2025 – PAGE 140 – CARDIOLOGY
PERICARDIAL EFFUSIONS
In pericardial effusions, the heart can look like a “bag of water” heart on the chest X-ray. It can also result in Kussmaul’s sign (increased JVD with inspiration). If you suspect this condition, the “best first test” to order is probably a cheap/quick CXR to look for the classic shape or cardiomegaly. Treat with PERICARDIOCENTESIS if causing cardiovascular compromise; smaller effusions may not require treatment or may be treated with anti-inflammatory drugs.
MYOCARDITIS
For myocarditis, tachycardia (sinus tachycardia or an arrhythmia) is often the presenting symptom. Also, look for fever, sudden heart failure symptoms (gallop, hepatomegaly, splenomegaly), pulsus paradoxus, or a combination of these. It may result in a new holosystolic, apical (mitral) murmur due to distortion of the LV, but there is usually no associated murmur. Differential includes COCKSACKIE B (obtain titers), Kawasaki’s Disease, Rheumatic fever, and a simple viral syndrome.
EARLY CONGESTIVE HEART FAILURE
If you note signs of CHF within the first week of life, consider obstructive lesions on the left side of the heart as well as a GREAT VEIN OF GALEN MALFORMATION (a type of intracranial AVM that results in a machine-like murmur in the SKULL). Treat with dobutamine for LV failure and use diuretics if there is pulmonary edema. Provide oxygen, correct an acidosis if present, and give PGE to maintain a PDA. For children with high fevers and a history of CHF, use antipyretics to prevent high output cardiac failure.
HYPERTROPHIC CARDIOMYOPATHY = HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HCM, HOCM)
Hypertrophic cardiomyopathy (HOCM) is usually an AUTO DOMINANT disorder resulting in septal hypertrophy which leads to left ventricular outflow tract (LVOT) obstruction and mitral regurgitation. Patients are at risk for sudden collapse and death. It is a major cause of sudden death in young athletes. Any child with an affected first-degree relative should be followed by a cardiologist for early detection of HOCM as they get older. The murmur of HOCM is unique in that it increases with standing or Valsalva, and decreases with squatting. HOCM is more likely in children with NOONAN SYNDROME. INFANTS OF DIABETIC MOTHERS (IDM) may have a transient form of HOCM that generally resolves spontaneously and is not a risk factor for later disease.
PEARLS: The murmurs of MVP and HYPERTROPHIC CARDIOMYOPATHY (HCM or HOCM) are both murmurs that increase with standing or Valsalva, and decrease with squatting. There are two ways to differentiate these murmurs.
- CLICK: Only MVP murmurs are preceded by a CLICK.
- HAND GRIP MANEUVER: Increases the MVP murmur and diminishes the HOCM murmur.
- MNEMONIC: (DOUBLE TAKE) “Baseball’s MVP (most valuable player) is a pitcher. Whenever he’s STANDING on the mound and HOCing loogies/spit, the crowd gets extremely LOUD to see him in action! If he gets hurt and has to SQUAT, the noise from the crowd suddenly DIMINISHES.” This should help you remember the key exam findings for MVP and HOCM.
- KEY: GRIP = Increased noise for MVP only: “When the MVP gets his trophy, he stands at a podium and GRIPS the trophy tightly over his head, and the stadium erupts in LOUD cheer.”
- “A MOONMAN stands on the moon in his astronaut suit and HOCs/spits a loogie into her RIGHT PALM.” MOONMAN = NOONAN, HOCs a loogie = HOCM, RIGHT = Right side of the heart, and PALM = “PALMonary stenosis”
- IDM association: The “D” of Diabetes looks like a hypertrophic septum.