Cardiac

Assessment

SickKids Advanced Paediatric

Cardiology Program
Disclosures

• I have no actual or potential conflict

of interest in relation to this
program or presentation.
Disclosures
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Prenatal Health History

Maternal

• Viral Infections
• Medications &
Substance Use
• Conditions
Maternal Viral Infections
Q1. Which of the following maternal viral infections are
associated with cardiovascular abnormalities?

a) HIV in the 3rd trimester - is associated with

myocarditis
b) Cytomegalovirus in the 2nd trimester – is associated with
non-cardiac abnormalities, such hearing loss, intellectual
disability, developmental delay, and visual impairment
c) Measles in the 1st trimester – is associated with low birth
weight
d) Rubella in the 1st trimester - is associated with PDA
and PA stenosis
Maternal Medications & Substance Use
Medications Cardiac abnormalities
Amphetamines VSD, PDA, ASD, TGA

Phenytoin PS, AS, COA, PDA

Trimethadione TGA, VSD, TOF, HLHS

Lithium Ebstein's Anomaly

Retinoic Acid Conotruncal abnormalities

Valproic Acid Various noncyanotic defects

Progesterone or Estrogen VSD, TOF, TGA

Warfarin (15-45%) TOF, VSD

Excessive alcohol intake VSD, PDA, ASD, TOF

Maternal Conditions

Conditions Associated cardiac abnormalities

TGA, VSD, PDA (3-5%)
Maternal diabetes Cardiomyopathy (10-20%)
PPHN
Maternal lupus erythematous and
Congenital heart block
collagen diseases

Maternal congenital heart disease CHD

Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Postnatal and present health history

• Associations with cardiac abnormalities

• Symptoms
• Syndromes
• Diseases of other systems
Q2. Which of the following symptoms are commonly
associated with cardiac conditions?

a)Poor weight gain, delayed development – is associated

with CHF, severe cyanotic lesions
b)Cyanosis, squatting, blue spells – is associated with
RVOTO lesions, cyanotic CHDs
c)Tachycardia, systemic edema – is associated with CHF
d)Tachypnea, frequent respiratory tract infections – is
associated with CHF, large LT-RT shunt lesions
Q3. Which of the following symptoms are commonly
associated with cardiac conditions?

a)Poor activity tolerance – is associated with more severe CHD and

poor ventricular function
b)Diastolic Murmurs – are associated with aortic and pulmonic
valve regurgitation, and tricuspid and mitral valve stenosis, and
ASDs
c)Systolic Murmurs – are associated with aortic and pulmonary
valve stenosis, tricuspid and mitral valve regurgitation, and VSDs
d)Non-exertional chest pain – is usually not associated with cardiac
conditions (with the exception of pericarditis)
e)Exertional chest pain – is more likely to be associated with
cardiac conditions
f) Palpitations – are associated with cardiac conditions such as
arrythmias and mitral valve prolapse
Q4. Which of the following symptoms are commonly
associated with cardiac conditions?

a)Joint pain – is associated with rheumatic fever

b)Stroke-like – thrombotic strokes are associated with infective
endocarditis, polycythemia, CHD with RT-LT shunt lesions AND
ischemic strokes are associated with cyanotic lesions, CHD that
causes hypoperfusion to the brain pre and postnatally such as,
HLHS, TGA
c)Headache – is associated with polycythemia, and hypertension
(rare)
d)Syncope – can be associated with vasovagal responses however,
can also be associated with arrythmias such as, SVT, PVCs, VT,
Long QT
 Syndromes commonly associated
with cardiac anomalies
PDA, PA stenosis
RUBELLA SYNDROME 95%

TRISOMY 18 SYNDROME (EDWARD

90% VSD, PDA, PS
SYNDROME)

ALAGILLE SYNDROME 85% PA stenosis, complex

VELOCARDIOFACIAL SYNDROME (SPLINTZEN Truncas, TOF, PA w/

85%
SYNDROME) VSD, IAA, VSD, D-TGA

TRISOMY 13 SYNDROME (PATAU

80% VSD, PDA, dextrocardia
SYNDROME)
 Syndromes commonly associated
with cardiac anomalies
TOF, truncas,
CHARGE ASSOCIATION aortic arch defects 65%

CARPENTER SYNDROME PDA, VSD, PS, TGA 50%

VATR ASSOCIATION (VATR/VACTERL
50% VSD, other
SYNDROME)
DOWN SYNDROME (TRISOMY 21) 50% ECD, VSD

COA, bicuspid aortic

TURNER SYNDROME 35%
valve, AS, HTN, aortic
dissection
GOLDERHAR SYNDROME VSD, TOF 35%

0% 10% 20% 30% 40% 50% 60% 70%

Other syndromes frequently associated with cardiac
anomalies
Syndrome Associated cardiac anomalies

