Cardiovascular system. Systolic blood pressure

1. CARDIOVASCULAR SYSTEM

2. Plan of the lectures

1. Semiotic of disorders of CVS.

3. BLOOD PRESSURE

Systolic blood pressure:
till 1 year old = 76 + 2 x n (n – months)
above 1 year old = 90 + 2 x n (n – years old)
Diastolic blood pressure:
above 1 year old = 60 + n (n – years old)

4. COMPLAINS

Weakness
Fatigability
Disorders of appetite
Dyspnoea
Color of the skin: cyanosis or paleness
Pain of the heart region
Headache
Palpitation

5. INSPECTION

General condition
Position of child in the bed
Physical development (proportional or
disproportional)
Deformation on the chest (cardiac hump)
Color of the skin
Temperature of extremities
Moistness of the skin
Edema of low extremities
Pulsation of carotids
Jugular venous distention
Visible pulsation of heart
(intensive apical thrust (N-1cm2); heart thrust)

6. PALPATION

Localization of apical thrust
Cardiac thrust
Trembling above the mitral valve and it’s
characteristic
Presents of cat’s purr

7. Estimation of pulse:

Rhythm (N - respiratory arrhythmia reveals
from 2 till 10 years old)
Rate
Symmetric
Synchronic
Tension
Size

8. PERCUSSION

Method of percussion of children over 4
years old is same with adults.
Until 4 years old use modification.

9. BORDERS OF RELATIVE HEART’S DULNESS

Age
(years
old)
Borders
Upper
Right
Left
under 2
II costae
2 cm outside from
right sternalis line
2 cm outside from
left medioclavicular line
2–6
II intercostals
space
1 cm outside from
right sternalis line
1 cm outside from
left medioclavicular line
7 – 12
upper border
of III costae
0,5 cm outside from
right sternalis line
0,5 cm outside from
left medioclavicular line
older 12
III costae
or
right sternalis line
III intercostals
space
left medioclavicular line
or 0,5 cm inwards

10. BORDERS OF RELATIVE HEART’S DULNESS

Upper
under 2 у.о.
II costae
2–6
II intercostals
space
7 – 12
upper border
of III costae
older 12
III costae
or
III intercostals space

11. Right

under 2
2 cm outside from
right sternalis line
2–6
1 cm outside from
right sternalis line
7 – 12
0,5 cm outside from
right sternalis line
older 12
right sternalis line

12. apical thrust

4 intercostals space to the
left of sternum (5) from left
medioclavicular line

13. Left

under 2
2 cm outside from
left medioclavicular line
2–6
1 cm outside from
left medioclavicular line
7 – 12
0,5 cm outside from
left medioclavicular line
older 12
or
left medioclavicular line
0,5 cm inwards

14. SEQUENCE OF AUSCULTATION OF HEART

Sequence of
auscultation
points
Place of auscultation
Valves
1st
Cardiac apex
Mitral
2nd
II intercostals space to the right of
sternum
II intercostals space to the left of
sternum
Place of connection xiphisternum to
sternum, a little to the right
Aortal
3rd
4th
5th
Pulmonary
Tricuspid
Place of joining III-IV ribs to the edge Mitral and
of sternum
Aortal

15. 1st

Cardiac apex

16. 2nd

II intercostals space to
the right of sternum

17. 3rd

II intercostals space to
the left of sternum

18. 4th

Place of
connection
xiphisternum to
sternum, a little to
the right

19. 5th

Place of joining IIIIV ribs to the edge of
sternum

20. CARDIAC MURMURS

21. Cardiac murmurs – additional sounds heard during auscultation of the heart.

22. CHARACTERISTIC OF MURMURS

Organic
Functional
Organic-functional
Physiological
Cardiac
Extracardial
Combined
Systolic
Diastolic
Timbre
Irradiation
Force
Duration

23.

