THE SEMEIOLOGY OF CARDIOVASCULAR SYSTEM AFFECTIONS IN CHILDREN

The right and left ventricles have approximately the equal size in newborn, thickness of their
wall is about 5 mm. The atria and main vessels have a relatively larger size in comparison with
the ventricles than those in adults.
The growth of the left part of the heart, especially the left ventricle, is more intensive after
birth, than the right part. It is caused by an increase of vascular resistance and arterial pressure.
The growth of the heart is accompanied with tissue differentiation.
The histological features of the cardiac muscle of children are as follows.
1. Slenderness of muscular fibers, their closer congregation.
2. Poor development of connective tissue.
3. Muscular cells in newborns and infants are shorter and much thinner than those of adults.
4. Muscle cell nuclei have an elongated oval configuration.
5. The total amount of nuclei is greater than in adults.
6. The elastic tissue is poorly developed, abundant.
Blood vessels. The arteries of the child are relatively wider than in adults. The capillaries are
particularly wide in infancy. Contrarily, the veins of young children are relatively narrow. (In
adults the diameter of the veins is twice as wide as the diameter of the arteries).
A feature of the cardiovascular system in childhood consists in its lesser impairment by use,
owing to the absence of a number of chronic infections and intoxications (nicotine, alcohol, etc).
Physiological features of the cardiovascular system.
The pulse. The rate of pulse in children is relatively high.
Pulse rate at different age levels (per minute)
Newborn 120-160
First 2-3 months 140-120
7-12 months 130-120
1-2 years 90-120
3-5 years 72-110
6-7 years 70-80
The schematic average norm is:
Newborn infants 140
5-6 years 100
Older than 5-6 years 80-90
Adults 70-80
The respiration is accompanied by 3.5-4 heart beats.
Arterial pressure is relatively low in infants owing to the low pumping force of the heart and
the greater width of the vessels, and also the greater elasticity of the arterial walls. The maximum
blood pressure of infants is 66-76 mm Hg, the minimum one is 34-36 mm Hg, in one-year-olds
these values are respectively 90-100 mm Hg and 58 mm Hg. According to V. Molchanov, the
maximum arterial pressure in children is 80 plus the doubled number of years of life. The
minimum pressure, like in adults, is from two-thirds to one half of the maximum.
The neural regulation of the cardiovascular system is complete. Peripheral receptors include
thermo-, baro-, and chemoreceptors, which can accept any changes in homeostasis. Impulses
from receptors reach the centre of medulla and brain cortex. Neural regulation acts through
sympathetic and parasympathetic neural systems. The tone of the sympathetic neural system in
young children is stronger than their vagus tone. The vagus regulation of the heart becomes stronger
after 3 years of age.
 Function abilities of the cardiovascular system are characterized by the data of heart rate,
bioelectric and sound heart features, circulating blood volume, arterial and venous blood
pressure, blood flow speed, stroke and minute blood volume. All these characteristics are
changing parallelly with the growth and maturation of a child.
Methods of investigation of the cardiovascular system.
Clinical methods of investigation:
1. Questioning (including complaints, case history, life history).
2. Objective physical examination:
– visual examination;
– palpation;
– percussion;
– auscultation;
– examination of the heart rate (pulse rate);
– examination of blood pressure.
Paraclinical methods of investigation:
– routine methods of investigation, i.e. clinical examinations of blood and urine;
– X-ray examination of the thoracic organs;
– ECG investigation (electrocardiography);
– PCG (phonocardiography);
– ultrasound investigations of the heart, i.e. echocardiography and Doppler
ultrasoundgraphy;
– cardiac catheterization and angiography;
– biochemical methods of investigation, i.e. Ht, blood electrolytes, blood pH and acid-base
balance, gas content, i.e. oxygen and carbon dioxide volumes;
– exercise testing.
Clinical assessment of the cardiovascular system requires a rational approach in order to
analyze the available information in a coherent manner. In each patient the clinician must
integrate: the facts available from history; the examination and investigations to reach a
conclusion about the structure and function of the heart, and the pulmonary and systemic
vascular trees.
Careful assessment of the arterial and venous pulses and of the precardiac impulse should
always precede auscultation of the heart. The detection of abnormalities in these areas not only
provides valuable evidence about the nature of any cardiac abnormality, but often provides
valuable information on the functional severity of any lesion which may be present. Thus, by the
time the examiner has reached the stage of auscultation the salient point of the history and
examination frequently suggest findings which may then be detected by stethoscope. When
auscultating the heart, it is important to have some idea what abnormalities you expect to hear.
For these reasons it is best to examine the cardiovascular system in the following order:
arterial pulses, blood pressure, venous pulses, praecordia, auscultation.
However, before proceeding to this examination, certain general points should be noted:
paleness of the skin and mucous membranes, cyanosis, enlargement of the abdomen due to
enlargement of the liver and ascitis, oedema, finger-clubbing, splinter hemorrhages in the
nailbeds of fingers and toes and small petechial hemorrhages in the conjunctivae, breathlessness.
Praecordia is the term used to indicate the anterior aspect of the chest wall which overlies
the heart. Deformation of the chest wall can be noticed if the heart is enlarged (cardiac hump);
visible pulsation can be noticed.
 The presence or absence of the main peripheral arterial pulses should be noted and the
volume of each pulse compared with other side.
The arterial pulses are detected by gently compressing the vessel against some firm
underlying structure, usually bones. The main peripheral arterial pulses are as follows: radial,
brachial, carotid, femoral, popliteal, posterial tibial.
The following examinations should be made with regard for the cardiac function: rate of
pulse, rhythm of pulse, character of pulse, volume of pulse, presence or absence of delay of the
femoral pulse compared with the radial ones, the peripheral vessels and circulation.
To assess the rate and rhythm, the radial pulse is generally used. When the character and
volume of the arterial pulse are being analyzed, one should examine the carotid artery, which is
