Chapters Transcript Video Common Pediatric Cardiology Referrals Part 2 (EKGs, Arrhythmias, Palpitation, and Hypertension) Thank you. And good afternoon, everyone, everyone might be having palpitations by this point after their third cup of coffee, but we're almost at the end and there's a wonderful lunch where we can all meet. Um We're gonna review palpitations, EKG S and hypertension together. And we'll start with a case. A young lady who would come to see us in our office, 14 year old who's having palpitations about once a week, they're occurring at rest, quick onset, spontaneous termination, but lasting for several minutes. And she does sometimes experience dizziness with them. So, when we're approached by a patient with palpitations, we're thinking to ourselves, could this be sinus tachycardia or is this a tachy arrhythmia? And does this patient have any risk factors for sinus to act? Does she have a history of anemia? Does she have particularly heavy periods? Is there any suggestion she has hypothyroidism? Any skin hair changes, changes in bowel habits? Was she febrile in pain, anxious or exercising at the time of these episodes? And those are all times where we expect her heart rate to be faster in terms of tachyarrhythmia. We thankfully have a number of tools we can turn to uh we have our EKG which is just that 12th recording of a heart rhythm. We can run longer rhythm, rhythm strips if we're noticing abnormality while they're with us in the office. And then our Holter and Zio patches allow for longer term monitoring. So the Holter has sticker electrodes attached to wires attached to a small device about the size of a old pager. Um A Zio patch, I always describe as a, a big band aid with a button in the middle that the patient can depress. If they're having any symptoms, both can be accompanied by a diary. So the patient can tell us when they're experiencing something what they're experiencing, but we really don't need that. We are going to look at every heartbeat that's recorded from those monitors. Neither device is actively transmitting to us, but we can review all the data after they're returned to us, we can upload and look at it in more detail. Um The Zio patch is really convenient for letting kids go about their normal day to day activities. You can shower in it. You just can't immerse the Zio patch in water in a pool or bath, for example. And when we review these EKG S, we're really trying to separate out. Is this something that's too fast? Are there ectopic beats? Is there a tachyarrhythmia or is the sinus tachycardia? Is it too slow? Am I seeing an abnormal conduction issue or other abnormal patterns. That could give me a clue. Is there preexcitation that's putting this patient at risk for a tachyarrhythmia. Is there hypertrophy? Um ST and T wave abnormalities make us concerned about function. Um or ischemia and abnormal QTC can put you at risk for torso. So we're gonna walk through a number of EKG S that we would typically see in our office and then we'll return to our case. Um So on this telemetry strip up here, you can march out that there's a P QR STP QR ST all the way across the rhythm strip. But what's varying is the heart rate and we all have a normal variation in our heart rate over the course of a respiratory cycle. And we refer to that somewhat unfortunately, as arrhythmia um now that records are immediately available to patients and families, we have gotten more calls. My daughter has an arrhythmia. I see it in her chart. I'm very concerned. Um So I really try to explicitly say in visits that if this is in the chart, this is what it is. It's normal heart rate variation over the course of the respiratory cycle. Um The 12 lead EKG can make us more confident that is, it is in fact sinus because we use the 12 lead EKG to confirm that the P wave is coming from an area in the right atrium that could correspond with the sinus node. We do that by looking at the P wave axis, so since it's coming from the right atrium, we want that P wave to be upright in lead one and upright in a VL, a left word and figure you're facing lead um to go along with the vector that we expect of an an elec electronic electric impulse coming from the sinus node. So here we have a normal P wave axis, it's upright in one and a VF and we have normal P. QR Stpqst PR SD all the way across our rhythm strip. And the only variation we're seeing is in the rate not in any of the intervals or any extra beats or missing beats. So, normal finding, um we also commonly see patients with bradycardia. Uh This rate is around 36 beats per minute. One of our first questions is, is this patient symptomatic? Are they warm well perfused with the normal blood pressure, not having any dizziness with postural changes. And in that case, could this be a very well conditioned athletic young person? Um We also think to ourselves about anorexia, nervosa sinus bradycardia is