2025 – PAGE 141 – CARDIOLOGY

CARDIOMEGALY AND HYPERTROPHY

Cardiomegaly means a “big” heart, whereas hypertrophy means a “thick” heart (which can result in cardiomegaly). For the purposes of the boards, these terms are likely synonymous. Cardiomegaly is often a NORMAL finding in athletic kids. Septal hypertrophy/HOCM is not.

CHEST PAIN

Chest pain in children is common, but it is rarely due to cardiac issues. The cause is often unknown. Refer the patient to a cardiologist only if the chest pain is noted with exertion. If a patient has left-sided chest pain at rest that increases with inspiration and resolves without intervention within seconds to minutes, it’s probably PRECORDIAL CATCH SYNDROME. Consider pericarditis if the history, physical exam, or EKG findings are suggestive.

SVC SYNDROME

SVC syndrome is most commonly due to some type of cancer, especially lymphoma. Symptoms include facial swelling, grayish/dusky skin color, weight loss, and night sweats. There is no pulmonary issue, and the arterial circuit is unaffected, so the patient’s O₂ saturations should be NORMAL. Treat with steroids, radiation, and cancer-specific therapy.

MEDIALLY DISPLACED PMI

A medially displaced PMI can be found in:

• DEXTROCARDIA: If presented with a patient whose PMI is on the RIGHT, think DEXTROCARDIA.
• PRIMARY CILIARY DYSKINESIA= KARTAGENER SYNDROME: Autosomal recessive disorder. Patients with this disorder have dextrocardia (heart on the right side) and also SITUS INVERSUS (major visceral organs in a mirrored position). In addition to dysfunctional cilia in the respiratory tract, they also have nasal polyps and immotile sperm. If presented with a patient who has nasal polyps, a PMI on the RIGHT side of the chest, and a history of chronic sinus or pulmonary infections, think PRIMARY CILIARY DYSKINESIA. Diagnose by obtaining electron microscopy of nasal scrapings.
  • PEARL: Patients’ medical histories can sound very similar to cystic fibrosis patients, so focus on subtleties such as the PMI or an X-ray showing an inverted location of bowel loops.

PEDIATRIC BLOOD PRESSURE GUIDELINES

Hypertension affects 3.5% of all children and adolescents and many of these kids go undiagnosed and untreated. Therefore, the most recent guidelines released by the AAP simplify the identification and treatment of high blood pressure in children.

• NORMAL BP: For someone with a normal BP, do annual BP screenings at well-child checks starting at 3 years of age and routine lifestyle counseling about weight and nutrition.
• ELEVATED BLOOD PRESSURE: This is defined as a blood pressure that is between the 90^th and 95^th percentile for height. Offer counseling on lifestyle modifications (healthy diet, sleep, physical activity) and schedule a second BP measurement in 6 months. If the 2^nd measurement is also high, check upper and lower extremity BPs. If it still falls in the “elevated BP” range, get a third BP measurement in another 6 months. If it’s still elevated, start ambulatory blood pressure monitoring (ABPM), start a diagnostic evaluation and consider a subspecialty referral.
• STAGE 1 HYPERTENSION WITH INITIAL BP MEASUREMENT: This is defined as a blood pressure that is > 95^th Offer lifestyle counseling and obtain a second BP measurement in 1-2 weeks. If it’s still at Stage 1, check upper and lower extremity BPs and repeat BP measurements in 3 months. If it’s still at Stage 1, start ambulatory blood pressure monitoring (ABPM) to confirm HTN, start a diagnostic workup, initiate pharmacologic treatment and consider a subspecialty referral.
• STAGE 2 HYPERTENSION: This is defined as a blood pressure that is ³ 99^th Check upper and lower extremity BPs and offer lifestyle counseling. The second BP measurement should occur within 1 week OR you can make a subspeciality referral immediately and schedule a consultation within 1 week. If you check the second BP measurement yourself in about a week and it still fits the Stage 2 criteria, start ambulatory blood pressure monitoring (ABPM) and start pharmacologic treatment, or refer to a subspecialist to be seen within 1 week. If the patient is ever symptomatic, or the BP is very high (> 30 mm Hg above the 95^th percentile), refer to the ED. A child with any of the following criteria should be started on a low dose on a single medication (ACE inhibitor, ARB, long-acting calcium channel blocker, or a thiazide diuretic):
  • Remains hypertensive despite lifestyle modifications
  • Has symptomatic hypertension
  • Has persistent Stage 2 hypertension with or without a risk factor (e.g., obesity)
  • Has hypertension associated with chronic kidney disease or diabetes mellitus
• DIFFERENTIAL DIAGNOSIS: Wrong cuff size (cuff bladder length should be long enough to encircle 80% to 100% of the patient’s arm circumference, and the bladder width should equal 40% to 50% of the upper arm circumference), Cushing’s, 17-hydroxylase deficiency, Pheochromocytoma, Hyperaldosteronism, Lupus, Renal artery stenosis, Polycystic Kidney Disease (PCKD), Vesicoureteral Reflux (VUR), and Coarctation. Treat essential hypertension with WEIGHT LOSS first or admit the patient for IV nitrates if extremely high.
  • PHEOCHROMOCYTOMA: Labs include elevated serum metanephrines and elevated urine vanillylmandelic acid(VMA, which can also be elevated in neuroblastoma). Treat with alpha blockade prior to resection. Because of downregulation of catecholamine receptors, patients are highly susceptible to orthostatic hypotension. Children may also have labile blood pressure.
• Use a screening table (like this www.pbrlinks.com/BPGUIDE) to identify children at risk for high blood pressure. Locate the age and the child’s percentile of height. Then locate the 90^th percentile of blood pressure for those parameters. Higher blood pressures could mean “elevated blood pressure” or hypertension.