Paediatric Cardiology for

General Paediatricians
Dr Talal Farha

Consultant Paediatrician
SpR Regional Teaching
Taunton 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 tips

 How do you determine Sinus rhythm?

 What is T axis?

 What is QRS/T angle?

 Rhythm

 P before every QRS

 P axis (0-90). P inverted in aVR
 P wave axis

 The location of the P-wave axis determines the origin of

an atrial-derived rhythm:

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

 90 to 180 degrees = a high left
 180 to 270 degrees = a low left
 270 to 0 degrees = a low right
 T wave
 In most leads, the T wave is positive.

 A negative T wave is normal in lead aVR.

 Lead V1 may have a positive, negative, or biphasic T

wave. In addition

 It is not uncommon to have an isolated negative T wave

in lead III, aVL, or aVF.
Inverted (or negative) T waves can be a sign of
 Coronary ischemia
 Left ventricular hypertrophy
 T axis
 Determined by the same methods as QRS

 0 to + 90 is normal

 T Axis out side the normal quadrant could suggest

conditions with Myocardial dysfunction.
 QRS-T Angle

 Formed by the QRS axis and the T axis

 QRS-T angle >60 degrees is unusual but if > 90

degrees, it is abnormal.

 Abnormally wide angle, with T axis outside the normal

quadrant is seen in
- severe ventricular hypertrophy with starin
- Ventricular conduction disturbances
- Myocardial dysfunction of a metabolic or ischemic nature.
 Top Tip For ECG

 Read more ECGs

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

teaching 1.asx
 Syncope
 How often related to the heart?

 What are the related cardiac conditions?

 How do we approach it?

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

 Near syncope:
premonitory signs and symptoms of imminent syncope
occur; dizziness with or without blackout, pallor,
diaphoresis, thready pulse and low BP
 Cause
 Brain function depends on Oxygen and glucose.

 Circulatory, metabolic, or neuropsychiatric causes.

 Adults syncope mostly cardiac.

 Children’s mostly benign.

 Causes of Syncope in Children

 Extra cardiac causes

 Vasovagal
 Orthostatic
 Failure of systemic venous return
 Cerebrovascular occlusive disease
 Hyperventilation
 Breath holding
 1- Vasovagal Syncope
Neurocardiogenic
Common Syncope

 Predrome for few seconds; dizziness, light-headedness,

pallor, palpitation, nausea, hyperventilation then Loss of
consciousness and muscle tone

 Falls without injury

 Lasts about a minute, awake gradually

 Vasovagal Syncope
 Anxiety
 Fright
 Pain
 Blood
 Fasting
 Hot and humid conditions
 Crowded places
 Prolonged motionless standing
 Vasovagal Syncope
Pathophysiology
 Standing posture without movement shifts blood to the
lower extremities

 Decrease venous return, stroke volume, BP

 Less stretching of vent muscle and mechanoreceptors

(mrcpts), decline in neural traffic form mrcpts, decreased
arterial pressure, increase sympathetic output with

 Higher HR, vasoconstriction (higher diastolic pressure)

 Vasovagal Syncope Patients
 Decreased venous return produces large increase in
ventricular contraction force

 Activation of LV mechanoreceptors (normally only

responds to stretch)

 Increase neural traffic mimicking high BP condition

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

 Reduction of brain perfusion

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

 Tilt test
 Management
 Supine +/- feet up
 Prevention
 Pseudoephedrine
 Metoprolol
 Fludrocortisone
 Disopyramide
 Scopolamine
 2- Orthostatic Hypotension
 What happen when we stand up?
HR, vasoconstriction

Absent or inadequate upright position response,

Hypotension without increased HR
 Diagnoses
 BP and HR supine and standing up.

