High-Yield Board Pearls¶
47 Essential Pearls for Pediatric Cardiology Boards
Core Topics (1-18)¶
1. Kawasaki Disease¶
Z-score ≥2.5 or age <6 months = HIGH RISK Intensify initial treatment beyond standard IVIG alone
2. IE Prophylaxis¶
Only for HIGH-risk lesions Most CHD (VSD, ASD, AS) does NOT require prophylaxis
3. Pediatric Hypertension¶
Use 2017 AAP tables (normal-weight only); adult criteria at age ≥13 Major change from 2004 Fourth Report
4. Sports Participation¶
Shared decision-making is now standard Absolute disqualification is rare; athletes may compete with many conditions
5. MIS-C Follow-up¶
Echo at 7-14 days and 4-6 weeks minimum Even if initial echo is normal
6. Pediatric HCM¶
Extreme LVH is most common SCD risk marker in children More predictive than NSVT or syncope
7. Myocarditis Return-to-Play¶
Minimum 3-6 months restriction Requires normal echo, Holter, AND exercise test
8. ARF (Jones Criteria)¶
Subclinical carditis on echo NOW counts as major criterion Echo ALL suspected ARF cases
9. LQTS Treatment¶
Beta-blockers for ALL diagnosed patients Nadolol/propranolol preferred; avoid metoprolol
10. CPVT Management¶
Exercise restriction is CLASS I Flecainide added to beta-blockers if breakthrough events
11. Neurodevelopmental Risk¶
CPB in infancy OR chronic cyanosis = HIGH RISK Refer for developmental evaluation
12. Cardiomyopathy¶
Genetic testing recommended for ALL children with cardiomyopathy ~30% of "idiopathic" have identifiable genetic cause
13. Lipid Screening¶
Universal at 9-11 years and 17-21 years Targeted screening if risk factors ages 2-8
14. Turner Syndrome¶
Echo + MRI at diagnosis Aortic dissection risk 27x higher than general population
15. Down Syndrome¶
Echo ALL infants Physical exam alone misses ~50% of CHD; AVSD most common
16. CCHD Screening¶
PASS = SpO2 ≥95% in BOTH pre- and post-ductal Only 1 retest allowed (2025 update)
17. Syncope¶
Vasovagal most common in children Beta-blockers NOT effective (Class III: No Benefit)
18. Fetal Echo Indications¶
Abnormal OB screen, first-degree relative with CHD, pregestational diabetes = Class I
3% CHD risk warrants referral
Expanded Topics (19-28)¶
19. Fontan Surveillance¶
Annual echo + liver imaging + AFP ALL patients need thromboprophylaxis (aspirin vs warfarin)
20. Fontan Complications¶
PLE and plastic bronchitis = poor prognosis Refer for transplant evaluation
21. PDA in Preterms¶
Prophylactic treatment NOT recommended Conservative management is acceptable for most
22. PDA Closure Trends¶
Transcatheter closure rising rapidly; surgical ligation decreasing Piccolo device approved for preterms (0% → 20%; surgery 25% → 4%)
23. DMD Cardiac¶
Baseline echo by age 6; annual echo after age 10 ACEi when dysfunction detected; consider prophylactic by age 10
24. Pericarditis Treatment¶
NSAID + colchicine first-line (NOT steroids) Steroids increase recurrence risk
25. Pericarditis in Children¶
Avoid aspirin <12 years (Reye syndrome risk) Colchicine reduces recurrence by 50%
26. AAOCA - Left from Right¶
AAOLCA = HIGH SCD risk → surgery Regardless of symptoms if interarterial course
27. AAOCA - Right from Left¶
AAORCA with negative stress test may participate in competitive sports Class IIa recommendation
28. Heart Transplant Bridge¶