24. RHEUMATIC FEVER (ACUTE RHEUMATIC HEART DISEASE)

Rheumatic heart disease (RHD) occurs after
acute rheumatic fever (ARF), which is a
postinfectious immune disease secondary
to a streptococcal infection.
RHD affects the valves of the heart, with the
mitral and aortic being the most commonly
affected valves. RHD is more likely to
occur with recurrent episodes.

25. Diagnosis

Diagnosis of ARF is made from the
modified Jones criteria, with a positive
diagnosis requiring two major or one
major and two minor criteria.

26. SYMPTOMS

Carditis: chest pain, shortness or breath, cough,
palpitations with sensation of elevated or irregular
rate or rhythm, anorexia, fatigue, and exercise
intolerance.
Arthritis: occurs in 70% of patients with ARF;
symptoms include joint pain.
Sydenham’s chorea: affects 15% of patients with
ARF; reflects involvement of basal ganglia of central
nervous system; appears ~3 months after
streptococcal infection; symptoms include emotional
liability and loss of attention span.

27. SIGNS

carditis
tachycardia
murmur: mitral insufficiency, relative mitral stenosis,
or aortic insufficiency
congestive heart failure
arrhythmias
pericarditis
arthritis: large joints (knees, ankles, wrists, elbows);
asymmetric and migratory
Sydenham’s chorea: involuntary and purposeless
movements and muscular incoordination; erythema
marginatum: 5%; subcutaneous nodules: <5%.

28. INVESTIGATIONS

Chest radiography: cardiomegaly when carditis is present;
pulmonary venous congestion and/or pulmonary edema may
be present when congestive heart failure occurs.
ECG: sinus tachycardia; PR prolongation with myocarditis;
nonspecific ST-T abnormalities or T wave inversion;
premature atrial or ventricular contractions.
Echocardiography: used to evaluate the presence and
degree of myocardial dysfunction, specific chamber
enlargement
Acute phase reactants: elevated WBC , ESR, CRP.
Streptococcal infection: elevated streptozyme; antistreptolysin O, antistreptokinase, anti-hyaluronidase.

29. Modified Jones criteria for the diagnosis of acute rheumatic fever

Major
manifestations
Minor
manifestations
Supporting evidence
Carditis
Arthralgia
Positive throat culture
for group A
Streptococcus
Polyarthritis
Fever
Chorea
Erythema marginatum
Elevated acute phase Elevated or rising
reactants: ESR and C- streptococcal
reactive protein
antibody titer
Subcutaneous nodules
Prolonged PR interval

30. MYOCARDITIS

Definition
Inflammation of myocardium in association with
necrosis.
Presentation
Mild to moderate congestive heart failure
(CHF).
Severe CHF or shock.
Non-CHF: arrhythmia, sudden death.
History of prior gastrointestinal or flu-like
illness.

31. SYMPTOMS

Poor feeding or decreased appetite,
shortness of breath or dyspnea, easy
fatigability or general malaise: indicate
CHF.
Palpitations with sensation is
increased, irregular heart rate or
skipped or hard beats; chest pain;
dizziness, presyncope or syncope;
cardiac arrest/sudden death: indicate
arrhythmia.

32. SIGNS

Tachycardia, irregular pulse.
Soft, indistinct heart sounds.
Mitral or tricuspid regurgitation.
Systolic murmur of atrioventricular (AV) valve
regurgitation.
Tachypnea.
Rales: associated with pulmonary edema.
Hepatomegaly.
Hypotension: associated with shock.
Weak peripheral pulses.
Poor perfusion.
Jugular venous distention.
Pallor or cyanosis.

33. INVESTIGATIONS

ECG
Chest radiography
Echocardiography (ECHO)
Radionuclide studies
Laboratory studies
Endomyocardial biopsy

34. ENDOCARDITIS

35. SYMPTOMS

Fever and sweating.
Easy fatiguability, malaise.
Palpitations.
Weight loss and anorexia.
Signs
Fever.
Tachycardia with new (or changing) cardiac
murmur(s).
Splenomegaly.
Embolic phenomena

36. INVESTIGATIONS

Laboratory tests
Blood cultures.
Acute phase reactants
Complete blood count
Urinanalysis: hematuria.
Echocardiography!