the closest pulse to the ascending aorta; here modifications to the waveform by the vessels of the
peripheral arterial system are kept to the minimum.
The rate of the pulse is noted in beats per minute. In newborn infants, in case of tachycardia
the count of pulse rate at the wrist will not be comfortable and heart rate in such cases should be
counted by auscultation of the apex.
The parasympathetic and sympathetic components of the autonomic nervous system have a
major effect on heart rate. The pulse rate is increased by exercise, fever and in thyrotoxicosis. It
also increases in abnormal tachyarrhythmia. Functional abnormalities of the sinus or
atrioventricular nodes may reduce the heart rate to below 50 beats per minute.
Next, one should decide whether the rhythm is regular or irregular. If it is irregular, decide if
it is completely irregular or the irregularity is not constant. If the rhythm has a recurring pattern,
or there are occasional irregularities, these are likely to be due to extrasystoles. An extrasystole is
a beat which occurs prematurely, is therefore of a reduced volume and is followed by a
lengthened diastole, which is clinically appreciated as a “pause”.
Study the character or form of the arterial pulse wave by palpation of the carotid pulse. This
is best felt with the thumb pressing backwards at the medial border of the sternomastoid at the
level of the thyroid cartilage. The most important changes in the character of the arterial pulse
are as follows: slow rising pulse, collapsing (water-hammer) pulse, paradoxical pulse, alternating
pulse.
The pulse volume gives a rough guide to the pulse pressure, which depends on the stroke
volume and vascular compliance.
Delay of the femoral versus radial pulse is found in coarctation of the aorta.
Taking of blood pressure. Blood pressure can be taken by Korotkoff’s method.
The Korotkoff sound may be heard with stethoscope at the brachial artery while the pressure
in the occlusion cuff around the upper arm is gradually reduced. The first sound that occurs
(phase one) indicates the peak systolic pressure. The second and third phases are due to a
turbulent flow of blood through a partially occurred vessel. The fourth phase occurs, when the
sound becomes muffled, and the fifth phase when the sounds disappear. The fourth phase is 7-10
mm Hg above the true diastolic pressure. The fifth phase corresponds more accurately to true
diastolic pressure.
Check that the width of the cuff is correct according to the age. For an adult, the standard
cuff width is 12 cm, for children it varies from 1.5 to 10 cm. Select the size which covers most of
the upper arm but leaves a gap of 1 cm below the axillary and above the antecubital fossa. In
suspected coarctation of the aorta it may be useful to compare systolic blood pressure in the arm
with that in the leg; the patient lies with his face downwards, an 18 cm cuff is applied above the
knee and auscultation is carried out over the popliteal artery. If a narrower cuff is used, the
recorded pressure will be falsely high. In nervous patients, the first reading is often too high; the
second reading when the patient has become accustomed to the procedure and is more relaxed
may be more representative. It is useful to note the pulse rate at the same time, as circulating
catecholamine will affect both measurements. An elevated pulse rate in the presence of an
elevated blood pressure suggests that some of the “hypertension” is due to a temporary rise in
circulating adrenaline and noradrenalin levels.
It is essential to work as quickly as is compatible with accuracy, for compression of a limb per se
induces a rise in blood pressure. To reduce this source of error, when successive estimations are
made, the air pressure in the armlet should always be allowed to fall to zero as soon as each reading
has been taken.
Abnormal blood pressure must be considered in relation to the patient’s age. A blood pressure of
140/90 would indicate quite severe hypertension in a child.
The venous pulse is examined in neck veins. The importance of studying the level of pressure
in the internal jugular veins lies in the fact that these vessels are usually in direct communication
with the right atrium. In this way the pressure changes within the heart may be predicted by a
simple clinical observation. It may be easier to recognize the pulsation in the external jugular
system.
The praecordia is examined by visual examination and palpation. Deformities of the chest
wall can affect the physical signs found in the examination of the heart. The commonest finding
associated with deformities is an ejection systolic murmur, which may be wrongly attributed to
some organic heart disease. The presence of kyphosis, scoliosis or sternal depression should
therefore be noted. Sternal depression is also associated with a loud tricuspid component to the
first heart sound, appearance of cardiac enlargement on the chest X-ray and a slight broadening
of the QRS-complex, with a right bundle branch block pattern.
Next identify the apex beat, and assess the cardiac impulse. It should be emphasized that the
term “cardiac impulse” not only refers to the character of the apex beat but also includes other
pulsation and palpable murmurs (thrills) and heart sounds. It is customary to locate the apex beat,
which is the lowest and outermost point of definite cardiac pulsation, and to eliminate its position
in terms of the particular intercostal space and distance from the midline, from which it is to the
left. The normal position of the apex beat is 1 cm internal to the midclavicular line in the fifth
intercostal space. The left ventricle normally produces the apex beat. When it is hypertrophied, the
impulse is more forceful and extends towards the axilla. If the right ventricle is extremely dilated it
may form the apex of the heart.
The area immediately to the left of the sternum should be carefully palpated. Failure to detect an
apex beat is usually due to obesity or obstructive airway disease but may be feature in patients with
pleural or pericardial effusions. Dextrocardia is a very rare reason for failure to detect the apex beat
in the left chest.
In addition to arterial and venous pulses, pulsation may be noted at the neck (anxious patients,
in diseases which cause hyperdynamic circulation, such as thyrotoxicosis, in aortic regurgitation,
hypertension, aneurysm of the aorta), in the chest wall (aneurysm of the aorta) over the scapulae
due to aortic pulsation accentuated by nervousness or excitement in a thin patient.
The physical energy of a sound or murmur which makes it loud will also allow it to be
detected by palpation.

