Additional Information
Book Details
Abstract
Most physicians entering the field of pediatric cardiology are drawn to it by an interest in the wide variety of congenital heart defects which present at various ages. Most congenital heart disease will be evident in early life, presenting with cyanosis, heart murmur, congestive heart failure or shock. Textbooks in pediatric cardiology are filled overwhelmingly with chapters on the various congenital heart lesions which are encountered, both rare and common. However, practicing pediatric cardiologists will be quick to point out that a significant number of referrals to any practice do not involve congenital heart problems. Reviewing our own statistics at the Children’s Hospital of Michigan Cardiology Center for the past two years (2010-2012) reveals that outpatient visits for new patient consultations examined by age groups are: less than 1 year of age – 11%; 1-5 years – 23%; 6-10 years – 21%; 11-18 years – 45%. Retrospective data collected from billing codes, as in this brief survey, may imprecise. However, it does provide a snapshot of the usual referral problems encountered by pediatric cardiologists. In our practice, the most common overall reason for referral in all ages was "heart murmur", constituting 26% of total referrals. Second were rhythm and rhythm related problems (inclusive of palpitations, abnormal ECG and diagnosed premature beats) constituted 19% of the total. In the age group of interest for this book of 11-18 years, the most common presenting issues were rhythm related (23%) and chest pain (23%), followed by syncope or dizziness (19%) and heart murmur (12%). Congenital heart disease diagnoses encountered in the 11 to 18 year age group comprised only 6.5% of referrals within that age group. It is likely that many of these were not new diagnoses (with a few exceptions), but rather represented transfers to our practice. Our own outpatient clinical experience reveals that the majority of outpatients referred by pediatricians for pediatric cardiology evaluation are between the ages of 11 and 18. The majority of these new referrals are not for congenital heart disease. Our intent for this edition of Pediatric Clinics of North America is to describe the types of problems which seem to be of concern to the pediatric community within this age group and to describe strategies for evaluation.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Adolescent Cardiac Issues\r | i | ||
| Copyright\r | ii | ||
| Contributors | v | ||
| Contents | ix | ||
| Pediatric Clinics Of North America\r | xiii | ||
| Foreword\r | xv | ||
| Preface\r | xvii | ||
| Teenage Heart Murmurs | 1 | ||
| Key points | 1 | ||
| Introduction | 1 | ||
| What is a murmur? | 2 | ||
| Cardiac cycle | 2 | ||
| Atrial Contraction | 2 | ||
| Isovolumetric Contraction | 2 | ||
| Rapid Ejection Phase | 2 | ||
| Reduced Ejection Phase | 2 | ||
| Isovolumetric Relaxation | 3 | ||
| Rapid Filling Phase | 3 | ||
| Reduced Filling Phase | 3 | ||
| Characteristics of murmur | 3 | ||
| Timing and Duration | 4 | ||
| Intensity | 4 | ||
| Location | 4 | ||
| Configuration | 4 | ||
| Quality | 4 | ||
| Pitch | 5 | ||
| Radiation | 5 | ||
| Murmur classification | 5 | ||
| Systolic Murmurs | 8 | ||
| Diastolic Murmurs | 8 | ||
| Continuous Murmurs | 8 | ||
| Response to the maneuvers | 9 | ||
| Respiration | 9 | ||
| Valsalva Maneuver | 9 | ||
| Exercise | 9 | ||
| Positional Changes | 9 | ||
| Premature Ventricular Contraction | 9 | ||
