cardiovascular diseases in child health nursing

A congenital heart defect is a problem with the structure of the heart that a child is born with.

Some congenital heart defects in children are simple and don't need treatment. Others are more complex. The child may need several surgeries done over a period of several years.

1. CARDIOVASCULAR DISEASE in children B havya N Kelavadiya Nursing Tutor CONTINUE

2. CONGENITAL HEART DISEASE (CHD)

3. CONGENITAL HEART DISEASE (CHD) It is the structural malformation of heart or great vessels, present at birth. It is the most common congenital malformation. The exact number of prevalence is not known.

4. ETIOLOGY The exact cause of CHD is unknown in about 90% of cases. Heredity and consanguineous marriage are important etiological factor. Genetic disorders and chromosomal aberrations are also known to predispose CHD. Other associated factors responsible for CHD include fetal and maternal teratogenic infections (rubella), teratogenic drug ( tholidomide ) intake, alcohol intake by the mother and irradiation in first trimester of pregnancy, maternal IDDM, high altitude, fetal hypoxia, birth asphyxia etc.

5. C lassification CHD can be grouped into three categories: Acyanotic CHD Cyanotic CHD Obstructive lesions

6. Ventricular septal defect A ventricular septal defect (VSD) is an abnormal opening in the septum between right and left ventricles. It is the most common acyanotic congenital heart disease with left to right shunt. It is found approx. 25% of all CHD. The size of defect can be small or large. Large VSD can be restrictive or nonrestrictive type.

7. Number of defects can be single or multiple. VSD can be found as perimembranous or muscular. Pathophysiology: There is flow of oxygenated blood from high pressure left ventricle to low pressure right ventricle through the VSD. Increased right ventricular and pulmonary arterial pressure leads to pulmonary over circulation. Increased venous return to the left heart result in left heart dilation.

8. Long-standing pulmonary over circulation causes change in pulmonary arterial bed resulting increased pulmonary vascular resistance, which can reverse the shunt from right to left. This complicated condition is known as Eisenmenger’s complex. The child with this condition present with cyanosis and surgical correction of VSDs is not possible in this stage.

9. Clinical manifestations Small VSDs are asymptomatic. In large defects, symptoms develop within 1 to 2 month of age. The manifestation are, Recurrent chest infections Feeding difficulties Tachypnea Exertional dyspnea Pale tachycardia

10. Exertional dyspnea Delicate looking Excessive sweating associated with feeding Poor weight gain Failure to thrive Hepatomegaly

11. Diagnostic evaluation History of illness Physical examination Auscultation of harsh systolic murmur and pulmonary second sound (p2) are important for diagnosis of the condition. Chest X-ray shows enlargement of the heart and increased pulmonary vascular marking. ECG reveals biventricular hypertrophy.

12. Management In small VSD, usually no medical management is required. Surgical repair may be indicated in some cases. Prevention of complication is very essential measures. Surgery is done as one-stage or two-stage operation.

13. Arterial septal defect (ASD) is an abnormal opening between right and left atria resulting left to right shunting of blood. It accounts for 9% of all CHDs. A rterial septal defect

14. T ypes Ostium secundum ASD- middle of the arterial septum Ostium primum ASD- at the bottom of arterial septum Sinus venosus ASD- at the Top of arterial septum.

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16. Clinical manifestations Ostium secundum and sinus venosus ASDs are usually asymptomatic. The child may have recurrent chest infections Dyspnea on exertion Easy fatigability Bulging on chest Poor weight gain Cardiac enlargement

17. Diagnostic evaluation Physical examination Chest X-ray shows right atrial and ventricular dilation ECG Doppler

18. Management Surgical closure of the defect is planned in early childhood to prevent further complication. Repair of defect is done by suture closure or pericardial patch repair by open heart surgery.

19. C ongestive cardiac failure (CCF) CCF is a common pediatric emergency. It is also termed as congestive heart failure (CHF). It indicates inadequate cardiac output. It is defined as “ inability of the heart to maintain an output at rest or during stress, necessary for the metabolic needs of the body (systolic failure) and inability to receive blood into the ventricular cavities at low pressure during diastole (diastolic failure)”.

20. It is a syndrome due to various anatomical or pathological causes. Systolic failure is much more common clinical problem.