Subject 8. Percussion of the heart in children

 The ability to use percussion of the absolute and comparative borders of the heart is
important for determining semiotics of affection of the cardiovascular system. The knowledge of
semiotics of diseases is necessary for their diagnosis.
Contents
Percussion of the heart in children.
The absolute and comparative dullness of heart in children. Semiotics of affection and the
main diseases of cardiovascular system in children.
Percussion of the heart is used for examining borders of heart dullness.
The following rules should be observed in percussion of the heart:
– the procedure is conducted from the lung to the heart, i.e. from clear to dull sounds, as it is
easier in this manner to detect where the flatness begins;
– light percussion is employed, as more forceful taps produce sounds in the surrounding
pulmonary tissue;
– percussion over the area of absolute dullness must be still lighter than over the area of
relative dullness. The borders of relative dullness show the actual dimensions of the heart. The
area of absolute dullness depends on how much of the heart is screened by the lungs. Increased
absolute dullness may be due to enlargement of the heart and to collapse or displacement of the
free margin of the lung. A decreased area of absolute dullness is mostly observed in emphysema
of the lungs, in cases of so-called vicarious expansion, in pneumonia and also in bronchial
asthma and other toxicoallergic conditions (toxic dyspepsia, dysentery).
Borders of cardiac dullness. For greater convenience in determining the cardiac boundaries,
childhood may be subdivided into three periods: from birth to 2 years, from 2 to 7 years, and
from 7 to 12 years of age (See Table 1, Fig. 4).
One should not forget that the boundaries of the heart do not depend on age alone, but also
on the development and shape of the chest. The figures cited in Table 1 are merely of relative
value. When examining adipose children and girls in the puberty period, use the midclavicular
line instead of the mamillary one. In addition to delineation of the cardiac boundaries the
transverse diameter of the heart must likewise be ascertained.
Table 1
Site of cardiac impulse and borders of cardiac dullness
(after V. Molchanov)

Age 0-2 years 2-7 years 7-12 years

On the
1-2 cm lateral of 1 cm lateral of
mamillary line
the left the left
icaidraC

or 0.5-1 cm
mamillary line mamillary line
eslupm

medial of it
The 4th th
The 5 intercostal space
intercostal space
dullnessAbsolute

The upper The 3rd

The 3rd rib The 4th rib
border intercostal space
The left Between left mamillary and parasternal lines
(outer) border Closer to the In the middle Closer to the
medial of mamillary line parasternal line
impulse
 Right (inner)
The left margin of the sternum
border
The transverse
diameter of 2-3 cm 4 cm 5-5.5 cm
the heart
The upper The 2nd
The 2nd rib The 3rd rib
border intercostal space
The left
1-2 cm lateral of the left On the
border (lateral
mamillary line mamillary line
of impulse)
Midway
ssenllud evitaleR

Slightly between the

medial right parasternal
The right The right parasternal of the line and right
border line right sternal margin,
paraster- or slightly closer
nal line to the sternal
margin
The transverse
diameter of 6-9 cm 8-12 cm 9-14 cm
the heart

Fig. 4.
Margins of absolute (black areas) and relative cardiac dullness at different ages.

a – from birth to 2 years;

b – from 2 to 7 years;
c – from 7 to 12 years.