| Innocent murmurs | 12 | ||
| Approach to a teenager with a murmur | 12 | ||
| “New” congenital heart disease in teenage years | 12 | ||
| Recommendations for performing echocardiography in patients with heart murmurs | 14 | ||
| Class I | 14 | ||
| Class IIa | 14 | ||
| Class III | 14 | ||
| Summary | 14 | ||
| References | 14 | ||
| A Teen with Chest Pain | 17 | ||
| Key points | 17 | ||
| Introduction: nature of chest pain | 17 | ||
| Noncardiac chest pain | 18 | ||
| Costochondritis or costosternal syndrome | 18 | ||
| Tietze syndrome | 18 | ||
| Trauma and muscle strain | 18 | ||
| Idiopathic chest-wall pain | 19 | ||
| Pulmonary | 20 | ||
| Gastrointestinal | 20 | ||
| Psychogenic | 20 | ||
| Miscellaneous | 20 | ||
| Cardiac chest pain | 21 | ||
| Inflammatory | 21 | ||
| Tachyarrhythmia | 21 | ||
| Left Ventricular Outflow Tract Obstruction | 21 | ||
| Kawasaki Disease | 21 | ||
| Coronary Artery Anomalies | 22 | ||
| Connective Tissue Disorders | 22 | ||
| Mitral Valve Prolapse | 23 | ||
| Patient history | 23 | ||
| Physical examination | 25 | ||
| Imaging and additional testing | 26 | ||
| Summary | 27 | ||
| References | 27 | ||
| A Teenage Fainter (Dizziness, Syncope, Postural Orthostatic Tachycardia Syndrome) | 29 | ||
| Key points | 29 | ||
| Syncope | 29 | ||
| Vasovagal syncope | 29 | ||
| Syncope games and lark | 31 | ||
| Psychogenic syncope | 31 | ||
| Cardiac syncope | 31 | ||
| Distinguishing simple fainting from cardiac syncope | 31 | ||
| Tilt table test | 33 | ||
| Treatment of simple fainting | 34 | ||
| Pharmacologic treatment | 37 | ||
| Midodrine | 37 | ||
| β-Blockers | 38 | ||
| Fludrocortisone | 38 | ||
| Other medications | 38 | ||
| Pacing | 38 | ||
| Postural orthostatic tachycardia syndrome | 39 | ||
| Diagnosis | 39 | ||
| Treatment | 40 | ||
| Medications for treating POTS | 41 | ||
| Summary | 41 | ||
| References | 41 | ||
| The Asymptomatic Teenager with an Abnormal Electrocardiogram | 45 | ||
| Key points | 45 | ||
| Introduction | 45 | ||
| Normal variants | 45 | ||
| Abnormal ECG findings in asymptomatic teenagers | 46 | ||
| Chamber Enlargement or Hypertrophy | 46 | ||
| Axis Deviation | 49 | ||
| Abnormal Rhythm | 49 | ||
| Ectopic Beats | 51 | ||
| Bundle Branch Block Pattern | 52 | ||
| AV Block | 53 | ||
| Wolff-Parkinson-White Pattern | 55 | ||
| Abnormal Repolarization (ST Wave and T Wave Changes) | 55 | ||
| Deep Q Waves | 56 | ||
| Abnormal QT Interval | 56 | ||
| Summary | 58 | ||
| References | 58 | ||
| The Teenager with Palpitations | 63 | ||
| Key points | 63 | ||
| Introduction | 63 | ||
| Epidemiology | 64 | ||
| Differential diagnosis | 64 | ||
| Diagnostic approach to a teenager with palpitations | 64 | ||
| History | 64 | ||
| History of present illness | 64 | ||
| Review of systems | 66 | ||
| Past medical history and review of medications | 67 | ||
| Family and social history | 67 | ||
| Physical Examination | 68 | ||
| ECG | 68 | ||
| Echocardiogram | 68 | ||
| Laboratory Testing | 68 | ||
| Ambulatory ECG Monitors (Holter Versus Event Monitor) | 69 | ||
| Exercise Stress Testing | 71 | ||
| Electrophysiology Study | 71 | ||
| Specific causes and management | 72 | ||
| Sinus Tachycardia | 72 | ||
| Appropriate sinus tachycardia: physiologic and nonphysiologic causes | 72 | ||
| Congenital and acquired heart disease | 73 | ||
| Medications and substance abuse | 73 | ||
| Anxiety | 73 | ||
| Eating disorders | 74 | ||
| Inappropriate sinus tachycardia | 74 | ||
