10.4 Lifespan Cardiovascular Issues

ANCC scores cardiovascular items across eight age groups — infant through frail elderly — not only on 55-year-old primary prevention. Sections 10.1–10.3 taught adult diagnosis, drugs, and lifestyle. This section is the overlay that changes the answer when the patient is four, pregnant, 88 and frail, or a varsity athlete who fainted in practice.

Children: Still murmur versus a murmur you refer

A Still murmur is the classic innocent musical or vibratory grade 1–2 systolic sound, usually in a preschool or early school-age child, heard at the lower left sternal border toward the apex. It is louder when the child is supine and softer sitting or standing. The child is growing, pink, and otherwise well. Femoral pulses are equal. There is no click, no thrill, no diastolic component, and no family cardiomyopathy story. Document it, show the family it is common, and do not pathologize a well child into a sports restriction.

A venous hum is a continuous cervical sound that disappears when the child lies down or when you compress the neck veins. That is also innocent. What is not innocent: any diastolic murmur, a systolic murmur ≥3/6, a holosystolic murmur, a continuous murmur that is not a venous hum, a thrill, failure to thrive, hepatomegaly, unequal or delayed femoral pulses, exertional symptoms, or a concerning family history. Those go to pediatric cardiology. Do not reassure on a grade because the child "looks fine" if the murmur itself is a referral grade.

Kawasaki disease and coarctation

Kawasaki disease is a medium-vessel vasculitis of young children. The recognition pattern is fever for ≥5 days plus mucocutaneous signs: bilateral nonexudative conjunctival injection, oral changes (cracked lips, strawberry tongue), cervical lymphadenopathy, a polymorphous rash, and extremity changes (redness, swelling, later peeling). Incomplete Kawasaki is still Kawasaki. The FNP's job is urgent recognition and referral, not office observation while you "see if the fever breaks Monday." Coronary-artery aneurysms are the feared complication. Intravenous immunoglobulin and aspirin are specialty/inpatient therapy. You do not start that pathway from a well-child slot and send the family home.

Coarctation of the aorta is a mechanical reason a child or young adult has hypertension. Compare arm and leg blood pressures and palpate femoral pulses. Higher BP in the arms than the legs and delayed or weak femorals are the exam. Rib notching is a later radiographic clue, not a screening test. There is a strong association with bicuspid aortic valve. Do not treat isolated upper-extremity hypertension in a 7-year-old with an adult ACE inhibitor and call it essential HTN. Refer.

Familial hypercholesterolemia screening in the family you already know

Universal pediatric lipid screening commonly lands around ages 9–11 and again at 17–21. That calendar does not apply when the family history is already screaming. If a parent or sibling has FH, tendon xanthomas, or premature ASCVD, screen the child as early as age 2. An LDL-C that stays very high after you exclude hypothyroidism and nephrotic syndrome is FH until genetics or a lipid clinic says otherwise. Cascade-screen the household. Lifestyle starts immediately; statin decisions in children are comanaged with someone who does this weekly. Missing the family history and waiting for the 10-year well visit is the exam miss.

Pregnancy: stop the ACE inhibitor, know preeclampsia

ACE inhibitors, ARBs, ARNIs, aliskiren, and spironolactone are contraindicated in pregnancy. A positive test in a woman on lisinopril is an Implementation emergency: stop the drug now, document the exposure, and transition to a pregnancy-compatible agent. Preferred antihypertensives in pregnancy are labetalol, extended-release nifedipine, and hydralazine. Methyldopa is historically acceptable but is no longer the first drug most obstetric partners reach for. Statins are generally stopped for pregnancy planning and pregnancy. Atenolol is a poor beta-blocker choice because of fetal-growth concerns. Do not "just lower the dose" of lisinopril and recheck next trimester.

Preeclampsia is new hypertension after 20 weeks plus proteinuria or end-organ injury (severe headache, visual change, right-upper-quadrant pain, thrombocytopenia, rising creatinine, elevated liver enzymes, pulmonary edema). Superimposed preeclampsia can land on chronic hypertension. This is emergency obstetrics, not a primary-care hydrochlorothiazide increase and a follow-up in two weeks. Eclampsia (seizure) and HELLP are the same building, faster. Postpartum preeclampsia still exists — a 10-day-postpartum headache with a BP of 170/110 is not "new-mom stress."

Older and frail adults

Isolated systolic hypertension — high systolic, lower diastolic, wide pulse pressure — is the usual older-adult pattern of stiff arteries. It still counts as hypertension by the 2025 categories. Treat it. Also stand the patient. Orthostatic hypotension is a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within three minutes of standing. It is how you convert a "successful" clinic BP of 118/64 into a fall, a hip fracture, and an Evaluation disaster. Measure sitting and standing, especially after a new diuretic, alpha blocker, or nitrates, and after a hospital stay.

The usual 2025 goal remains <130/80 mm Hg for most older adults who tolerate therapy. The same guideline allows looser individualization when life expectancy is limited, when severe frailty or a high fall burden makes harm likely, or when the patient, after a shared-decision talk, declines aggressive titration. That is not permission to ignore a systolic of 180 in a robust 82-year-old, and it is not a return to a universal 150/90 target from older consensus statements. Start low, use once-daily first-line agents, avoid stacking centrally acting drugs, and recut the regimen after any fall.

Polypharmacy is the other older-adult CV exam. An ACE inhibitor plus spironolactone plus a potassium salt substitute plus trimethoprim is a hyperkalemia stem (Sections 9.2 and 10.3). Digoxin in reduced GFR is a toxicity stem (Section 10.2). Beers Criteria flag many antihypertensives only when they cause orthostasis or when a safer option exists — they are a risk list, not an automatic ban (Section 9.2).

Sports clearance when the heart is the question

Preparticipation clearance is a risk screen, not a signature on a form because the season starts Friday. Red flags that stop clearance: exertional chest pain, exertional syncope or near-syncope, unexplained dyspnea or fatigue out of proportion to training, exertional palpitations, a family history of sudden death or known cardiomyopathy or channelopathy in a close relative, a Marfanoid habitus with a murmur, or a pathologic murmur on your exam. Those athletes get an ECG, often an echocardiogram, and cardiology — before return to play. A normal exam today does not clear last week's exertional syncope. Hypertrophic cardiomyopathy, anomalous coronaries, and inherited arrhythmias are why this is not a paperwork item.

An athlete with a Still-type innocent murmur and a negative history can usually play. An athlete with fever and a new murmur may have carditis — do not clear through a possible myocarditis. When in doubt, hold the form.

Vignette. A well 4-year-old has a grade 2/6 musical systolic murmur, louder supine, equal femorals — Still murmur, follow growth. A 6-year-old with six days of fever, strawberry tongue, and red eyes is Kawasaki until a pediatric center says otherwise. A 32-year-old on lisinopril and a positive home pregnancy test stops the ACE inhibitor today and starts labetalol or nifedipine. An 86-year-old with systolic 148, diastolic 62, and a 24-point standing drop needs the regimen recut for orthostasis, not another 10 mg of chlorthalidone because "the goal is 120." A 16-year-old who fainted during sprints does not play Saturday.

Exam trap. Lifespan items punish adult-only thinking: treating a child's delayed femorals as essential HTN, continuing an ACE inhibitor "because her BP is finally good" into pregnancy, clearing exertional syncope, and driving a frail elder to 110/50 without a standing blood pressure.