the most common arrhythmia observed in anorexia. So you want to keep that um within your differential and then thyroid conditions as well that could contribute to bradycardia or increased vagal tone in the setting of G I distress or vomiting. Um To think about when we see Wolf Parkinson white, we absolutely wanna see all of these patients for a consultation in our office. Um On this EKG, you can see it's a sinus rhythm, normal P wave access, normal QR S access. However, there's a very short pr interval. So we can look at this zoomed in picture, there's really no flat segment from the end of the P to the beginning of our QR S. There's this up swooping which is referred to as the delta wave and that's occurring because the electric impulse is making its way to the ventricles by way of an extra pathway and not having that pause as it travels through the A V node to get to the ventricles. Um Why do we follow these patients closely? Well, there's a risk of having a rapid atrial arrhythmia that could be conducted down the pathway and turn into a rapid ventricular arrhythmia like VFIB. So there is a very small but real risk of sudden cardiac death if that were to occur. Um And it's important that we counsel patients about this and sometimes we risk stratify that extra conduction pathway to see um how risky it is that a fast rhythm would be conducted on that pathway. And some patients will decide to have that extra pathway ablated, meaning frozen or burned so that they're no longer at risk. Premature atrial contractions are um a common finding that we see particularly in the newborn nursery. So, about 1 to 5% of newborns have some type of arrhythmia and PAC S are the most common that we see they typically self resolve within the first month of life and often don't need additional work up. Um But they would if you have any other concerns or if they are um sustained for a longer period of time. So, on this telemetry strip, we see PQSTPQSTPQST and in this down slope of the T wave, we see an early um atrial beat that's conducted and then we have a normal P wave. QR ST wave and again, an extra P wave that's not conducted. So a nice example of a both conducted and nonconducted PAC, you might notice these in your office when you're listening, something just sounds irregular in that little baby. And then we see these other times they're picked up um for relative bradycardia in the newborn nursery from having so many blocked PAC S that overall they have a lower average heart rate. Um PV CS, we more commonly do a thorough work up from the outset. Um So on this telemetry strep, we CP QR ST and then there's no preceding P wave, but there's a wide QR s consistent with a premature ventricular contraction. And in these cases, we like to make sure electrolytes are normal, the heart's structurally normal. There's no systolic dysfunction or myocarditis that's happening. Um We can do all those things on an echo. And we also like to quantify how often a patient is having PV CS over 20% of the time you're at higher risk to have systolic dysfunction secondary to those PV CS. So we'll often do a holter or a Z oat to quantify how often that's happening. Um We've talked over the course of the day about the utility of EKG for looking at um risk of hypertrophy based on the voltage on the EKG S EKG S do often overcall hypertrophy um particularly in certain racial subpopulations. And that has a lot to do with the voltage criteria being based on a white population and a small number of patients. The pediatric heart network has made an extended expanded um criteria for us to use that's more diverse and hopefully um more clinically relevant. Um This is an example of a patient where it's not an overall a very abnormal looking EKG that is sinus rhythm with a normal QR S access does meet voltage criteria for left ventricular hypertrophy and has diffused T wave inversions, 12 A VL and the lateral precordial leads. And this young man was found to have hy hypertrophic cardiomyopathy um and did require close monitoring and treatment. I would say that we don't see that this commonly, but we have had a run of atrial fibrillation in the past few months. I was on cons service for most of them. Um And what are we noticing? You can't pick out, you know how I always want to say is the P wave as normal. You can't really identify where that P wave is. So it's hard to discern. Is there a clear P wave and your Q RSS are irregularly irregular. And then also in this lead, you do see some fibrillation along your baseline. Um These patients did require admission and anti arhythmic treatment and uh work up on every EKG. We're looking at the intervals to check the conduction and um electrical impulses going through the heart. These are all examples of different types of prolonged QT. Um I was always taught that if your T wave sits more than halfway between your RR interval, that's very suggestive of, of