Expansion of the cardiac dullness area is

observed in hypertrophy and expansion of the heart,
fatty heart, cardiac lesions and exudative pericarditis,
pulmonary collapse and thoracic deformation. Left
ventricular hypertrophy (expansion of the heart
leftward and downward) accompanies cardioaortic diseases. Right ventricular hypertrophy
(expansion to the right) is seen in uncompensated cardiac disease, disturbances of pulmonary
circulation (tuberculosis, pneumonia, whooping cough), congenital heart lesions, particularly
constriction of the pulmonary artery.
Reduction of the area of relative dullness and of the heart dimensions (as revealed by x-ray)
may be observed in states of shock and of certain allergic reactions, owing to a redistribution of
blood (congestion in the area of the portal vein and a decrease of the volume of blood in
circulation).
A point to bear in mind is that thoracic deformations, especially pigeon breast, may be
attended by an apparent enlargement of the heart, when the chest borders on it laterally. In cases
of anterior mediastinum pathology the resultant shortening of the heart may coalesce with its
dullness.
In exudative pericarditis the shape of the heart resembles an isosceles triangle with its base
on the diaphragm and its apex on the 2nd and 3rd ribs; the cardiohepatic angle is cut down.
Reduction of the absolute cardiac dullness occurs in pulmonary emphysema.

Subject 9. Auscultation of the heart in children. Semiotics of diseases of the cardiovascular