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

 Positive tilt test without autonomic signs

 Management
 Elastic stockings
 High salt diet
 Corticosteroids
 Slow upright position
 Micturition Syncope
 Rare form of orthostatic

 Rapid bladder decompression associated with

degreased total peripheral vascular resistance.
 3- Failure of systemic venous return
 Increased intrathoracic pressure

 Decreased venous tone (drugs; nitroglycerin)

 Decreased volume (bleed…)

4- Cerebrovascular occlusive disease

 Mainly adult
 Cardiac causes of Syncope
 Structural heart disease

 Arrhythmia
 Why Cardiac ?
 Syncope at rest
 Provoked by exercise
 Chest pain
 Heart disease
 FH of sudden death
 What Cardiac

 Obstructive lesions

 Myocardial dysfunction

 Arrhythmias
 Obstructive lesions

 AS, PS, HOCM, PHTX

 Precipitated by exercise, no increase in cardiac output to

accommodate increased demand.

Examination, CXR, ECG, Echo

 Myocardial Dysfunction

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

 Myocarditis
 Arrhythmia

Arrhythmia
Lack of output
(Fast or slow heart)
SVT, VT, SSS, CHB,

Abnormal Heart
Structure
Normal Ebstein's, MS, MR,
heart structure CCTGA
Long QT, WPW Post op, TOF, TGA
MVP VT
Cmpthy SVT, VT,
s brady
 Long QT
 Syncope, seizures, palpitation during exercise or with
emotion

 ECG

 Ventricular arrhythmias (Tachy) with risk of sudden

death
 Long QT
Defective ion
channels

Congenital
Over 50 mutations in
Acquired
4 sites
Drugs, illnesses,
Jarvell-lange-nielson
Autoimmune
Deafness AR
Neurological
Romano-ward
Nutritional
no deafness AD
Electrolytes
Sporadic no FH
no Deafness
 clinically
 FH 60%

 Deafness 5%

 Presentation with Syncope 26%, seizure 10%, cardiac arrest 9%,

presyncope palpitation 6%

 Symptoms during exercise or emotion

 Normally symptoms related to ventricular arrhythmias, mostly end of

second decade of life.
 Syncope in adrenergic arousal, exercise (swimming is a
particular trigger)

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

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

 Exercise test, maximum prolongation after 2 minutes of

recovery, ventricular arrhythmia in 30% during exercise
 Holter monitoring may show longer QTc
 Diagnoses Criteria
 Electrophysiological society
- QTc >0.44 with no other causes (0.46 sec)
- Positive family history plus unexplained syncope,
seizure or cardiac arrest proceeded by trigger such as
exercise, emotion
 Treatment

 Discuss with cardiologist

 Avoid drugs associated with long QT
 Avoid swimming, competitive sports
 Beta blockers
 Demand cardiac pacing (Pacemaker and defib)
 Left cardiac sympathetic denervation
 Prognoses
 Untreated 75-80% mortality

 Beta blockers reduce mortality to some extent

 The adjusted annual mortality rate on treatment is 4.5%

(10 year mortality of 50%)
 Advise related to CHD
 If one child has CHD, what are the chances of the
second?

 One parent has CHD, can offspring be affected? What

are the chances?

See Handouts, statistical list of potential risks

Pathophysiology of congenital heart lesions
Pathophysiology of left to right shunt lesions ASD
Pathophysiology of left to right shunt
lesions VSD
Pathophysiology of left to right shunt
lesions PDA
Pathophysiology of left to right shunt
lesions AVSD
Pathophysiology of Obstructive and valvular
regurgitation lesions MR
Pathophysiology of Obstructive and valvular
regurgitation lesions AR
Pathophysiology of Obstructive and valvular
regurgitation lesions PR
Pathophysiology Cyanotic lesions
TGA with good mixing

65%

LA 90%

RV 80% LV 90%
 Pathophysiology
TGA with poor mixing

30% 100%

45%
LA 92%

RV 45% LV 92%

45%
 Pathophysiology
TGA with poor mixing

30% 100%

45%
LA 92%

RV 45% LV 92%

45%
 Tips

 Read ECGs, easy to loose ECG skills.

 Ask for help
 As all specialties, it is only common sense.