37. COMPLICATIONS

Destruction of cardiac valve tissue: can
result in aortic, mitral, or tricuspid
insufficiency; resultant need for cardiac
valve replacement.
Congestive heart failure.
Myocardial abscesses with cardiac
arrhythmias and atrioventricular block.
Systemic embolization: potential for
stroke or cerebral mycotic aneurysm.

38. PERICARDITIS AND TAMPONADE

39. Pericarditis

SYMPTOMS AND SIGNS
Mild to severe pericardial pain on inspiration
or worse on inspiration: may radiate to neck
and shoulders; worse on coughing,
swallowing, or sneezing; improved by
leaning forward.
Fever.
Pericardial, often pleuropericardial, coarse
rub: best heard at left sternal edge with
patient leaning forward
Pericardial effusion: varies from small to
large.

40. Tamponade

Symptoms similar to pericarditis: pain, cough, hoarseness,
tachypnea, dysphagia; malaise, cyanosis, dyspnea, sweating,
anxiety.
Tachycardias.
Low blood and pulse pressures.
Pulsus paradoxus: exaggerated reduction (>10 mm Hg) of
the normal inspiratory decrease in systolic blood pressure;
pulse may disappear on inspiration.
Hypotension: accompanied by signs of low cardiac output
(pallor, diaphoresis, poor perfusion with cool extremities).
Jugular venous distention: may increase on inspiration.
Hepatomegaly.
Muffled heart sounds.
Tachypnea.
Friction rub: heard with small to moderate effusions (may not
be present with
large effusions or tamponade).

41. INVESTIGATIONS

• For any pericardial disease, the underlying
cause must always be sought.

42. Pericarditis

Complete blood count, erythrocyte
sedimentation rate.
Antistreptolysin O titer, antineutrophil factor,
rheumatoid factor analysis.
Cardiac enzyme tests
Paired viral antibody screening:
Mantoux test.
ECG
Chest radiography.

43. Tamponade

Echocardiography.
Complications -Relapsing or
constrictive pericarditis, pericardial
effusion, and tamponade,
Hypotension, renal failure

44. CONGENITAL HEART DISEASE

Acyanotic
Cyanotic
Atrial septal defect
Tetralogy of Fallot
Ventricular septal defect
Pulmonary atresia with VSD
Patent ductus arteriosus
Pulmonary atresia with intact
ventricular septum
Atrio-ventricular canal defect
Transposition of the great arteries
Pulmonary stenosis
Double outlet right ventricle
Left ventricular outflow
onstruction
Ebstein’s anomalies
Coarctation of the aorta
Hypoplastic left heart

45. A ventricular septal defect

Oxygenated blood is usually shunted from
the left ventricle to the right ventricle.
Mixed blood then flows through the
pulmonary arteries. The incidence is from
1.5:1000 to 2.5:1000 live births.

46.

47. AN ATRIAL SEPTAL DEFECT

Oxygenated blood is usually shunted from
the left atrium to the right atrium. Mixed
blood then flows to the right ventricle and
into the pulmonary arteries.

48.

49. A PATENT DUCTUS ARTERIOSUS

Oxygenated blood from the aorta flows
through the patent ductus arteriosus and
mixes with the unoxygenated blood
flowing to the lungs in the pulmonary
arteries. The incidence is 1:2000 live
births.

50.

51. TETRALOGY OF FALLOT

(1) Right ventricular outflow obstruction,
(2) Ventricular septal defect,
(3) The aorta overriding the ventricular
septal defect.
(4) Right ventricular hypertrophy. The
incidence is 1:2000 live births.

52.

53. COARCTATION OF THE AORTA

Narrowing of the lumen results in
increased systolic blood pressure
proximal to the coarctation and
decreased systolic blood pressure distally.
The incidence is 1:13,000 live births.