FNP2 Module 5
CV/LIFE SPAN AND VASCULAR STUDY GUIDE
PEDI CAD
What are causes of CP in children? Palpitations?
● Chest pain in children
○ Most common = Costochondritis (inflammation in the joint between the breastbone and
ribs s/t viral illness or coughing)
○ Asthma
○ stress/anxiety
○ Acid reflux
● Palpitations?
○ Causes
Dehydration
Poor physical conditioning
Startled, frightened or stressed
Cold, allergies, or asthma medication
○ Red flags
anemia
thyroid issues
arrhythmias
What is exercise associated collapse?
● Endurance running
● Endurance sports
What is long QT syndrome?
● Long QT syndrome (LQTS) is a heart rhythm condition that can potentially cause fast, chaotic
heartbeats. These rapid heartbeats might trigger a sudden fainting spell or seizure. In some
cases, the heart can beat erratically for so long that it causes sudden death.
● You can have a genetic mutation that puts you at risk of being born with congenital long QT
syndrome. In addition, certain medications, imbalances of the body's salts and minerals
(electrolyte abnormalities), and medical conditions might cause acquired long QT syndrome.
What is ASD? VSD? PDA? What are signs and symptoms of each?
● Atrial Septal Defect: hole between the heart’s upper chambers (atria).
● Ventricular Septal Defect: hole between the heart’s lower chambers (ventricles).
● Patent Ductus Arteriosus: unclosed hole in the aorta (open in utero, should close after birth).
Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus:
● Acyanotic Lesions: L → R shunting = too much blood through lungs
● Think CHF (right sided failure) and pulmonary edema!
● Repeated respiratory infection
● Failure to thrive
● + Murmur
● Signs and symptoms of CHF
○ Tachypnea
○ Tachycardia
○ Sweating with feeds – Irritable
, ○ Edema
○ Rales
○ + Dyspnea
○ Hepatomegaly
***Know that a child should be referred for elevated B/P if under the age of 10.
What are common cardiovascular problems seen in children with Down’s Syndrome?
Atrioventricular Septal Defect
Ventricular Septal Defect
Persistent Ductus Arteriosus
Tetralogy of Fallot
Know 7 S’s of innocent murmurs
1. Sensitive (Murmur accentuates with position changes, activity - see below)
2. Short duration (Not holosystolic)
3. Single (Isolated murmur without click, gallop or other extra heart sounds)
4. Small (Murmur limited to small, focal distribution without radiation) - pulmonic area L sternal
border
5. Soft (Low amplitude Grade I- II)
6. Sweet (Non-harsh quality- vibratory or musical)
7. Systolic (Limited to systole)
Pathologic murmurs in children:
Grade 3 or greater
Holosystolic timing
Max intensity at LUSB
Harsh or blowing
Systolic clicks
Diastolic murmurs
Increased intensity in upright position
Gallop rhythm
Friction rub
Pathologic murmurs are also accompanied by signs and symptoms; in other words the patient
will be symptomatic
ADULT CARDIOLOGY
What are risk factors for CAD? Differentiate between modifiable and non-modifiable.
● Non-modifiable
○ Age - men > 45, women > 55
○ Sex - men > premenopausal women, men = women postmenopausal
○ Genetics/Family hx - <55 yoa for men, <65 yoa for women
○ Race/Ethnicity - AA population highest risk
● Modifiable
○ Smoking
○ Hypertension
○ Diabetes
○ Hyperlipidemia
, ○ Obesity
○ Sedentary lifestyle
What is the pathophysiology of CAD?
● CAD = insufficient blood flow through the coronary arteries
● Atherosclerosis is the underlying pathogenesis of CAD.
● Atherosclerosis = “Hardening of the vessels”
● The key processes in atherosclerosis are
○ intimal thickening
○ lipid accumulation
These will produce atheromatous plaque
● Chronic, repetitive injury to the endothelial lining in the blood vessel causing a neurohormonal
inflammatory response
What is asymptomatic angina?
● The degree of obstruction sometimes does not correlate with symptoms.
● Patient may be still asymptomatic despite high degree of obstruction
● Patient may also loss the sensation of pain as a result of neuropathy especially with diabetes
mellitus
● 25% of pt with asymptomatic angina the first manifestation is sudden death.
○ 20% of pt with AMI die before reaching hospital
○ Most common cause V-fib.
What is the pathophysiology of angina?
● Imbalance of oxygen supply and demand
● Decreased blood flow to myocardium
● Switch to anaerobic metabolism
● Lactic acid builds up
● Kinins, histamine, other substances released
● Nerve fibers are stimulated
○ → Results in chest pain
What is typical angina pain like?
