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.