21. Causes Acute rheumatic fever Rheumatic heart disease Myocarditis HTN Cardiomyopathy Paroxysmal supra-ventricular tachycardia. Chronic pulmonary disease Respi . Infection anemia

22. Clinical manifestation Tachycardia Poor peripheral perfusion Pallar skin Cool extremities Excessive perspiration Restlessness Tachypnea Cyanosis Chest retraction Nasal flaring/ grunting

23. Pulmonary edema Dyspnea Hepatomegaly Scrotal and orbital edema Oliguria Water weight gain Neck vein distension Feeding difficulties Abdominal discomfort anorexia

24. Diagnostic evaluation History collection Physical examination Auscultation Capillary refill Palpation Chest X-ray

25. Management Correction of inadequate cardiac output Positioning O2 therapy Sedatives Digitalis is most important drugs for management Diuretics Diet

26. ARF is an acute autoimmune collagen disease occurs as a hypersensitivity reaction to group-A beta hemolytic streptococcal infection. It is characterized by inflammatory lesions of connective tissue and endothelial tissue. It affects heart, joint, blood vessels and other connective tissue. Acute R heumatic Fever

27. It is the most important acquired heart disease in children and commonly found in 4 to 15 years of age children. The predisposing factors of ARF are genetic predis - position, temperate climate, winter season, unhygienic living conditions, overcrowding in the family, poor dietary intake and increasing immunological response.

28. P redisposing factors and etiology The predisposing factors of ARF are genetic predispose . position , temperate climate, winter season, unhygienic living conditions , overcrowding in the family, poor dietary intake pride, and increasing immunological response . The etiology of rheumatic fever is not clear, but there strong association with beta-hemolytic streptococcal sore throat.

29. The clinical features of acute rheumatic fever can be grouped as major, minor and essential manifestations or criteria, as described in modified Jones criteria (revised) for diagnosis of rheumatic fever . A. Major manifestations or criteria B. Minor manifestations or criteria C. Essential criteria Clinical manifestation

30. A.Major Manifestations or Criteria Carditis : It is an early manifestation of rheumatic fever as pancarditis , i.e. pericarditis, myocarditis and endocarditis. Polyarthritis : It is usually flitting or migratory type of joint inflammation with pain, decreased active movements, warm, tenderness, redness and swelling. Two or more joints are affected. Chorea : It is purposeless involuntary, rapid movements, usually associated with muscle weakness, incoordination, involuntary facial grimace .

31. Subcutaneous nodules : It is found as firm painless nodule over the extensor surface of certain joints, (elbows, knees and wrists), occiput and vertebral column . Erythema marginatum : It is pink macular non-itching rash, found mainly over trunk, sometimes on the extremities but never on face.

32. B.Minor Manifestations or Criteria Fever : Increase in body temperature is common findings. Arthralgia : Pain in the joints occurs in about 90 % cases. ECG changes with prolonged P-R interval is considered minor criterion.

33. C. Essential Criteria: Elevated antistreptolysin -O (ASO) titer indicates previous streptococcal infection (normal 200 IU/mL ). Positive throat swab culture may show streptococcal infection (sore throat, scarlet fever, etc.)

34. Other Manifestations: which may found in case of ARF include precordial pain, abdominal pain, headache, easy fatigability, general weakness, tachycardia, malaise, sweating, vomiting skin rash, epistaxis, anemia, pleuritis , weight loss, etc.

35. Diagnostic Evaluation: Doppler echocardiography is considered as an important diagnostic approach . Artificial subcutaneous nodule test. Endomyocardial biopsy Chest X-ray shows cardiomegaly and heart failure. Electrocardiography Blood test for ESR, ASO-titer, WBC counts (leukocytes).

36. Management: Bed rest is important in the management of children with rheumatic fever. Nutritious diet to be provided with sufficient amount of protein, vitamins and micronutrients. Avoid rich spicy food . Antibiotic therapy, penicillin is administered after skin test to eradicate streptococcal

37. Infective endocarditis Infective endocarditis is the inflammation of the endocardium, the inner lining of the heart . It occurs due to bacterial and fungal infection and as serious complication of congenital heart disease and rheumatic ( valvular ) heart disease . Infective endocarditis should be considered as medical emergency, since it can damage valves, myocardium and other vital organs like brain and kidneys.

38. Etiological factors The most common infective organisms are: Streptococcus E-coli Pseudomonas And some gram negative bacterias etc.

39. Clinical manifestation The onset of endocarditis may be acute or chronic. Low-grade fever Chills Night sweating Malaise Anorexia Rigor Weight loss

40. Pain and diffuse myalgia may present. Initially features of cardiovascular involvement may be absent. Appearance of features of heart failure, abnormal heart sound and splinter hemorrhages (under nails and conjunctiva) are found. Clubbing , petechiae , anemia and splenomegaly are usually present.

41. Osier nodes (tender erythematous nodules over the pulp of fingertips) may be seen in some patients. Hematuria , GI bleeding, CNS embolism indicates cardiovascular involvement. Janeway lesion as non-tender erythematous patches over palms and soles also may found in some cases.