● paroxysmal and usually recurrent attacks of substernal or precordial chest discomfort
● Described as constricting, squeezing and choking or knifelike
What is stable angina (exertional angina)? What are the pharmacologic and non-pharmacologic
treatments?
● Stable Angina
○ Also called exertional angina
○ The lumen of coronary artery is narrowed and hard; thus, dilation in response to
increased demand is impossible
○ Initiated by known amount of activity
○ Same activity tends to produce same symptoms
○ Produced by
Physical activity
Emotional excitement
, Extreme cold or hot weather
Large meals
Alcohol
○ Relieved by
Rest
Nitrates
● Clinical Manifestations
○ paroxysmal and usually recurrent attacks of substernal or precordial chest discomfort
○ described as constricting, squeezing, choking, or knifelike
● Pharmacologic Treatment:
○ Aspirin
○ Clopidogrel (Plavix)
○ Beta-blocker
○ ACE
○ Calcium channel blockers
○ Nitrates both long and short acting
○ Ranexa
○ Statins
● Non-Pharmacologic Treatment:
○ Smoking cessation
○ Physical activity 30-60 minutes, 5-7x/week
○ Cardiac rehab
○ Weight management
○ Stress management
○ Limited alcohol (1/day women, 2/day men)
What is unstable angina?
● Unstable Angina:
○ Recent onset
○ increase in severity, frequency or duration from usual
○ symptoms at rest
○ nocturnal symptoms.
● Chest pain
○ NO cardiac enzyme changes
○ NO ST elevation in ECG
Prinzmetal’s Angina (AKA Vasospastic Angina, or variant angina.)
Differs from atherosclerotic angina; resulting from coronary artery vasospasm; occurs in atypical
non-exertional, patterns
Sx of chest pain tend to be cyclical, with most episodes occurring in the early morning, w/o
regard to cardiac workload
Is believed to be due to vasospasm in coronary arteries w/o obstructive lesions
Distinguishing unstable angina pectoris r/t coronary atherosclerosis from variant angina may be
difficult & require special investigations for dx, including angiography.
Only about 4% of patients who undergo coronary angiography show evidence of focal spasm.
What is the difference from unstable angina vs. acute coronary syndrome (ACS)?
CV/LIFE SPAN AND VASCULAR STUDY GUIDE
PEDI CAD
What are causes of CP in children? Palpitations?
● Chest pain in children
○ Most common = Costochondritis (inflammation in the joint between the breastbone and
ribs s/t viral illness or coughing)
○ Asthma
○ stress/anxiety
○ Acid reflux
● Palpitations?
○ Causes
Dehydration
Poor physical conditioning
Startled, frightened or stressed
Cold, allergies, or asthma medication
○ Red flags
anemia
thyroid issues
arrhythmias
What is exercise associated collapse?
● Endurance running
● Endurance sports
What is long QT syndrome?
● Long QT syndrome (LQTS) is a heart rhythm condition that can potentially cause fast, chaotic
heartbeats. These rapid heartbeats might trigger a sudden fainting spell or seizure. In some
cases, the heart can beat erratically for so long that it causes sudden death.
● You can have a genetic mutation that puts you at risk of being born with congenital long QT
syndrome. In addition, certain medications, imbalances of the body's salts and minerals
(electrolyte abnormalities), and medical conditions might cause acquired long QT syndrome.
What is ASD? VSD? PDA? What are signs and symptoms of each?
● Atrial Septal Defect: hole between the heart’s upper chambers (atria).
● Ventricular Septal Defect: hole between the heart’s lower chambers (ventricles).
● Patent Ductus Arteriosus: unclosed hole in the aorta (open in utero, should close after birth).
Atrial Septal Defect, Ventricular Septal Defect, Patent Ductus Arteriosus:
● Acyanotic Lesions: L → R shunting = too much blood through lungs
● Think CHF (right sided failure) and pulmonary edema!
● Repeated respiratory infection
● Failure to thrive
● + Murmur
● Signs and symptoms of CHF
○ Tachypnea
○ Tachycardia
○ Sweating with feeds – Irritable
, ○ Edema
○ Rales
○ + Dyspnea
○ Hepatomegaly
***Know that a child should be referred for elevated B/P if under the age of 10.
What are common cardiovascular problems seen in children with Down’s Syndrome?
