Paediatric Cardiology for Paediatric Cardiology for General PaediatriciansGeneral Paediatricians

Dr Talal FarhaDr Talal Farha

Consultant PaediatricianConsultant PaediatricianSpR Regional Teaching SpR Regional Teaching

Taunton 22 Jan 2008Taunton 22 Jan 2008

Essentials in looking at an ECG

Rhythm (sinus….nonsinus)

Rate, Atrial and ventricular rates.

QRS axis, T axis, QRS-T angle

Intervals: PR. QRS, and QT

P wave amplitude and duration

QRS amplitude and R/S ratio

Q wave

St- Segment and T wave abnormalities

ECG tipsECG tips

How do you determine Sinus rhythm?How do you determine Sinus rhythm?

What is T axis?What is T axis?

What is QRS/T angle?What is QRS/T angle?

RhythmRhythm

P before every QRSP before every QRS P axis (0-90). P inverted in aVR P axis (0-90). P inverted in aVR

P wave axisP wave axis

The location of the P-wave axis determines the origin of The location of the P-wave axis determines the origin of an atrial-derived rhythm:an atrial-derived rhythm:

0 to 90 degrees = a high right (normal sinus rhythm) 0 to 90 degrees = a high right (normal sinus rhythm)

90 to 180 degrees = a high left90 to 180 degrees = a high left

180 to 270 degrees = a low left180 to 270 degrees = a low left

270 to 0 degrees = a low right270 to 0 degrees = a low right

T waveT wave

In most leads, the T wave is positive. In most leads, the T wave is positive.

A negative T wave is normal in lead aVR. A negative T wave is normal in lead aVR.

Lead V1 may have a positive, negative, or biphasic T Lead V1 may have a positive, negative, or biphasic T wave. In additionwave. In addition

It is not uncommon to have an isolated negative T wave It is not uncommon to have an isolated negative T wave in lead III, aVL, or aVF.in lead III, aVL, or aVF.

Inverted (or negative) T waves can be a sign of Inverted (or negative) T waves can be a sign of Coronary ischemiaCoronary ischemia Left ventricular hypertrophyLeft ventricular hypertrophy

T axisT axis

Determined by the same methods as QRSDetermined by the same methods as QRS

0 to + 90 is normal0 to + 90 is normal

T Axis out side the normal quadrant could suggest T Axis out side the normal quadrant could suggest conditions with Myocardial dysfunction.conditions with Myocardial dysfunction.

QRS-T AngleQRS-T Angle

Formed by the QRS axis and the T axisFormed by the QRS axis and the T axis

QRS-T angle >60 degrees is unusual but if > 90 QRS-T angle >60 degrees is unusual but if > 90 degrees, it is abnormal.degrees, it is abnormal.

Abnormally wide angle, with T axis outside the normal Abnormally wide angle, with T axis outside the normal quadrant is seen in quadrant is seen in

- - severe ventricular hypertrophy with starinsevere ventricular hypertrophy with starin

- Ventricular conduction disturbances- Ventricular conduction disturbances

- Myocardial dysfunction of a metabolic or ischemic nature.- Myocardial dysfunction of a metabolic or ischemic nature.

Top Tip For ECGTop Tip For ECG

Read more ECGs Read more ECGs

Do not forget, nothing replaces good traditional Do not forget, nothing replaces good traditional clinical examination and detailed historyclinical examination and detailed history

teaching 1.asx

SyncopeSyncope

How often related to the heart?How often related to the heart?

What are the related cardiac conditions?What are the related cardiac conditions?

How do we approach it?How do we approach it?

DefinitionDefinition

Syncope is a transient loss of consciousness and muscle Syncope is a transient loss of consciousness and muscle tone.tone.

Near syncope: Near syncope:

premonitory signs and symptoms of imminent syncope premonitory signs and symptoms of imminent syncope occur; dizziness with or without blackout, pallor, occur; dizziness with or without blackout, pallor, diaphoresis, thready pulse and low BPdiaphoresis, thready pulse and low BP

CauseCause

Brain function depends on Oxygen and glucose.Brain function depends on Oxygen and glucose.

Circulatory, metabolic, or neuropsychiatric causes.Circulatory, metabolic, or neuropsychiatric causes.

Adults syncope mostly cardiac.Adults syncope mostly cardiac.

Children’s mostly benign.Children’s mostly benign.