DiGeorge Syndrome IAA, TA, VSD, PDA, TOF

Ehlers-Danlos Syndrome ASD, aneurysm of the aorta and

carotids, MVP
Friedreich Ataxia hypertrophic cardiomyopathy

Glycogen Syndrome (Pompe cardiomyopathy

Disease)
Holt-Oram Syndrome ASD, VSD

LEOPARD Syndrome PS, HOCM, long PR interval

Marfan's Syndrome aortic aneurism, AVR, MVR

Other syndromes frequently associated with cardiac
anomalies
Syndrome Associated cardiac anomalies

Mucopolysaccharidosis IAA, TA, VSD, PDA, TOF

• Hurler Syndrome
• Hunter Syndrome
• Morquito Syndrome
Muscular Dystrophy cardiomyopathty
Noonan Syndrome PS, LHV

Tuberous Sclerosis thabdomyoma

Williams Syndrome supravalvular AS, PA stenosis

Zellweger Syndrome PDA, VSD, ASD

(Cerebrohepatorenal Syndrome)
 Diseases of other systems commonly
associated with cardiac abnormalities
RENAL AGENESIS (BILATERAL) 43%

HORESHOE KIDNEY 39%

ANORECTAL ANOMALIES 22%

OMPHALOCELE 21%

TE FISTULA, ESOPHAGEAL ATRESIA 21%

RENAL AGENESIS (UNILATERAL) 17%

DUODENAL ATRESIA 17%

AGENESIS OF CORPUS CALLOSUM 15%

0% 10% 20% 30% 40% 50%

Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Family health history

Family History of:

• CHD
• Hereditary diseases
Q5. What is the risk of CHD recurrence when one parent
has CHD?

a) Up to 3% if the mother is affected

b) Up to 3% if the father is affected
c) Up to 18% if the mother is affected
d) Up to 18% if the father is affected
 Syndromes commonly associated
with cardiac anomalies
RUBELLA SYNDROME 95%

TRISOMY 18 SYNDROME (EDWARD

90%
SYNDROME)

ALAGILLE SYNDROME 85%

VELOCARDIOFACIAL SYNDROME (SPLINTZEN

85%
SYNDROME)

TRISOMY 13 SYNDROME (PATAU

80%
SYNDROME)
 Syndromes commonly associated
with cardiac anomalies
CHARGE ASSOCIATION 65%

CARPENTER SYNDROME 50%

VATR ASSOCIATION (VATR/VACTERL
50%
SYNDROME)
DOWN SYNDROME (TRISOMY 21) 50%

TURNER SYNDROME 35%

GOLDERHAR SYNDROME 35%

0% 10% 20% 30% 40% 50% 60% 70%

Other syndromes frequently associated with cardiac
anomalies
Syndrome Associated cardiac anomalies

DiGeorge Syndrome IAA, TA, VSD, PDA, TOF

Ehlers-Danlos Syndrome ASD, aneurysm of the aorta and

carotids, MVP
Friedreich Ataxia hypertrophic cardiomyopathy

Glycogen Syndrome (Pompe cardiomyopathy

Disease)
Holt-Oram Syndrome ASD, VSD

LEOPARD Syndrome PS, HOCM, long PR interval

Marfan's Syndrome aortic aneurism, AVR, MVR

Other syndromes frequently associated with cardiac
anomalies
Syndrome Associated cardiac anomalies

Mucopolysaccharidosis IAA, TA, VSD, PDA, TOF

• Hurler Syndrome
• Hunter Syndrome
• Morquito Syndrome
Muscular Dystrophy cardiomyopathty
Noonan Syndrome PS, LHV

Tuberous Sclerosis thabdomyoma

Williams Syndrome supravalvular AS, PA stenosis

Zellweger Syndrome PDA, VSD, ASD

(Cerebrohepatorenal Syndrome)
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Inspection – general appearance
TITLE
TITLE
Inspection – capillary refill
Inspection – precordial bulge
Inspection – pre and post ductal saturations
Inspection – four limb blood pressures
Inspection – jugular vein distension
Inspection – cyanosis and clubbing
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Palpation – Precordium
Palpation – pulses
Palpation – femoral pulses
Palpation – liver

Infants normal
at 2 cm below
costal margin

Children
normal at 1 cm
below costal
margin
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Paediatric Cardiac Assessment

• Health history
• Prenatal
• Postnatal and present
• Family history

• Physical assessment
• Inspection
• Palpation
• Auscultation
Auscultation – lungs
Auscultation – heart sounds
Bedside Paediatric Early Warning System (BPEWS)
References

1. Lehrer, S. (2003) Understanding Pediatric Heart Sounds (Text

and CD Package), Elsevier
2. Park, Myunh K. (2016) Park's The Pediatric Cardiology
Handbook, fifth Edition, Elsevier, Print ISBN: 9780323262101,
0323262104
3. Parshuram, Duncan, Joffe, Farrell, Lacroix, Middaugh,
Hutchison, Wensley, Blanchard, Beyene, Parkin (2011),
Multicentre validation of the bedside paediatric early warning
system score: a severity of illness score to detect evolving critical
illness in hospitalised children, Critical Care, 15(4): R184.