Atrioventricular Septal Defect
Ventricular Septal Defect
Persistent Ductus Arteriosus
Tetralogy of Fallot
Know 7 S’s of innocent murmurs
1. Sensitive (Murmur accentuates with position changes, activity - see below)
2. Short duration (Not holosystolic)
3. Single (Isolated murmur without click, gallop or other extra heart sounds)
4. Small (Murmur limited to small, focal distribution without radiation) - pulmonic area L sternal
border
5. Soft (Low amplitude Grade I- II)
6. Sweet (Non-harsh quality- vibratory or musical)
7. Systolic (Limited to systole)
Pathologic murmurs in children:
Grade 3 or greater
Holosystolic timing
Max intensity at LUSB
Harsh or blowing
Systolic clicks
Diastolic murmurs
Increased intensity in upright position
Gallop rhythm
Friction rub
Pathologic murmurs are also accompanied by signs and symptoms; in other words the patient
will be symptomatic
ADULT CARDIOLOGY
What are risk factors for CAD? Differentiate between modifiable and non-modifiable.
● Non-modifiable
○ Age - men > 45, women > 55
○ Sex - men > premenopausal women, men = women postmenopausal
○ Genetics/Family hx - <55 yoa for men, <65 yoa for women
○ Race/Ethnicity - AA population highest risk
● Modifiable
○ Smoking
○ Hypertension
○ Diabetes
○ Hyperlipidemia
, ○ Obesity
○ Sedentary lifestyle
What is the pathophysiology of CAD?
● CAD = insufficient blood flow through the coronary arteries
● Atherosclerosis is the underlying pathogenesis of CAD.
● Atherosclerosis = “Hardening of the vessels”
● The key processes in atherosclerosis are
○ intimal thickening
○ lipid accumulation
These will produce atheromatous plaque
● Chronic, repetitive injury to the endothelial lining in the blood vessel causing a neurohormonal
inflammatory response
What is asymptomatic angina?
● The degree of obstruction sometimes does not correlate with symptoms.
● Patient may be still asymptomatic despite high degree of obstruction
● Patient may also loss the sensation of pain as a result of neuropathy especially with diabetes
mellitus
● 25% of pt with asymptomatic angina the first manifestation is sudden death.
○ 20% of pt with AMI die before reaching hospital
○ Most common cause V-fib.
What is the pathophysiology of angina?
● Imbalance of oxygen supply and demand
● Decreased blood flow to myocardium
● Switch to anaerobic metabolism
● Lactic acid builds up
● Kinins, histamine, other substances released
● Nerve fibers are stimulated
○ → Results in chest pain
What is typical angina pain like?
● paroxysmal and usually recurrent attacks of substernal or precordial chest discomfort
● Described as constricting, squeezing and choking or knifelike
What is stable angina (exertional angina)? What are the pharmacologic and non-pharmacologic
treatments?
● Stable Angina
○ Also called exertional angina
○ The lumen of coronary artery is narrowed and hard; thus, dilation in response to
increased demand is impossible
○ Initiated by known amount of activity
○ Same activity tends to produce same symptoms
○ Produced by
Physical activity
Emotional excitement
, Extreme cold or hot weather
Large meals
Alcohol
○ Relieved by
Rest
Nitrates
● Clinical Manifestations
○ paroxysmal and usually recurrent attacks of substernal or precordial chest discomfort
○ described as constricting, squeezing, choking, or knifelike
● Pharmacologic Treatment:
○ Aspirin
○ Clopidogrel (Plavix)
○ Beta-blocker
○ ACE
○ Calcium channel blockers
○ Nitrates both long and short acting
○ Ranexa
○ Statins
● Non-Pharmacologic Treatment:
○ Smoking cessation
○ Physical activity 30-60 minutes, 5-7x/week
○ Cardiac rehab
○ Weight management
○ Stress management
○ Limited alcohol (1/day women, 2/day men)
What is unstable angina?
● Unstable Angina:
○ Recent onset
○ increase in severity, frequency or duration from usual
○ symptoms at rest
○ nocturnal symptoms.
● Chest pain
○ NO cardiac enzyme changes
○ NO ST elevation in ECG
Prinzmetal’s Angina (AKA Vasospastic Angina, or variant angina.)
Differs from atherosclerotic angina; resulting from coronary artery vasospasm; occurs in atypical
non-exertional, patterns
Sx of chest pain tend to be cyclical, with most episodes occurring in the early morning, w/o
regard to cardiac workload
Is believed to be due to vasospasm in coronary arteries w/o obstructive lesions
Distinguishing unstable angina pectoris r/t coronary atherosclerosis from variant angina may be
difficult & require special investigations for dx, including angiography.
Only about 4% of patients who undergo coronary angiography show evidence of focal spasm.
What is the difference from unstable angina vs. acute coronary syndrome (ACS)?