system

The ability to use auscultation of the heart in children is necessary for estimating the
condition of the heart. The knowledge of the main clinical symptoms and syndromes is necessary
for diagnosing congenital and acquired diseases of the heart and vessels. The knowledge of
peculiarities of ECG, PCG and echocardiography are necessary for diagnosis of the
cardiovascular system pathology.
Contents of subject includes:
Rules of auscultation of the heart in children. Sounds of heart. The main clinical signs of
affection of the cardiovascular system in children (cyanosis, bradycardia, tachycardia and
others). Semiotics of congenital and acquired diseases of the heart and vessels in children.
Peculiarities of ECG, PCG in healthy children of different age. Echocardiography.
Auscultation of the heart often presents difficulties for the beginner. The skilled
examiner listens for specific findings focusing attention on particular parts of the cardiac
cycle.
The stethoscope used for auscultation of the heart should combine both a bell-type chest
piece and a diaphragm. High-pitched sounds, such as aortic diastolic murmurs, systolic murmurs,
the first and second heart sounds and opening snaps, are heard better with the diaphragm, while
low-pitched sounds, such as the third or fourth heart sounds or mitral diastolic murmurs, with the
bell.
Auscultatory areas.
Certain areas of the praecordia are customarily named according to the valve from which
murmurs and sounds arise:
– the mitral area corresponds to the apex beat;
– the tricuspidal area lies just to the left of the lower sternum;
– the aortic area is to the right of the sternum in the second intercostal space;
– the pulmonary area is to the left of the sternum in the second intercostal space.
Heart sounds.
At the onset of ventricular systole, the mitral and tricuspid valves close consecutively to give
the first heart sound, M1, T1. Opening of the pulmonary and aortic valves occurs next and is
normally inaudible. The closure of the aortic and pulmonary valves gives rise to two components
of the second sound, A2P2.
It will be a sign that because of a lower pressure in the right vertical versus the left one,
closure of the pulmonary valve follows that of the aortic valve. After a brief period the mitral and
tricuspid valves open inaudibly in the normal heart.
Abnormal heart sounds.
In diseases, the following deviations from the norm may occur:
– the sounds may have a different intensity, either increased or decreased;
– the sounds may be abnormally split;
 – low-frequency sounds in diastole, the 3rd or 4th sounds may be heard;
– additional high-pitched sounds, originating from abnormal valves, may be heard.
Murmurs.
Murmurs are due to turbulence in the blood flow at or near a valve or an abnormal
communication between chambers of the heart. It follows that a loud murmur may originate from
a rather small orifice such as a ventricular septal defect. Equally a soft murmur may originate
from a large abnormal orifice as in very severe aortic regurgitation. Not all murmurs are
produced by structural disorders of the heart; they may be due to an abnormally rapid flow of
blood through a normal valve. Such murmurs are called flow murmurs; it should be remembered
that they do not indicate any valvular disease.
Murmurs may be systolic, diastolic or continuous throughout systole; diastolic murmurs are
either pansystolic, as in mitral or tricuspid regurgitation and ventricular septal defects, or ejection
ones, when they arise either from the pulmonary or aortic outflow tracts. Pansystolic murmurs
start immediately with the first heart sound and continue through to the second one. Typically
they have uniform intensity. By contrast, ejection systolic murmurs have a diamond-shaped
configuration building to a peak in mid-systole. Ejection murmurs typically diminish before the
second heart sound.
Diastolic murmurs are of two types: early diastolic murmurs start at the second heart sound and
occur as a result of aortic or pulmonary regurgitation, while mid-diastolic murmurs, in which there is
a short gap after the second heart sound before the beginning of the murmur, arise from the mitral or
tricuspid valve. The maximum intensity point and direction of selective propagation must be noted.
The character of a murmur is now considered an unreliable guide to its origin. Rough
murmurs are associated with obstruction to flow through a narrowed valve; blowing murmurs are
more typical of an incompetent valve.
The instrumental methods of investigation of the cardiovascular system are as follows.
Electrocardiography (ECG). This is recording of the electrical changes, which occur within
the heart during the cardiac cycle, from the body surface. The main areas, in which ECG can
prove useful, are:
– analysis of abnormal rhythms;
– detection and localization of changes in the myocardium;
– detection of hypertrophy of walls in the atria and ventricles;
– detection of changes in electrical activity due to pericardial disease;
– detection of changes in electrical activity of the heart consequent on general metabolic
changes.
Additional valuable information may be obtained by recording ECG during physical
exercise.
Four limbs together with specific positions on the thorax are points of electrical contact, i.e.
electrode positions. The limb leads are arranged so as to provide an analysis of the vector of the
electrical forces arising in the heart.
Standard limb leads
Bipolar leads Unipolar leads
Leads Connections Leads Connections
lead 1 Right arm – left arm avR Right arm
lead 2 Right arm – left leg avL Left arm
lead 3 Left arm – left leg avF Left foot
 The standard placement for active electrodes of the chest leads in the heart region is as
follows:
V1 – the 4th intercostal space on the right border of the sternum;
V2 – the 4th intercostal space on the left border of the sternum;
V3 – IV rib on the left parasternal line;
V4 – the 5th intercostal space on the left midclavicular line;
V5 – the 5th intercostal space on the left anterior axillary line;
V6 – the 5th intercostal space on the left medium axillary line.
Leads II, III and aVF record changes from the lateral border of the heart, and chest leads overlie
the interventricular septum and the anterior wall of the left ventricle.