Causes of Syncope in ChildrenCauses of Syncope in Children

Extra cardiac causesExtra cardiac causesVasovagalVasovagalOrthostaticOrthostaticFailure of systemic venous returnFailure of systemic venous returnCerebrovascular occlusive diseaseCerebrovascular occlusive diseaseHyperventilationHyperventilationBreath holdingBreath holding

1- Vasovagal Syncope1- Vasovagal SyncopeNeurocardiogenicNeurocardiogenicCommon SyncopeCommon Syncope

Predrome for few seconds; dizziness, light-headedness, Predrome for few seconds; dizziness, light-headedness, pallor, palpitation, nausea, hyperventilation then Loss of pallor, palpitation, nausea, hyperventilation then Loss of consciousness and muscle toneconsciousness and muscle tone

Falls without injury Falls without injury

Lasts about a minute, awake graduallyLasts about a minute, awake gradually

Vasovagal Syncope Vasovagal Syncope

AnxietyAnxiety FrightFright PainPain BloodBlood FastingFasting Hot and humid conditionsHot and humid conditions Crowded placesCrowded places Prolonged motionless standingProlonged motionless standing

Vasovagal Syncope Vasovagal Syncope PathophysiologyPathophysiology

Standing posture without movement shifts blood to the Standing posture without movement shifts blood to the lower extremitieslower extremities

Decrease venous return, stroke volume, BPDecrease venous return, stroke volume, BP

Less stretching of vent muscle and mechanoreceptors Less stretching of vent muscle and mechanoreceptors (mrcpts), decline in neural traffic form mrcpts, decreased (mrcpts), decline in neural traffic form mrcpts, decreased arterial pressure, increase sympathetic output witharterial pressure, increase sympathetic output with

Higher HR, vasoconstriction (higher diastolic pressure)Higher HR, vasoconstriction (higher diastolic pressure)

Vasovagal SyncopeVasovagal Syncope Patients Patients

Decreased venous return produces large increase in Decreased venous return produces large increase in ventricular contraction forceventricular contraction force

Activation of LV mechanoreceptors (normally only Activation of LV mechanoreceptors (normally only responds to stretch) responds to stretch)

Increase neural traffic mimicking high BP condition Increase neural traffic mimicking high BP condition

Paradoxical withdrawal of sympathetic activity, Paradoxical withdrawal of sympathetic activity, vasodilatation, hypotension and bradycardiavasodilatation, hypotension and bradycardia

Reduction of brain perfusion Reduction of brain perfusion

DiagnosesDiagnoses

ECG, Holter, EEG, glucose tolerance test all are ECG, Holter, EEG, glucose tolerance test all are normally negative in V V Enormally negative in V V E

Tilt test Tilt test

ManagementManagement

Supine +/- feet upSupine +/- feet up Prevention Prevention

PseudoephedrinePseudoephedrine MetoprololMetoprolol FludrocortisoneFludrocortisone DisopyramideDisopyramide ScopolamineScopolamine

2- Orthostatic Hypotension2- Orthostatic Hypotension

What happen when we stand up? What happen when we stand up?

HR, vasoconstrictionHR, vasoconstriction

Absent or inadequate upright position response, Absent or inadequate upright position response, Hypotension without increased HRHypotension without increased HR

DiagnosesDiagnoses

BP and HR supine and standing up.BP and HR supine and standing up.

BP drop after 5-10 minutes up still by 10-15 mmHGBP drop after 5-10 minutes up still by 10-15 mmHG

Positive tilt test without autonomic signsPositive tilt test without autonomic signs

ManagementManagement

Elastic stockingsElastic stockings High salt dietHigh salt diet Corticosteroids Corticosteroids Slow upright positionSlow upright position

Micturition SyncopeMicturition Syncope

Rare form of orthostaticRare form of orthostatic

Rapid bladder decompression associated with Rapid bladder decompression associated with degreased total peripheral vascular resistance. degreased total peripheral vascular resistance.

3- Failure of systemic venous return3- Failure of systemic venous return

Increased intrathoracic pressureIncreased intrathoracic pressure

Decreased venous tone (drugs; nitroglycerin)Decreased venous tone (drugs; nitroglycerin)

Decreased volume (bleed…)Decreased volume (bleed…)

4- Cerebrovascular occlusive disease4- Cerebrovascular occlusive disease

Mainly adult Mainly adult

Cardiac causes of SyncopeCardiac causes of Syncope

Structural heart diseaseStructural heart disease

ArrhythmiaArrhythmia

Why Cardiac ?Why Cardiac ?

Syncope at restSyncope at rest Provoked by exercise Provoked by exercise Chest painChest pain Heart diseaseHeart disease FH of sudden deathFH of sudden death

What CardiacWhat Cardiac

Obstructive lesionsObstructive lesions

Myocardial dysfunctionMyocardial dysfunction

ArrhythmiasArrhythmias

Obstructive lesionsObstructive lesions

AS, PS, HOCM, PHTXAS, PS, HOCM, PHTX

Precipitated by exercise, no increase in cardiac output to Precipitated by exercise, no increase in cardiac output to accommodate increased demand.accommodate increased demand.

Examination, CXR, ECG, EchoExamination, CXR, ECG, Echo

Myocardial DysfunctionMyocardial Dysfunction

Ischemia, infarction secondary to CHD, Kawasaki’s..Ischemia, infarction secondary to CHD, Kawasaki’s..