42. Diagnostic evaluation History collection Blood culture Echocardiography ECG and immunological examination Urine examination

43. Management Management of infective endocarditis should be started as early as possible using heavy dose of antimicrobial agents for a long period to treat current episodes and to prevent relapse of the condition . Appropriate antibiotic therapy need to be administered for 4 to 6 weeks . The commonly used antibiotics are penicillin in massive dose, gentamicin, streptomycin, cefezolin , ampicillin, coxacillin , amikacin , vancomycin , etc.

44. R heumatic heart disease 2 Rheumatic fever may have complications as valvular involvement resulting the diseases of mitral, aortic and tricuspid valves. The common rheumatic heart disease includes mitral regurgitation and mitral stenosis. Aortic valve and tricuspid valvular disease include mainly aortic and tricuspid regurgitation.

45. Mitral regurgitation or incompetence Mitral regurgitation is the backflow of blood from the left ventricle into the left atrium resulting from imperfect closure of the mitral valve. It is the most common complication of acute or recurrent rheumatic carditis . There is left ventricular dilation and hypertrophy along with shortening and thickening of the chordae tendineae .

46. Clinical manifestation Left atrial enlargement with atrial arrhythmias, pulmonary edema and pulmonary hypertension may develop in long-term illness with this condition . The patients may present with easy fatigability, exertional dyspnea due to reduced cardiac output and palpitation due to atrial arrhythmias.

47. Diagnostic evaluation The most important auscultatory finding is a moderately low blowing pansystolic murmur at the apex . It may be transmitted to the left axilla, to back and upwards . A systolic thrill is usually felt at the mitral area. Echocardiography (ECG) and chest X-ray are important diagnostic measures.

48. Management Medical management is done for controlling of CCF, penicillin prophylaxis against future recurrence of rheumatic fever and prevention against infective endocarditis . Surgical management of mitral regurgitation includes mitral valve repair or replacement of it by prosthetic valve.

49. Mitral stenosis Mitral stenosis is the narrowing of the mitral orifice obstructing free flow of blood from the left atrium to the left ventricle . Mitral opening gets tight due to progressive sclerosis of the base of the mitral ring, It develops relatively late in children with rheumatic carditis .

50. Clinical manifestation The child with mitral stenosis presents with dyspnea on exertion or even at rest or as paroxysmal nocturnal dyspnea and palpitation, Tiredness, cough, hemoptysis and peripheral cyanosis may present. Pulmonary edema, atrial fibrillation and atypical angina may also develop but in less frequency.

51. Diagnostic evaluation On examination, distended neck veins, weak peripheral pulses, palpable RV impulse and prominent precordium are found . Diagnosis is confirmed by important auscultatory findings, ECG, echocardiography and chest X-ray.

52. Management Medical management of a patient with mitral stenosis is done with rest, digitalis, diuretics, activity restriction, salt restricted diet. Surgical management is performed as closed mitral valvotomy , if the heart failure does not responds to medical management. Surgery is done in absence of carditis .

53. Aortic Regurgitation or Incompetence Aortic regurgitation is the backflow of blood into the left ventricle due to an incompetent aortic valve. It is less frequent than mitral regurgitation. It occurs due to sclerosis of aortic valve resulting shortening, distortion and retraction of the cusps leading to inadequate closure . Left ventricular hypertrophy , pulmonary edema and CCF developed as consequence of the condition.

54. Clinical manifestation In chronic and severe cases, the clinical presentations include palpitations, exercise intolerance, exertional dyspnea, even paroxysmal nocturnal dyspnea and angina pain. CF Characteristic rapid water-hammer pulse, wide pulse pressure, early diastolic murmur and cardiac enlargement are important features present in case of aortic regurgitation.

55. Diagnostic evaluation Chest X-ray Physical examination ECG and clinical examination along with history of illness help in diagnosis

56. Medical management Medical management of aortic regurgitation is done with diuretics, digoxin, salt restriction in diet and vasodilators like ACE inhibitors and antiarrhythmic agents . Surgical management is done in the form of aortic valvotomy or aortic valve replacement by prosthetic valve and homograft. Valve replacement should be planned before the child develops CCF.

57. Tricuspid Regurgitation Tricuspid regurgitation is the backflow of blood from the right ventricle into the right atrium. It is found in about 20 to 50% cases of rheumatic heart disease. There are no specific symptoms of this condition. It is a common accompaniment of mitral stenosis and mitral incompetence.