a prolonged QT. It's a great rule of thumb. But you can see that it's not perfect and that you can have prolonged QT with the T wave sitting before the 50% mark between the RR intervals. So it's great to look at what the um computer has calculated as your QTC and also to recalculate it if you have concern. Speaking of intervals, um we look at the PR interval which is the amount of time the impulse is taking from the sinus node message down to the R QR s normally that's no more than 200 milliseconds or a little bit shorter even in younger kids. So one big box and you can see that this is definitely larger than one big box. When we see patients come in with first degree heart block, we're thinking, is there a thyroid issue? Do they have a good history for a lyme exposure that might have contributed to that. And then uh another conduction issue here, we have P waves that are marching out independently very regularly across the strip and Q RSS that are also looking very regular and narrow, but much slower. So we have more A's than vs both are independent, unrelated. There's really no relationship. And it's a good example of complete heart block, advanced lime can contribute to complete heart block. So can um maternal anti antibodies or SS A antibodies? Sometimes if an infant wasn't diagnosed, um this can incidentally be found in a teenager and the assumption is that it was congenital sometimes that's how we diagnosed the mom with um having anti antibodies. So back to the patient who presented to us with palpitations um during an er visit, we were able to capture that she was having SVT during these episodes um at a fairly fast rate. Her baseline EKG did not show any evidence of preexcitation or Wolff Parkinson white. And for SVT patients, we do like to evaluate with an echo to make sure their function is fine. There's no structural abnormality that's putting them at greater risk for that SVT. Um we can monitor the symptoms, quantify how often the SVT is occurring with a holter or Zia patch. And um this family initially decided to pursue uh pharmacologic treatment, but with breakthrough episodes has now undergone ablation. So freezing or burning of that extra conduction pathway that allows for the um, arrhythmia loop that causes the SVT. All right, we've walked through common EKG S that present to our office. Now we're gonna turn to thinking about hypertension, which we've already touched on a bit today. Um We're gonna keep in mind as we walk through these guidelines, a 13 year old young man with class three obesity whose blood pressures are consistently in the one thirties over eighties at his pediatric visits. What do we do next? I'm very thankful for our clinical practice guidelines for screening and management of high BP and kids and adolescence. They came out in 2017 and they really provide a step by step guide of um how to manage these patients. A major take home from the guidelines is to repeat the measurements serially both at the same visit where you identify the abnormality and at your follow up visits. Um ideally, the measurement should be performed after a patient has been resting for 3 to 5 minutes seated with their backs, supported their feet flat on the floor, legs uncrossed really hard to achieve depending upon the workflow of your clinic. Um But I think the time to focus on trying to get that best measurement is if you have a first abnormal, then you'll really try to have the child rest and stay seated. You want to make sure you're using an appropriate cuff size, too small of a cuff can um falsely raise your blood pressure, uh, too big of a cuff can lower it but not to the same degree. So the bladder should be, the bladder cuff usually has an arrow that goes all the way across the cuff should be 80 to 100% of the circumference of the arm. If you turn it sideways and hold the width, that should be about 40% of the circumference of the arm for a good fit. And the guidelines suggest tossing that first abnormal measurement and averaging your 2nd and 3rd. So it is a lot of work um for you or your medical assistant or your nurse depending upon your workflow. Thankfully, the guidelines do allow for automated blood pressure measurement this time around because I think realistically we all use them and then if you're still having abnormalities to repeat it manually, the um guidelines um have new definitions of what, how we define blood pressure. So you're for kids age 1 to 13 of years, you have a normal blood pressure. If you're below the 90th percentile, it's considered if you're 90th percentile to less than 95th. Stage one is 95th to less than 95th plus 12. And stage two is that next category higher for kids who are 13 or older, like the patient we're keeping in mind normal is less than 1 20/80. Stage one is between 130 to 1 39/80 to 89 elevated sits between those. And stage two is anything over 1 40/90. Um You may recall these tables