Cardiology

Who to refer:

Murmurs
There is no automatic need to refer patients with a soft systolic murmur heard only at the front of the chest unless it has features suggestive of a cardiac fault.  Innocent murmurs occur in up to 60% of children and the service would be overwhelmed if everyone were referred to confirm an innocent murmur (see information sheet).  Murmurs that are harsh, heard in diastole, heard at the back of the chest or are accompanied by a thrill should be referred.

Reduced Femoral Pulses
All patients should have normal femoral pulses.  If femoral pulses are not palpable or are weaker than upper limb pulses, patients should be referred. 

Syncope
Not all patients with syncope need to be referred.  They should however, be referred if the episodes result in injury, occur during as opposed to after exercise, there is a family history of sudden death,  ventricular dysrhythmias or prolonged QT syndrome.

Palpitations
The majority of children who present with a fast heart rate usually have exaggerated awareness of normal sinus tachycardia rather than SVT.  VT is very uncommon in children.  “Normal” episodes may appear to start suddenly but if they are reported to stop gradually, they are unlikely to be caused by a dysrhythmia.

Chest Pain
None of the 400+ children referred for chest pain in the last 20 years have had a cardiac cause identified for their pain – one child had a tension pneumothorax and gave a clear history on enquiry of pain made worse by breathing in.  Chest pain should only be referred if it is clearly anginal in description, always occurs during exercise and not after exercise has stopped.  Pericarditis may cause chest pain at rest but should be accompanied by other signs such as a friction rub.

Family History of Cardiomyopathy
Screening for patients in whom a teenager or adult  family member has cardiomyopathy is not usually indicated before 10 years of age.

Known Congenital Heart Faults
If a patient moves into the area and is known to have a congenital heart fault, please enclose copies of all correspondence from the previous centre.  We will arrange the appointment to as close a time as possible to the planned review elsewhere.

Who not to refer:

Children who have a family history of coronary heart disease even if it occurs at a young adult age.  Parents should be give general advice about healthy living including diet, regular aerobic exercise and the absolute avoidance of smoking.  Fasting lipids may be helpful but probably only in teenage years.  Gene testing may become a future option Patients for cardiomyoapthy assessment where only distant relatives have the problem. Vasovagal episodes. Innocent murmurs

How to refer:

If urgent, please telephone 0131 536 0627 or 0621 during normal working hours and ask to speak to the consultant cardiologist on call.  If they are not available, the secretary will take your number and ask them to phone you back.

If urgent and out of hours, please phone switchboard on 0131 536 0000 and ask for the consultant cardiologist on call.  If it takes a long time for them to answer, ask to be put through to A&E and leave your number with them so that they can contact the cardiologist and ask them to return your call.

If you do not know whether a cardiology review is necessary, please write indicating you are seeking advice and not necessarily expecting an appointment.

If you want an appointment, use SCI Gateway to send a routine letter.

Innocent murmur information sheet for parents:

NORMAL MURMURS

Heart murmurs in childhood are very common but heart faults are uncommon. It is quite normal for healthy children with normal hearts to have a heart murmur.

IT DOES NOT MEAN THAT THERE IS A PROBLEM WITH THE HEART.

A murmur is the noise made as the blood flows through the chambers, tubes and valves of the heart. As many as 70% of all normal young children may have a heart murmur. No further tests are needed when:· the noise is typical and is not heard at the back,· the sounds made by the heart valves are normal· the pulses in the arms and legs are equal and felt at the same time. A normal murmur may be noted for the first time when a doctor listens to the chest during routine medical examination or when a child has a minor illness. It is often easier to hear when a child is unwell, anxious or has been exerting him or herself. Occasionally, a doctor may be unable to say for certain that the murmur is a normal one. S/he may then ask to examine the child again, usually when the child is older and less fidgety. Only if there is doubt whether the murmur is normal or abnormal do further tests need to be done. Normal murmurs often but not always disappear as the child gets older but they are also present in some adults.

IF THE MURMUR IS NORMAL, IT DOES NOT MATTER THAT IT PERSISTS.

http://www.rch.org.au/cardiology/health-info.cfm?doc_id=3537

http://www.aafp.org/afp/1999/0801/p558.html

http://circ.ahajournals.org/content/111/3/e20.full