58. Tetralogy of Fallot (TOF) TOF is the most common cyanotic congenital heart disease. It accounts for 6 to 10% of all CHDS. This condition is characterized by the combinations of four defects: (1 ) pulmonary stenosis, (2) ventricular septal defect, (3) overriding or dextroposition of the aorta and (4) right ventricular hypertrophy.

59. Clinical manifestation Clinical features of TOF depend with upon size of VSD and degree of right ventricular outflow obstruction. Blue baby or cyanosis of lips and nail beds with dyspnea is found initially with crying and exertion in neonates especially when the ductus arteriosus begins to close .

60. Diagnostic evaluation Details history of illness Physical examination Chest X-ray shows poorly vascularized lung fields, a mall boot-shaped heart ECG shows right axis deviation

61. Management Medical management: The child with TOF should be managed for cyanosis, hypoxic spells and other associated complications. Oxygen therapy, correction of dehydration, anemia, antibiotic therapy, supportive nursing care and continuous monitoring of child's condition are very important measures.

62. Surgical management: Surgical interventions can be planned as palliative surgery or definitive correction in one stage repair. Palliative surgery is performed by different techniques as Modified Blalock- Taussig (BT) shunt, Potts' operation or Waterson's operation.

63. Cardiomyopathy is the abnormalities of the myocardium in which there is impairment of the contractility of cardiac muscles . It includes any disease that affects the heart muscle resulting diminished cardiac performance . C ardiomyopathy

64. Clinical manifestation The child with cardiomyopathy may present with asymptomatic condition. Common symptoms are shortness of breath, chest pain, orthopnea and other symptoms of CHF. Patients may have ventricular arrhythmias, palpitation, syncope or sudden death.

65. Etiological factors The possible etiological factors are familial or genetic cause, infections, deficiency states (selenium), metabolic abnormalities and collagen vascular diseases . In children most of the cases of cardiomyopathy are considered as primary or idiopathic, in which the causes are unknown and the cardiac dysfunction is not associated with systemic disease.

66. They may be due to abnormalities of the cell function of the cardiac myocyte . Some known causes of secondary cardiomyopathy are drug toxicity (antineoplastic), hemochromatosis (excessive iron store ), Kawasaki disease, collagen disease and thyroid dysfunction.

67. Types of Cardiomyopathy Dilated Cardiomyopathy: It is most common type found in children and also known as idiopathic dilated cardiomyopathy (IDC). This condition is characterized by ventricular dilation with greatly decreased contractility and weakness of the heart muscle. Cause of this disease is mainly uncertain or may be due to familial inheritance or due to viral infection and toxic exposure.

68. Idiopathic dilated cardiomyopathy is manifested with CHF, tachycardia, dyspnea, hepatosplenomegaly , poor growth, fatigue and dysrhythmia. Chest radiography echocardiography, cardiac catheterization with endomyocardial biopsy are usually helpful to diagnose the condition , to identify the cause and to manage appropriately.

69. 2. Hypertrophic (Cardiomyopathy): It is characterized by an increase in heart muscle mass without an increase in cavity size usually in left ventricle. There is excessive and disorganized growth of myofibrils and impaired filling of heart with reduction in the size of ventricular cavity. Infant of diabetic mother may have this condition, which may resolve with time.

70. Clinical features usually present in school-aged children with time. or in adolescents. Common symptoms are anginal chest pain, dysrhythmias, syncope and sudden death. The child may present with CHF in infancy with poor prognosis. Diagnosis is confirmed by chest X-ray and ECG. Echocardiography is most helpful to identify septal hypertrophy and an increase in LV wall thickness with small LV cavity.

71. 3. Restrictive or Constrictive Cardiomyopathy: it is rare condition in children. This condition is caused by endocardial and myocardial disease or both due to lack of flexibility of ventricular walls. It may found in case of hemo - chromatosis and amyloidosis. Thrombus formation and embolic events are common. Elevation of pulmonary vascular resistance may occur. The child usually present with CHF.

72. 4. Congestive Cardiomyopathy: It is mainly found in myocardial disease associated with enlargement of left ventricle of the heart and CHF . 5. Secondary Cardiomyopathy: This condition is usually associated with well-defined systemic disease, like inflammation, toxic chemicals, metabolic abnormalities and inherited muscle disorders.

73. Therapeutic Management Treatment should be done according to the specific cause. Aim of treatment is management of CHF and dysrhy - thmias . Digoxin , diuretics and aggressive use of afterload reduction agents have been found to be helpful for dilated cardiomyopathy . Beta-blockers or calcium channel blockers have been used for hypertrophic cardiomyopathy.

74. 4. Careful monitoring and treatment of dysrhythmias are essential. Anticoagulants may be given to reduce the risk of thromboembolic events.