Atrial depolarization is the source of changes in electrical potentials, which cause the P
wave. The QRS complex is due to ventricular depolarization, and the T wave is due to
ventricular depolarization. Atrial depolarization is associated with very small electrical changes
which are not recorded on the conventional surface ECG. The Q wave in an initial negative
deflection in the QRS complex.
The P-R interval (measured from the beginning of the P wave to beginning of the QRS
complex) is normally less than 0.2 seconds in adult. The duration of the normal QRS complex is
less than 0.12 seconds in adult.
Reading and interpreting of ECG.
ECG must be examined systematically. A convenient method is as follows:
– determine the cardiac rate and rhythm;
– assess the P-R interval and the width of the QRS complex;
– examine the P wave and the QRS complex;
– examine the ST segment and T wave.
ECG in children of different age (newborns, infants, children from 2-6 years, 6-12 years, and
12 years) has some peculiarities.
ECG of newborns and children of an early age is normally characterized by right ventricular
dominants.
I. P waves in neonatal ECG.
a. P waves are normally upright in leads I, II, and AVF. Inverted P waves may indicate an
abnormal atrial rhythm or dextracardia.
b. Peaked P waves greater than 2.5 mm may indicate right atrial enlargement.
c. Broad notched P waves greater than 0.08 seconds may indicate left atrial enlargement.
II. PR interval.
a. PR interval should not exceed 0.11 seconds.
b. Prolonged PR interval is seen in primary AV conduction defects, endocardial cushion
defects, digitalis effect, and bradicardia.
III. QRS.
a. Duration: less than 0.09 seconds.
IV. QT interval.
a. QT interval / RR interval should not exceed 0.44.
b. Prolonged QT is seen in hypocalcaemia, hypokalaemia, metabolic derangement and
inherited defects.
V. T wave.
a. Birth to 5 days – normally upright in V1 and V2, inverted in V5 and V6.
b. Five days to adolescence – normally inverted in V1 and V2 and upright in V5 and V6.
ECG in cardiac rhythm disorders can be different.
 Sinus tachycardia. The cardiac impulse arises normally from the sinus node in sinus
tachycardia, and ECG is normal in form. Sinus tachycardia may result from emotion, exercise,
fever, hyperthyroidism and anemia.
Sinus bradycardia. ECG is normal in form, but the heart rate is less than 60 beats/minute.
Sinus bradycardia occurs in trained sportsmen and in patients with increased intracranial
pressure, myxoedema and jaundice.
Sinus arrhythmia. The cardiac impulse arises normally in the sinoatrial node, whose
rhythmicity varies; the heart rate increases with inspiration and diminishes with expiration. ECG
is normal apart from variation in the RR intervals. This arrhythmia is a normal finding in
children after 3-4 years; it is increased by deep breathing and abolished by exercise.
Extrasystoles. These arise from foci in the atria or ventricles, which stimulate the heart
before the next sinus beat is due. In ventricular extrasystoles, P waves are absent and the QRS
complexes are broad, the T wave pointing in the opposite direction to the major deflection of the
QRS. The extrasystole comes prematurely and is followed by a pause (the compensatory pause).
ECG of the atrial extrasystole shows the P wave to be abnormal in form, but the QRS which
follows it is normal. The pause which follows the extrasystole is longer than normal. If an
extrasystole follows each normal beat the pulse is said to be coupled (bigeminy). If the patient is
being treated with digoxin the possibility of toxicity should be considered.
Atrial fibrillation. There is no coordinate atrial activity (either electrical or mechanical) in
atrial fibrillation. ECG shows (fibrillation) waves representing the atrial activity instead of P
waves, especially in lead V1. The QRS complexes are normal but occur irregularly.
Atrioventricular block (heart block). In first-degree atrioventricular block the P-R interval
exceeds 0.2 seconds and all atrial impulses reach the ventricles. When some impulses fail to reach
the ventricles but others do reach them, then there is second-degree atrioventricular block. In third-
degree (complete) atrioventricular block the atria and ventricles beat independently, i.e. they are
dissociated. The ventricular rate is usually slow, 20-40 beats/minute, often erratic and may fail
completely (ventricular standstill). In a routine X-ray of the chest the heart is seen as a flask-
shaped shadow, lying between the translucent lungs, about one-third of its area to the right of the
midline and two-thirds to the left.
Common alterations in disease can be detected by assessing the heart’s position in the chest
(pleural effusion, pneumothorax, scoliosis, dextracardia), the shape and size of the heart
(increase in ventricular mass, left atrial enlargement), the shape and size of the aorta, the
pulmonary vasculature.
Echocardiography. Ultrasound is increasingly used as a diagnostic technique and has
become of particular importance in the field of cardiology. The fact that the heart is continually
moving and that abnormalities of motion are of diagnostic importance gives echocardiography a
particular advantage over other imaging techniques.
– Echocardiography makes it possible to study a direct image of the left ventricle. The size
of the cavity in the end systole and end diastole can be measured and this permits the
quantification of overload of both volumes in the left ventricle, which leads to dilation of the
cavity in both systole and diastole.
– Hypertrophic cardiomyopathy is characterized by thickening of the interventricular
septum. Using echocardiography, it is possible to measure the thickness of this structure with
accuracy. In addition, abnormalities of motion of the mitral and aortic valves, found in this
condition, are well-displayed.
– The presence of various abnormal masses within the heart can be detected by
echocardiography. The commonest of these is some vegetation, associated with infective
endocarditis and usually attached to one of the valves. Cardiac tumors can also be diagnosed an
atrial myxoma being the most important of these, although rare.
Cardiac catheterization. This is carried out when it is necessary to obtain detailed