VAD use increased to 36% of pediatric transplants VAD preferred over ECMO
New Topics (29-34)¶
29. Marfan Syndrome¶
Beta-blockers OR ARBs for ALL patients Surgery at ≥5.0 cm (or ≥4.5 cm with risk factors)
30. Aortic Disease Screening¶
First-degree relatives of TAA/dissection patients need aortic imaging Class I recommendation
31. Rheumatic Fever¶
2015 Jones Criteria: Subclinical carditis counts as MAJOR criterion Population-based criteria differ
32. RHD Prophylaxis¶
Benzathine PCN G every 3-4 weeks Duration based on presence/severity of carditis
33. Turner CV Surveillance¶
ASI ≥2.5 cm/m² = at-risk for dissection MRI preferred over echo for aortic surveillance
34. Turner Pregnancy¶
HIGH RISK (~2% dissection rate) Contraindicated if ASI ≥2.5 cm/m²
35. Fetal Echo Timing¶
18-24 weeks optimal
3% CHD risk = Class I indication
36. Pediatric Echo Z-scores¶
Use PHN Z-scores for coronary arteries Always report Z-scores with measurements
37. Peds Cath Lab Requirements¶
Pediatric cardiac surgery backup REQUIRED Biplane fluoroscopy preferred
38. Cath Interventions¶
Balloon valvuloplasty = first-line for valvar PS Piccolo device for preterm PDA
Clinical Topics (39-46)¶
39. Innocent Murmurs¶
6 S's: Soft, Short, Systolic, Single S2, Symptom-free, no abnormal Sounds Still's murmur (vibratory LLSB) most common age 3-7; NO echo needed
40. Pediatric Chest Pain¶
<5% cardiac; most is musculoskeletal Red flags: exertional, syncope, palpitations, family history of SCD
41. Pediatric ECG¶
RV dominance normal in newborns; axis shifts left by 3-6 months QTc >460 ms abnormal; >500 ms high-risk
42. Cardiac Exam¶
Small VSD = LOUD murmur; Large VSD = SOFT murmur Fixed split S2 = ASD; Single S2 = suspect cyanotic CHD
43. Acyanotic CHD¶
VSD presents at 4-8 weeks when PVR drops Upper > lower BP by ≥20 mmHg = coarctation
44. Cyanotic CHD¶
Hyperoxia test: PaO2 <100 on 100% FiO2 = cardiac cause When in doubt, START PGE1 (0.05-0.1 mcg/kg/min)
45. Tet Spells¶
Knee-chest position FIRST Then: calm → O2 → fluids → morphine → phenylephrine → surgery
46. Vascular Rings¶
Stridor + dysphagia + recurrent respiratory infections = suspect vascular ring Double aortic arch most common complete ring; CT/MRI for diagnosis
47. Heart Sounds & Murmurs¶
Fixed split S2 = ASD; Single S2 = one semilunar valve (atresia, truncus, TGA) S3 normal in children, S4 ALWAYS abnormal; diastolic murmurs ALWAYS need echo
Quick Reference Tables¶
Key Numbers to Know¶
| Parameter | Value |
|---|---|
| Kawasaki high-risk Z-score | ≥2.5 |
| Hypertension adult criteria age | ≥13 years |
| Myocarditis RTP restriction | 3-6 months |
| Universal lipid screening | 9-11 years |
| CCHD passing SpO2 | ≥95% |
| Marfan surgery threshold | ≥5.0 cm |
| Turner at-risk ASI | ≥2.5 cm/m² |
| Fontan HCC risk (20+ years) | ~1.3% |
| DMD annual echo starts | Age 10 |
Common Medication Preferences¶
| Condition | Preferred Agent | Avoid |
|---|---|---|
| LQTS | Nadolol, propranolol | Metoprolol |
| Pericarditis | Ibuprofen + colchicine | Aspirin <12y, steroids |
| Marfan | Beta-blocker OR ARB | - |
| DMD | ACEi + beta-blocker + MRA | - |
| Vasovagal syncope | Lifestyle modifications | Beta-blockers |
Review these pearls regularly for board preparation Each pearl links to the detailed topic file for deeper study