MyocarditisMyocarditis

ArrhythmiaArrhythmia

ArrhythmiaLack of output Lack of output

(Fast or slow heart)(Fast or slow heart) SVT, VT, SSS, CHB,SVT, VT, SSS, CHB,

Normal heart structure

Long QT, WPW

Abnormal Heart Structure

Ebstein's, MS, MR, Ebstein's, MS, MR, CCTGACCTGA

Post op, TOF, TGAPost op, TOF, TGAMVP VTMVP VT

Cmpthy SVT, VT, Cmpthy SVT, VT, s bradys brady

Long QTLong QT

Syncope, seizures, palpitation during exercise or with Syncope, seizures, palpitation during exercise or with emotionemotion

ECGECG

Ventricular arrhythmias (Tachy) with risk of sudden Ventricular arrhythmias (Tachy) with risk of sudden deathdeath

Long QTDefective ion

channels

CongenitalOver 50 mutations in

4 sitesJarvell-lange-nielson Jarvell-lange-nielson

Deafness ARDeafness AR Romano-ward Romano-ward no deafness ADno deafness ADSporadic no FH Sporadic no FH

no Deafnessno Deafness

AcquiredDrugs, illnesses,

AutoimmuneNeurologicalNutritional

Electrolytes

clinicallyclinically

FH 60%FH 60%

Deafness 5%Deafness 5%

PresentationPresentation with Syncope 26%, seizure 10%, cardiac arrest 9%, with Syncope 26%, seizure 10%, cardiac arrest 9%, presyncope palpitation 6%presyncope palpitation 6%

Symptoms during exercise or emotionSymptoms during exercise or emotion

Normally symptoms related to ventricular arrhythmias, mostly end of Normally symptoms related to ventricular arrhythmias, mostly end of second decade of life.second decade of life.

Syncope in adrenergic arousal, exercise (swimming is a Syncope in adrenergic arousal, exercise (swimming is a particular trigger)particular trigger)

Abrupt noises (Alarm, doorbell, phone..)Abrupt noises (Alarm, doorbell, phone..)

TestsTests

ECG with QTc >0.46 secondsECG with QTc >0.46 seconds Frequently finding abnormal T waveFrequently finding abnormal T wave Bradycardia (20%)Bradycardia (20%)

Exercise test, maximum prolongation after 2 minutes of Exercise test, maximum prolongation after 2 minutes of recovery, ventricular arrhythmia in 30% during exerciserecovery, ventricular arrhythmia in 30% during exercise

Holter monitoring may show longer QTc Holter monitoring may show longer QTc

Diagnoses CriteriaDiagnoses Criteria

Electrophysiological societyElectrophysiological society- QTc >0.44 with no other causes (0.46 sec)QTc >0.44 with no other causes (0.46 sec)- Positive family history plus unexplained syncope, Positive family history plus unexplained syncope,

seizure or cardiac arrest proceeded by trigger such as seizure or cardiac arrest proceeded by trigger such as exercise, emotionexercise, emotion

TreatmentTreatment

Discuss with cardiologistDiscuss with cardiologist Avoid drugs associated with long QTAvoid drugs associated with long QT Avoid swimming, competitive sportsAvoid swimming, competitive sports Beta blockersBeta blockers Demand cardiac pacing (Pacemaker and defib)Demand cardiac pacing (Pacemaker and defib) Left cardiac sympathetic denervationLeft cardiac sympathetic denervation

PrognosesPrognoses

Untreated 75-80% mortalityUntreated 75-80% mortality

Beta blockers reduce mortality to some extentBeta blockers reduce mortality to some extent

The adjusted annual mortality rate on treatment is 4.5% The adjusted annual mortality rate on treatment is 4.5% (10 year mortality of 50%)(10 year mortality of 50%)

Advise related to CHDAdvise related to CHD

If one child has CHD, what are the chances of the If one child has CHD, what are the chances of the second?second?

One parent has CHD, can offspring be affected? What One parent has CHD, can offspring be affected? What are the chances? are the chances?

See Handouts, statistical list of potential risksSee Handouts, statistical list of potential risks

Pathophysiology of congenital heart lesionsPathophysiology of congenital heart lesions

Pathophysiology of left to right shunt lesions ASDPathophysiology of left to right shunt lesions ASD

Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions VSDlesions VSD

Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions PDAlesions PDA

Pathophysiology of left to right shunt Pathophysiology of left to right shunt lesions AVSDlesions AVSD

Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions MRregurgitation lesions MR

Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions ARregurgitation lesions AR

Pathophysiology of Obstructive and valvular Pathophysiology of Obstructive and valvular regurgitation lesions PRregurgitation lesions PR

Pathophysiology Cyanotic lesions Pathophysiology Cyanotic lesions TGA with good mixingTGA with good mixing

RV 80% LV 90%

65%

LA 90%

PathophysiologyPathophysiologyTGA with poor mixingTGA with poor mixing

RV 45% LV 92%

100%30%

LA 92%

45%

45%

PathophysiologyPathophysiologyTGA with poor mixingTGA with poor mixing

RV 45% LV 92%

100%30%

LA 92%

45%

45%

TipsTips

Read ECGs, easy to loose ECG skills.Read ECGs, easy to loose ECG skills. Ask for helpAsk for help As all specialties, it is only common sense.As all specialties, it is only common sense.