information about the heart, aorta and coronary vessels which cannot be obtained from clinical
and other non-invasive methods. The technique carries a small risk of both morbidity and
mortality. Cardiac catheterization provides information about the pressures in different cardiac
chambers and also allows angiography to be carried out. There are two peripheral sites at which
the circulation may be conveniently entered: the femoral artery and the femoral vein, and the
brachial artery and the cubital vein. This is an important method of determining the need for
surgical valve replacement and other surgical manipulation.
The examination of the cardiovascular system makes it possible to diagnose various diseases
of the cardiovascular system, to assess condition of the cardiovascular system in cases of
pathology of other systems, in emergency cases, during resuscitation measures.
The semeiology of the cardiovascular system affection includes cyanosis, edema, change
in the configuration of the chest, cardiac hump, retraction of the cardiac area, negative cardiac
impulses, visible pulsation, displacement of the cardiac impulse, intensification of the heart beat,
expansion and weakening of the impulse, expansion of the heart borders leftward and downward,
expansion to the right, diminution of heart sounds, embryocardia, arrhythmia (sinus tachycardia,
sinus bradycardia, breathing arrhythmia, extrasystolic arrhythmia, paroxysmal tachycardia,
disturbance of conduction, heart block, gallop rhythm, atrial fibrillation, alternating pulse, nodal
rhythm), murmurs (functional, systolic, diastolic, pericardial, pleuropericardial), increased pulse
rate, a weak and frequent pulse, a high tension pulse, increased arterial pressure, decreased
arterial pressure, changes of ECG and PCG data, functional diagnostic tests. Symptoms of
cardiac insufficiency are as follows: dyspnoea, pallor, cyanosis, disorder of haemocirculation,
collapse of blood pressure.
The main symptoms of cardiovascular system diseases in infants and older children differ.
Complaints:
– in infants: feeding difficulties; easy fatigability; vomiting; lethargy; increased perspiration;
rapid respiration; failure to thrive;
– in older children: easy fatigability; shortness of breath; dyspnoea on exertion, which is
usually described in term of specific activities like walking on level ground, walking upstairs,
and bicycle riding; orthopnoea, paroxysmal nocturnal dyspnoea and edema are uncommon
manifestations; cyanosis (cyanosis in the newborn is difficult to determine because the fetal
hemoglobin allows higher O2 saturation for given pO2 level than does adult hemoglobin).
Physical examination
Tachycardia may be seen as a manifestation of heart failure, or as a dysrhythmia.
Bradycardia is seen in patients with a high vagal tone, but may be a manifestation of the 2nd or 3rd
degree atrioventricular (AV) block.
The respiratory rate may be increased in case of failure to thrive, especially when the height
to weight ratio is increased.
Blood pressure should be taken in the upper and lower extremities to identify coarctation of
the aorta.
If the level of the jugular venous pulsation is increased, pulmonary stenosis or tricuspid
stenosis is suggested. An increase in the wave suggests tricuspid insufficiency.
Rales in the chest may be a sign of pulmonary edema due to an increased pulmonary venous
pressure.
Hepatomegaly is one of the cardinal signs of right-sided heart failure in the infant and child.
Cyanosis, a characteristic bluish discoloration of the skin, nails and mucous membranes, is
apparent in the infants and children with hypoxemia who have 3-5g/dl of reduced hemoglobin.
Rounding or convexity of the nails may be in infancy; it may become very prominent in
hypoxemic adolescents and young adults.
Prominence of the precordial chest wall is frequently seen in infants and children with
cardiomegaly and is especially prominent when the right ventricle is involved.
Prominence of the cardiac impulse at the xiphoid process or along the left sternal border
with systolic retractions outside the apex suggests right ventricular dilatation: an apical beat with
systolic retractions inside the apex is noted with left ventricular dilation.
Auscultation: characteristic of the 1st sound, systole, the 2nd heart sound, and diastole has to
be done. Splitting of 2nd heart sound, ejection clicks, murmurs (systolic, diastolic) may be heard.
Murmurs are usually described with regard to their intensity, timing, and pitch. The intensity
of systolic murmurs is classified by a scale of 1 to 6. Grade 1 murmur is soft and heard with
difficulty, especially when of low pitch; grade 2 is easily heard; grade 3 is a louder hit not
associated with a pericardial thrill; grade 5 is audible with only the edge of the stethoscope on
the chest; grade 6 is very loud and audible with the stethoscope on the chest or with the naked
ear. It is important to relate the murmurs to S1 and S2 and to describe their length.
Systolic ejection murmurs are typically associated with some obstruction to flow through the
abnormal semilunar valves or an increased flow through the normal semilunar valves.
Regurgitate murmurs, typically seen with a ventricular septal defect (VSD) with left to right
shunt or mitral regurgitation (MR), vary in length and timing.
Diastolic murmurs are heard when regurgitation occurs across the semilunar valves or when
stenosis of the atrioventricular valves is present.
Continuous murmurs are characteristic of a persistent patent arterial duct after the newborn
period.
Functional murmurs are quite common in children after 2 years.
Percussion of the heart region may assess borders of cardiac dullness. Expansion of the area
of cardiac dullness is observed in hypertrophy and expansion of the heart, cardiac lesions and
exudative pericarditis.
Investigation of vessels may be done by assessment of pulse rate and blood pressure.
An increased pulse rate is observed when the child is excited, during muscular activity, after
meals, in the acute period of infections, in hyperthyroidism. The pulse rate is decreased during
sleep, in malnutrition, tuberculous meningitis, typhoid fever.
A weak and frequent pulse is a sign of decreased cardiac activity.
