclude

• Anomalous left coronary artery

• Aberrant coronary artery

• Hypertrophic cardiomyopathy

Anomalous Left Coronary Artery

• Left coronary arises from pulm art

• Problem is not low oxygenated blood perfusingthe myocardium.

• Problem is run-off of blood bypassing the myocardial capillary bed and dumping into the low resistant pulmonary circulation.

• Age mode of presentation depend on collateral connections, flow, etc

Aberrant Coronary Artery

• Coronaries arise from aorta, but a major branch courses BETWEEN the Ao and PA

• Most common variant is LAD off the right

• Exercise gt high cardiac output gt Ao PA dilated gt compresses coronary gt oops !

Hypertrophic Cardiomyopathy

• Usually, physical exam and/or EKG are abnormal

• May not have positive family history

• Can be very subtle

Chest Pain

• Extremely common complaint, but I dont have any numbers

• Typically in the pre-teen, young teen age

• Probably all kids have some occasional pain, but not all of them complain

• Often it has been going on for a while but not mentioned to parent

The Benign Story

• Typical age is pre- to early adolescence

• SHARP, RANDOM stabbing mid-sternal chest pain

• Worse with breathing

• May have recently started a new activity or had an injury

• Sometimes mention a tender area on chest

• Often a family history of heart problems

History Tid-bits

• Establish that pain occurs sometimes at rest

• Confirm aggravating factors movement, deep breaths, etc

• Query about new activity (new bike, new exercise equipment, etc) or injury

• Ask about attempted home treatments (antacid, analgesics how given)

Physical Exam Tid-bits

• Obviously perform careful cardiac exam looking for cardiac enlargement, murmurs, single S2, etc

• Assess for tender areas

• Pressure on sternum

• Side rib squeeze

Costochondritis

• Explanation

• Stress benign nature of real pain (not imaginary!)

• Ibuprofen bid for several weeks

The Non-Benign Story

• Pressure, vise-grip substernal discomfort brought on only by activity (generally a predictable level)

• Relieved by rest

• Often associated with diaphoresis, nausea, dizziness

• OR

• Syncope associated with activity/pain

True Angina

• Obviously this is a horse of a different color

• Requires major work-up

• Differential includes

• Anomalous or aberrant coronary

• Myocardial bridging

• Hypertrophic cardiomyopathy

• Coronary stenosis congenital vs acquired

Conclusions

• Syncope can generally be fully evaluated by a very careful history physical (/- EKG)

• True syncope during exertion is a major red flag

• Chest pain is common and rarely cardiac

• True angina is rare, but obviously requires full evaluation

Physical Activity

• Guidelines from Dept of Health 2008

Children and adolescents 6-17 years of age should get 60 minutes of physical activity daily. Most of the 60 minutes should be either moderate or vigorous intensity.

Our recommendation( s) regarding exercise are as follows

• CLEAR FOR HIGH LEVEL OF EXERCISE (Including interscholastic athletics, contact sports) ( Dynamic and static boxing, long distance running, soccer, race walking, gymnastics, martial arts and weight lifting.)

• CLEAR FOR MODERATE LEVEL OF EXERCISE (Includes regular physical education classes, table tennis , baseball/softball, basketball, volleyball, running middle distance, skating, sprint running and swimming.)

• CLEAR FOR LOW LEVEL EXERCISE (non strenuous team games, recreational swimming, jogging, cycling, golf, bowling, riflery and ( No physical education).

• LIMITED activities and exercises according to patients tolerance. She/he should take rest whenever its required.