when you're trying to figure out what percentile the blood pressure is for your patients. Thankfully, a lot of electronic medical records now can pull in these percentiles for you. If they don't, then these tables are still incredibly useful. Um Some additions they made to the tables this time around are very helpful. So you have age in the left column here, height along the top, you no longer have to look up the height percentile because they do have the height in inches and centimeters across the top which saves you one step. Um And then you can use the table to figure out what percentile the blood pressure measurement is for that given patient, this um simplified table is really useful. So instead of going straight to those complicated tables, if you're seeing a patient, as long as the number sits below these, you don't have to pass, go and look at the complicated table. So I think this is great to sit with your medical assistants or nursing staff because if they find an abnormality, meaning a patient falls at this number or higher, it could be repeated for you or flagged for you to repeat and kind of get that process going earlier in the patient encounter. Um Then this table walks you through what to do. If you have an arm abnormality, we're just gonna zoom in on the top and bottom half separately. So it's easier to see if you have a normal blood pressure. You're just gonna do all that great lifestyle counseling we do for all of our patients at every visit. Um If it's elevated, you are gonna wanna repeat it within six months. And at that repeat time, you're gonna do an upper and lower extremity blood pressure measurement that we touched on earlier is a way of screening for coition of the aorta. So the lower extremity should be the same or higher than your arms. Normally, if your arm is higher than your leg, particularly if it's 20 millimeters of mercury or higher, really concerning for cohort of the aorta which does put you at risk for hypertension. Um If that's normal, you repeat the measurement six months later with ongoing lifestyle changes. And if you still have elevated uh blood pressure, you're gonna do ambulatory blood pressure monitoring to confirm that it's not white coat hypertension. And then there's some diagnostic evaluation. You'll go into labs urine that we'll we'll touch on in a moment. Stage one and stage two hypertension are very similar in the algorithm. It's just that you do your repeat measurements faster. So for stage one hypertension like the young man we're seeing in clinic, um you're gonna get that repeat measurement within a week or two and your third measurement in three months, if it's stage two, you would repeat and potentially refer all within a week. And of course, we send patients to the er, if they are symptomatic with hypertension, their blood pressure is more than 30 millimeters of mercury above the 95th percentile or more than 1 80/1 20 in a, in an adolescent. So, the patient we're seeing does have hypertension at this point, he's had three serial um confirmed readings at the 95th percentile are higher and we're referring him uh for ambulatory blood pressure monitoring. Here, we're really grateful to partner with pediatric nephrology um to do our ambulatory blood pressure monitoring. And we refer to them for pharmacologic treatment in pretty much all cases. There might be the rare case where we're managing a congenital heart disease patient with hypertension where we're titrating their medications. Otherwise we see our role really to rule out secondary effect from hypertension is their hypertrophy or dysfunction and to rule out coition as a cause of the hypertension. I love this as a reminder. Um to ask about certain pharmacologic medication agents that could raise BP. And our patients. Are they drinking some caffeinated sports drinks that we really don't want them to be drinking to begin with? Um Are they taking a decongestant that has a stimulant in it or are there any illicit drugs that we should be concerned about? So, these are the screening tests that are recommended, all patients who um have met that third or second staff where they have sustained blood pressure would get a urinalysis, a chemistry, a lipid profile that does not have to be fasting. You do a renal ultrasound if it's a young child, um under six, who has an abnormal U A or creatinine and doing that with dopplers is very helpful in an obese child. Like the patient we're seeing, you would add a hemoglobin A one c liver enzymes and I always include a thyroid screen, a urine toxicology if you're suspecting that. And then I often will ask um if there's any history that's suggestive of obstructive sleep apnea, uh where sending for a sleep study might be helpful. A CBC comes into play if you're worried about growth delay like in the setting of chronic kidney disease. Um Doctor Corey to whom we refer many of these patients. In addition