A high-tension pulse is seen when the activity of the left ventricle is intensified (nephritis).
An increased arterial pressure is observed in lung diseases, at the onset of infectious
diseases, in cases of nephritis. Transient hypertension is frequent in adolescents.
Decrease in arterial pressure is seen in acute nutritional disorders, shock and heart
insufficiency. A progressive fall in arterial pressure is a poor prognostic sign.
Paraclinical methods of investigation of the heart and vessels are used for completely
assessing functions of the cardiovascular system.
The main pathological syndromes of the cardiovascular system are: syndrome of heart
insufficiency (syndrome of decreased cardiac output and syndrome of standstill circulation),
edema syndrome, syndrome of arterial pressure disorders.
 There are various causes of heart insufficiency, which results in disturbance of myocardial
contractility. Congenital heart defects are the commonest of the above causes.
Congenital heart defects with arteriovenous shunts are characterized by overload pulmonary
(lesser) circulation with gradual formation of left ventricle insufficiency. Typical for the clinical
picture of this pathology is prevalence of frequent bronchitis or pneumonia with obstructive
syndrome. The main symptoms are: dyspnoea, cough, cyanosis, enlargement of heart borders,
tachycardia, enlargement of the liver, physical development retardation. Change of the shunt to
the venoarterial shunt is accompanied with some increase of cyanosis. Addition of infective
affection of the lungs causes an increase of heart insufficiency and development of acute
pulmonary edema.
Congenital heart defects with increase of pulmonary circulation (tetralogy of Fallot) are
characterized by heart failure with “cyanosis-dyspnoea” fits.
Heart insufficiency can be acute and chronic according to different tempo of its
development: from some days to a few months.
Cardiac insufficiency can be caused by 2 pathogenic variants: syndrome of decreased
cardiac output and syndrome of standstill circulation.
Syndrome of decreased cardiac output is characterized by acute onset and energy
development, its pathogenic basis lies in acute myocardial ischaemia. This pathological
syndrome can occur in children in case of acute infections (hypermotile toxicosis). Clinical
manifestations include symptoms of infections, tachycardia > 200 heart beats per minute,
tachypnoea, the rate of heartbeat does not correspond to the rate of breath. If treatment is not
effective, symptoms of cardiac insufficiency develop: decreased arterial pressure occurs; signs of
myocardial hypoxia are marked on ECG. Tachycardia is changed by bradycardia and cardiogenic
shock is developing.
Syndrome of standstill circulation is caused by the inability of the functionally exhausted
heart to manage the excess venous flow, or “preengagement”. This syndrome develops gradually.
The main clinical symptoms of this syndrome are: tachypnoea and dyspnoea, paleness and
cyanosis, tachycardia, cough, rales in the lungs, hepato- and splenomegaly.
Edema syndrome can develop in cases of cardiac insufficiency.
Heart affection in cases of cardiac insufficiency reflects the semeiology of some basic
disease, such as congenital heart disease, myocarditis, myocardiopathy.
The course of cardiac insufficiency includes I, IIa, IIb, III stages.
Total circulatory and microcirculation disturbance occurs in case of shock (centralization
and decentralization of hemodynamics), vascular insufficiency.
Syndrome of arterial pressure disorders includes arterial hypotonia and hypertension.
Recurrent arterial hypotonia includes such symptoms as general weakness, fatigue, irritability,
sleep disorder, paleness. Arterial hypertension in children is often symptomatic, headache and
tachycardia being its clinical symptoms.
The cardiovascular system pathology includes anomalies of development in the heart
(congenital cardiac lesions) and vessels, inflammatory diseases (endocarditis, myocarditis,
pericarditis), rheumatic fever, infectious endocarditis, etc.
Ventricular septal defects involving the membranous portion of the septum are the
commonest congenital cardiac malformation. It may be found as an isolated lesion, the defect is
also often associated with abnormalities of the conotruncal region. Tetralogy of Fallot is the most
frequently occurring abnormality of the conotruncal region. The defect is due to an unequal
division of the conus, resulting from an anterior displacement of the conotruncal septum.
Displacement of the septum produces four cardiovascular alterations: (a) pulmonary infundibular
stenosis in a narrow right ventricular outflow region; (b) a large defect of the atrioventricular
septum; (c) an overriding aorta that arises directly above the septal defect; and (d) hypertrophy of
the right ventricular wall due to a resultant higher pressure on the right side.
Persistent arterial trunk results when the conotruncal ridges fail to fuse and to descend
toward the ventricles. The persistent trunk is always accompanied by a defective interventricular
septum. Transposition of the major vessels occurs when the conotruncal septum fails to follow its
normal spiral course and descends straight downward. As a consequence, the aorta originates
from the right ventricle, and the pulmonary artery originates from the left ventricle.
Valvular stenosis of the pulmonary artery or aorta occurs when the semilunar valves are
fused for a variable distance.
Dextracardia is caused by formation of the cardiac loop to the left rather than to the right. In
this condition, the heart is located in the right side of the thorax; the abnormality is usually
associated with a total or partial visceral inversion (transposition of the viscera). Heart ectopia is
a rare anomaly in which the heart is located on the surface of the chest. This malformation is
caused by failure of the embryo to close the ventral body wall.
Children with cardiovascular diseases need proper regimen of nutrition, treatment according
to the therapeutic plan, bed regimen, control of diuresis, checking of the child’s weight for
control of edema. Patients with cardiovascular insufficiency need strict bed regimen, an elevated
position in the bed, fluid limitation, oxygen therapy, cardiovascular monitoring.