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Cardiovascular Disorders in Pediatrics

Congenital heart disease occurs in about 1% of children. Heart murmurs are much more common, and may be heard in virtually every child if examined carefully.

Clinical Evaluation of Cardiovascular Disorders

For neonates, a history of feeding problems, cyanosis, tachypnea, irritability or grunting respirations may indicate serious cardiac pathology. A history of feeding less than 2 ounces at each feeding in a term infant may indicate pathology. A family history of congenital heart disease may be helpful, but the incidence of congenital heart disease in families where the mother has congenital heart disease is only 5-10%.

For older children, it is unusual for a pathologic murmur to present for the first time outside of infancy. Two notable exceptions are hypertrophic cardiomyopathy and murmurs associated with dilated cardiomyopathy. Symptoms which indicate serious pathology include exercise-induced chest pain, exercise induced syncope, or cyanosis. Easy fatigability is non specific, and not helpful in differentiating pathologic from non-pathologic murmurs.

Physical Examination

Congenital heart disease is more common in infants with congenital anomalies.

Trisomy 21. The incidence of heart disease is about 50% in these children. Anomalies include ventricular septal defects, atrioventricular canal defects, and patent ductus arteriosus.

Trisomy 18. The incidence of heart disease is almost 100%in these children. Ventricular septal defect is the most common anomaly.

Trisomy 13. The incidence of heart disease is about 80%, usually VSD.

Turner syndrome (coarctation, hypertension), Marfan syndrome (aortic aneurysms), and Noonan syndrome (pulmonic stenosis, coarctation) are other congenital anomalies.

Growth parameters may suggest failure to thrive that is caused by cardiovascular disease. Infants with cardiovascular disease usually have a normal head circumference, and height may be normal, but the weight is usually lower than anticipated.

Blood pressure determination. All children 3 years of age and older should have their blood pressure measured on a yearly basis. The blood pressure cuff should be appropriate for the patient's size. The width of the cuff should be at least 2/3 the length of the upper arm, and the bladder should be long enough to almost encircle the upper arm. Blood pressure levels vary depending on the age of the child, and hypertension is defined as a blood pressure consistently greater than the 95th percentile for age.

Presenting symptoms of severe hypertension in infants include congestive heart failure (caused by coarctation), respiratory distress, and failure to thrive. Symptoms of severe hypertension in cardiovascular disorders, congenital heart disease older children may include headache, nausea, vomiting, mental status changes, and epistaxis.

Cardiovascular Examination


Conditions that cause cardiac enlargement (ventricular septal defect, atrioseptal defect, and a large patent ductus arteriosus) often cause the left side of the chest to protrude further than the right.

In patients with pectus chest deformities, functional murmurs are often heard.


In situations where there is a large left to right shunt (ie VSD, ASD) the precordial activity is often increased. Displacement of the apical impulse may be associated with cardiac enlargement. Palpation of femoral pulses is critical in diagnosing coarctation of the aorta.