cardiovascular diseases in child health nursing

CARDIOVASCULAR
DISEASE in
children
Bhavya N Kelavadiya
Nursing Tutor
CONTINU
E

CONGENITAL HEART DISEASE
(CHD)

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.

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.

Classification
 CHD can be grouped into three categories:
1) Acyanotic CHD
2) Cyanotic CHD
3) Obstructive lesions

Classification
ACYANOTIC
There is
increased
pulmonary blood
flow due to left
to right shunt.
Ventricular septal
defect (VSD)
Atrial septal defect
(ASD)
Patent ductus arteriosus
(PDA)
Atrioventricular canal
(AVC)
CYANOTIC
There is
diminished
pulmonary blood
flow due to right
to left shunt.
Tetralogy of fallot
(TOF)
Tricuspid atrsia
(TA)
Transposition of
great arteries
(TGA)
OBSTRUCTIVE
LESION
Coarctation of aorta
Aortic valve stenosis
Pulmonary valve stenosis
Congenital mitral
stenosis

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

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

o 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.
o This complicated condition is known as
Eisenmenger’s complex.
o The child with this condition present with cyanosis
and surgical correction of VSDs is not possible in
this stage.

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

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

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

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

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

Types
1) Ostium secundum ASD- middle of the
arterial septum
2) Ostium primum ASD- at the bottom of
arterial septum
3) Sinus venosus ASD- at the Top of arterial
septum.

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

Physical examination
Chest X-ray shows right atrial and ventricular
dilation
ECG
Doppler

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

Congestive 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)”.

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

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

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

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

• History collection
• Physical examination
 Auscultation
 Capillary refill
 Palpation
• Chest X-ray

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

• 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 Rheumatic Fever

• 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.

Predisposing 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.

• 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

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.

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.

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.

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.)

• 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.

• 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).

• 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

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.

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

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

• 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.

• 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.

• History collection
• Blood culture
• Echocardiography
• ECG and immunological examination
• Urine examination

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.

Rheumatic 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.

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.

• 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.

• 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.

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.

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.

• 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.

• 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.

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.

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.

• 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.

• Chest X-ray
• ECG and clinical examination along with
history of illness help in diagnosis

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.

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.

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.

• 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.

• Details history of illness
• Chest X-ray shows poorly vascularized
lung fields, a mall boot-shaped heart
• ECG shows right axis deviation

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.

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.

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.
Cardiomyopathy

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.

Etiological factors
1. 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.

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.

Types of Cardiomyopathy
1. 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.

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.

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.

• 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.

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
hemochromatosis and amyloidosis.
Thrombus formation and embolic events are
common. Elevation of pulmonary vascular
resistance may occur. The child usually
present with CHF.

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.

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

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

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