| Nonsinus Tachycardia and Other Causes of Palpitations | 74 | ||
| Atrial and ventricular premature beats | 74 | ||
| SVT | 75 | ||
| VT | 76 | ||
| Long QT Syndrome | 76 | ||
| Summary | 77 | ||
| References | 77 | ||
| Management of a Hyperactive Teen and Cardiac Safety | 81 | ||
| Key points | 81 | ||
| Introduction | 81 | ||
| Diagnosis | 82 | ||
| Management | 83 | ||
| Pharmacologic treatment | 83 | ||
| Controversial issues | 84 | ||
| Pertinent “guideline” publication issues | 84 | ||
| Current medication issues | 85 | ||
| Adolescents with ADHD and challenges | 88 | ||
| Summary | 89 | ||
| Acknowledgments | 89 | ||
| References | 89 | ||
| Sports Participation During Teenage Years | 91 | ||
| Key points | 91 | ||
| Introduction | 91 | ||
| Preparticipation screening | 92 | ||
| Acknowledging reasons for differences in outcome/philosophy | 93 | ||
| Current recommendations for preparticipation screening in the United States | 93 | ||
| Approach to cardiac history and physical examination in the athlete | 94 | ||
| History | 94 | ||
| Chest pain | 94 | ||
| Dyspnea on exertion | 95 | ||
| Palpitations | 95 | ||
| Syncope | 95 | ||
| Easy fatigue | 95 | ||
| Medications, supplements, and other substances | 96 | ||
| Family History | 96 | ||
| Physical Examination | 96 | ||
| Vital signs | 96 | ||
| General appearance | 96 | ||
| Chest wall | 97 | ||
| Lung examination | 97 | ||
| Cardiac examination | 97 | ||
| Abdominal examination | 97 | ||
| Extremities | 97 | ||
| Limitations of Testing | 97 | ||
| Restriction of athletic participation | 98 | ||
| The athlete's heart | 99 | ||
| ECG Findings in the Athlete's Heart | 99 | ||
| Echocardiographic Findings in the Athlete's Heart | 100 | ||
| Physical Examination Findings in the Athlete's Heart | 100 | ||
| Differentiating the Athlete's Heart from Hypertrophic Cardiomyopathy | 100 | ||
| Understanding disorders responsible for SCA | 101 | ||
| Hypertrophic Cardiomyopathy | 102 | ||
| Coronary Artery Abnormalities | 104 | ||
| Myocarditis | 105 | ||
| Channelopathies | 105 | ||
| Summary | 106 | ||
| References | 106 | ||
| Cardiac Trauma During Teenage Years | 111 | ||
| Key points | 111 | ||
| Introduction | 111 | ||
| Blunt cardiac injury | 112 | ||
| Background | 112 | ||
| Screening and Diagnosis | 115 | ||
| Chest Radiography | 115 | ||
| Electrocardiogram | 116 | ||
| Cardiac Enzymes | 116 | ||
| Echocardiography | 118 | ||
| Treatment | 118 | ||
| Penetrating cardiac injury | 119 | ||
| Background | 119 | ||
| Screening and Clinical Diagnosis | 120 | ||
| Investigations | 121 | ||
| Focused Assessment With Sonography in Trauma | 121 | ||
| Chest Radiography | 122 | ||
| Electrocardiogram | 122 | ||
| Pericardiocentesis | 122 | ||
| Subxiphoid Pericardial Window | 123 | ||
| Central Venous Pressure | 123 | ||
| Computed Tomography | 123 | ||
| Surgical management | 124 | ||
| Emergency-Room Resuscitative Thoracotomy | 124 | ||
| Open-Heart Resuscitation | 124 | ||
| Operating-Room Management | 124 | ||
| Postoperative Complications | 125 | ||
| Retained Cardiac Missiles | 126 | ||
| Prognosis | 126 | ||
| Summary | 127 | ||
| References | 127 | ||
| Hypertension in the Teenager | 131 | ||
| Key points | 131 | ||
| Introduction | 131 | ||
| Definition and classification of pediatric hypertension | 132 | ||
| Primary and Secondary Hypertension | 132 | ||
| Risk factors for essential hypertension | 133 | ||
| Diagnosis of hypertension | 134 | ||
| Clinical Evaluation of a Hypertensive Teen | 134 | ||