to these um recommendations uh recommends that we send metanephrines cortisol renin and aldosterone. So if you're doing it all at once, those are the doctor Corey recommendations to add in, in terms of other screening tests and EKG is not needed, but we will often do a screening echo prior to treatment. Um or if there's a blood pressure gradient again, to look for that cot or to look for secondary effects from the hypertension like dysfunction or hypertrophy. And some kids where there's a suspicion for renal artery stenosis would get an MRI or CT A in terms of treatment you want that systolic and diastolic blood pressure to essentially be in the normal range. Um We're more aggressive in patients with chronic kidney disease where you want it below the 50th percentile. And you're turning to pharmacologic treatment for patients who are remaining hypertensive despite lifestyle modification or have other risk factors in terms of counseling. What are we telling them? Um, we're focusing on the dash diet, which I'll go to in a little bit more detail and vigorous physical activity at least 3 to 5 days per week, 30 to 60 minutes per session. And we are targeting that AJ A 150 minutes per week that applies to all of us. Um And as uh doctor mcphillips, touch on these patients with hypertension can potentially participate in sports. Uh just not, if they have stage two or higher, then they really need to be treated first and you need a careful history and physical to, to make sure they're safe to exercise. Um Motivational interviewing has been shown to be an effective way of in affecting um behavior change. The change talk app is a free app you can download on your phone. It prepares providers for conversations with parents and kids about healthy weight. It does that by simulating a series of conversations so you can practice having these tough conversations um on your phone. I think it's really helpful uh for anyone and uh for patients who are obese with hypertension, it's the same counseling, but you also try to provide them with regular contact, whether that's, um, through uh, uh weight management program or a nutritionist or um, another provider and then more physical activity daily. We are really lucky to have the Kid FT Health Management program here at Atlantic Health. They see kids aged 3 to 18 who have, uh, overweight or weight related health problems or rapid weight gain. In terms of the dash diet. It's a diet that, um, is rich in fruits, vegetables, whole grains and low in sugar and sweets. Less sugar, less sodium than our pots. Patients are giving um in terms of resources for counseling. Um the Department of Health in New York City uh has really lovely handouts. You can find them on nyc.gov. This is the my plate planner that emphasizes half of your plate needs to be colorful with fruits and vegetables. A quarter can be your protein. A quarter can be your starch and I really like their um ended rules for portions. So the palm of your hand is the portion of your lean protein no thicker than the thickness of a stack of playing cards. Your fist is the amount of carb or starch pasta rice you could have with a meal and then everyone's really disappointed that this is your cheese, just a thumb full of cheese for your meal. Um So this is an example of the handouts that they have in multiple languages through nyc.gov. Um My plate.gov is through the US Department of agriculture. Al also has really nice counseling, um resources on their website, you can select different life stages. So different resources targeted towards toddlers, adolescents, et cetera. Um in the older kids, there's a lot of games and apps available to encourage healthy food choices. So, back to the young man, we saw um he did in fact have stage one hypertension on serial repeats. Um He was confirmed also on ambulatory blood pressure to be hypertensive. His diagnostic evaluation thankfully didn't show any other serious risk factors did have elevated triglycerides and low HDL which is a typical profile seen with obesity. Um and he was referred to pediatric nephrology for continued um surveillance and possible treatment. Um Thank you for joining me on that trip through EKG S and hypertension. And this is a picture of our, our children's specialty center across the street. Uh 55 Madison Avenue. There are lots of p subspecialists there. Um But relative to, to these topics, we're always happy to take your call. Um The number that you have here and in your packets works 24 7. I've been on service a lot and if I've spoken to you in the last few months, please come and introduce yourself. Um I'm always happy to, we all of us can review EKG S and help triage uh patients to get them in sooner if needed. Mr Coy um is a great partner in pediatric nephrology who helps us with our hypertensive patients. And the Kit FT Health Management program is a great resource. Thank you. Published Created by
