Cardiovascular Disorders in Pediatrics

Congenital heart disease occurs in about 1% of children. Heart murmurs are much more common, and may be heard in virtually every child if examined carefully.

I. Clinical Evaluation of Cardiovascular Disorders
A. History
1. For neonates, a history of feeding problems, cyanosis, tachypnea, irritability or grunting respirations may indicate serious cardiac pathology. A history of feeding less than 2 ounces at each feeding in a term infant may indicate pathology. A family history of congenital heart disease may be helpful, but the
incidence of congenital heart disease in families where the mother has
congenital heart disease is only 5-10%. 2. For older children, it is unusual for a pathologic murmur to present for the first time outside of infancy. Two notable exceptions are hypertrophic cardiomyopathy and murmurs associated with dilated cardiomyopathy.
Symptoms which indicate serious pathology include exercise-induced chest pain, exercise induced syncope, or cyanosis. Easy fatigability is non specific, and not helpful in differentiating pathologic from non-pathologic murmurs.

B. Physical Examination
1. Congenital heart disease is more common in infants with congenital anomalies.
Trisomy 21. The incidence of heart disease is about 50% in these children. Anomalies include
ventricular septal defects, atrioventricular canal defects,
and patent ductus arteriosus.
b. Trisomy 18. The incidence of heart disease is almost 100%in these children. Ventricular septal
defect is the most common anomaly.
c. Trisomy 13. The incidence of heart disease is about 80%, usually VSD.
d. Turner syndrome (coarctation, hypertension), Marfan syndrome (aortic
aneurysms), and Noonan syndrome (pulmonic stenosis, coarctation) are other congenital
anomalies.

2. Growth parameters may suggest failure to thrive that is caused by cardiovascular disease. Infants with cardiovascular disease usually have a
normal head circumference, and height may be normal, but the weight is usually lower than anticipated.

3. Blood pressure determination. All children 3 years of age and older should have their blood pressure measured on a yearly basis. The blood pressure cuff should be appropriate for the patient’s size. The width of the cuff should be at least 2/3 the length of the upper arm, and the bladder should be long enough to almost encircle the upper arm. Blood pressure levels vary depending on the
age of the child, and hypertension is defined as a blood pressure consistently greater than the 95th percentile for age.
a. Presenting symptoms of severe hypertension in infants include congestive heart failure
(caused by coarctation), respiratory distress, and failure to thrive.
b. Symptoms of severe hypertension in older children may include headache, nausea, vomiting,
mental status changes, and epistaxis.
4. Cardiovascular Examination
a. Inspection
(1) Conditions that cause cardiac enlargement (ventricular septal defect,

The recommendations in blood pressure management are from the National High Blood Pressure Education Project provides tables that will give you normal data for blood pressure that varies by age, by height of the patient. Blood pressure should be measured in all children greater than three years of
age. Blood pressure should be measured from the patient's right arm after they
have been sitting in a quiet room for three to five minutes. Blood pressure should be measured twice and the results averaged, and the blood pressure should be measured with an appropriate size cuff. The simplest way to remember that is to try and get the largest cuff you can get on the child's arm.
They recommend that in a pediatric practice you have six cuffs. Three small
cuffs, one adult cuff, a large adult cuff and then a thigh cuff.
For definition of the diastolic blood pressure, the fifth Korotkoff sound is used. The fifth sound is when the sound totally disappears. There are patients in
whom the fifth Korotkoff sound never occurs. In other words, the sound never disappears, but then if it goes all the way down to zero, they don't have diastolic
hypertension, which makes sense.
Hypertension is defined as a child that has an average systolic or diastolic
blood pressure greater than the 95th percentile on three separate occasions, not all done in the same day. So don't rush into the diagnosis of hypertension.
Most children that have modest elevations in blood pressure are overweight and possibly have a family history of high blood pressure. Those people might get just a very basic routine screening evaluation which might include a urinalysis (looking for casts, hematuria, proteinuria), a BUN creatinine, looking
for elevation of creatinine consistent with renal disease, and also a good
cardiac physical exam, feeling femoral pulses. Those people would be treated with weight reduction, dietary restrictions, and emphasis on physical activity. Patients should not be restricted from physical activity because of mild elevations in blood pressure.
People that have significantly elevated blood pressure, and these are the people in the 99th and above percentile, frequently have underlying disease that is causing their hypertension. It is not idiopathic or familial hypertension. The two organ systems that are most commonly implicated are the renal
system and the cardiovascular system. Remember to listen for bruits over the abdomen because renal artery stenosis is a fairly common cause of significant
hypertension in children, and remember to feel the femoral pulses.
Now, I am going to briefly go over the cardiovascular exam, specifically the acyanotic category for an atrioseptal defect (ASD). In order to diagnose an
ASD it is not what is outside your ears that is most important. It is what is
between your ears that is most important. You need to know what you are listening for. If you can do a good ASD exam, then you know how to use your stethoscope. If you can rule out an ASD every time you listen to a patient, you will refer many fewer functional murmurs for evaluation, and you will miss many
fewer ASDs.
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