| History | 134 | ||
| Physical examination | 134 | ||
| BP measurement | 135 | ||
| ABPM | 136 | ||
| Investigations in a Hypertensive Adolescent | 137 | ||
| Initial investigations | 137 | ||
| Subsequent investigations | 137 | ||
| Selected tests in unusual cases | 137 | ||
| Management of a hypertensive teen | 138 | ||
| Therapeutic Lifestyle Modification | 138 | ||
| Pharmacologic Therapy | 139 | ||
| Choice of antihypertensive medications | 139 | ||
| Benefits of antihypertensive therapy | 142 | ||
| Other forms of therapy | 142 | ||
| Sports participation for the hypertensive adolescent | 143 | ||
| Screening children for hypertension | 143 | ||
| AAP Recommendations | 143 | ||
| Complications of hypertension in adolescents | 144 | ||
| Summary | 145 | ||
| References | 145 | ||
| Identification of Obesity and Cardiovascular Risk Factors in Childhood and Adolescence | 153 | ||
| Key points | 153 | ||
| Definitions of adolescent obesity | 154 | ||
| Anthropometric measures of overweight and obesity | 155 | ||
| Racial/ethnic differences in obesity | 157 | ||
| Identification of the metabolic syndrome in childhood and adolescence | 158 | ||
| The cardiovascular impact of obesity | 159 | ||
| Hyperlipidemia | 159 | ||
| Increased left ventricular mass | 161 | ||
| Obesity prevention studies | 163 | ||
| Summary | 164 | ||
| References | 165 | ||
| Cardiomyopathies Encountered Commonly in the Teenage Years and Their Presentation | 173 | ||
| Key points | 173 | ||
| Introduction | 173 | ||
| DCM | 174 | ||
| Background | 174 | ||
| Cause | 174 | ||
| History | 174 | ||
| Physical Examination | 175 | ||
| Diagnostic Evaluation | 175 | ||
| Treatment | 176 | ||
| HCM | 177 | ||
| Background | 177 | ||
| Cause | 178 | ||
| History | 178 | ||
| Physical Examination | 179 | ||
| Diagnostic Evaluation | 180 | ||
| Treatment | 180 | ||
| RCM | 181 | ||
| Background | 181 | ||
| Cause | 181 | ||
| History | 182 | ||
| Physical Examination | 182 | ||
| Diagnostic Evaluation | 182 | ||
| Treatment | 183 | ||
| Summary | 184 | ||
| References | 184 | ||
| A Pediatric Approach to Family History of Cardiovascular Disease | 187 | ||
| Key points | 187 | ||
| Introduction | 187 | ||
| Family history of CVM | 189 | ||
| Family history of known genetic disease | 192 | ||
| Hypertrophic Cardiomyopathy | 192 | ||
| Long QT Syndrome | 194 | ||
| Thoracic Aortic Aneurysm and Dissection | 194 | ||
| Family history of SCD | 196 | ||
| Known Cause of SCD | 198 | ||
| Unknown Cause of SCD | 199 | ||
| Summary | 200 | ||
| References | 200 | ||
| Caring for a Teen with Congenital Heart Disease | 207 | ||
| Key points | 207 | ||
| Introduction | 207 | ||
| Approach to a teen with CHD: role of a primary provider | 208 | ||
| Compliance Issues: Lost to Follow-Up | 209 | ||
| Interventions | 209 | ||
| Cardiac interventions and reinterventions | 209 | ||
| Interventional/Device therapy | 210 | ||
| Noncardiac surgeries | 211 | ||
| Psychosocial Issues | 212 | ||
| Neurodevelopmental issues | 213 | ||
| Knowledge About Heart Disease | 214 | ||
| Educational intervention | 214 | ||
| Exercise recommendation | 215 | ||
| Endocarditis prophylaxis | 215 | ||
| High-risk behaviors and sexuality | 215 | ||
| Contraception | 216 | ||
| Pregnancy and reproduction | 217 | ||
| Genetic counseling | 217 | ||
| Career counseling and employment | 218 | ||
| Insurability and disability | 219 | ||
| End-of-life issues | 219 | ||
| Summary | 220 | ||
| References | 220 | ||
| Index | 229 |