Pediatric cardiologist Ana C. Coll, MD, discusses the conditions – from arrhythmias to Kawasaki’s disease to several genetic disorders – that warrant cardiac concern and sometimes referral in young patients. She covers signs calling for STAT investigation, key elements of the physical exam, and helpful tests. Included are usable tools, such as a murmur evaluation chart and a medications table with cardiac effects and monitoring recommendations.
Good afternoon to everybody. I'm going to try to make this presentation as painless as possible. Um I am a pediatric cardiologist basically clinical cardiologist for Pete's cardiology, fetal cardiology and adult congenital. I'm gonna try to talk to you about different um diagnosis or reasons for referring a patient to Pete's cardiology as you know. Um Now we well I based my this presentation in a paper that came out from the American Academy of Pediatrics few years ago it was a paper based on what was the most common diagnosis and the most common reasons for referral to pediatric cardiology. So I would be talking about matters of the heart at this point. And so I appreciate your time and joining us in this webinar when I look at it I uh to this paper I actually added a few more diagnosis and based on my experience working in the community for over 20 years. So you're gonna see some newer diagnosis that maybe we're not present many years ago. So I'm gonna talk about murmurs, palpitations, arrhythmias, abnormal E. K. G. Chest pain, seeing could be hypertension, A. D. H. D. Kawasaki disease. Few of the genetic disorders, preterm and term infants with congenital heart disease. Simple congenital heart disease. Hyperloop idem IA's and a newer diagnosis that is becoming um not that new but and actually common parts in the santa. No mia. So for murmurs I am uh very nervous when uh pediatrician called me and said they have a baby that is less than a month with a murmur babies infants can be very deceiving in terms of presentation. So, as a pediatric cardiology, if you have an infant that is less than a month and has uh, you know, a murmur and failure to thrive per feeding, cyanosis and other symptoms from the cardiovascular standpoint. We really need to see these babies on stat basis. And when I put, please call me is because I do have a very, you know, close connection to the pediatricians in the communities that I serve. And I like to be called immediately. So to get this baby sitting ASAP for echo and evaluation, uh, if basically these are 1 to 6 months and are asymptomatic with the murmur. We like to see these babies in about two weeks. So this could well consider this a s a p type of referral. Um, The most important thing is the assessment that you do in your office and what you can do is, you know, not just the murmur, uh ask the mother or the correct taker for um any other symptoms, urine output, stooling, eating habits and amount and always obviously weight gain. If the baby is more than six months, uh, and doesn't have any of these symptoms, then we will see them on first available. I still have a soft spot for infants or anybody that is less than 12 months. I tried to see in a very urgent matter. So please be free to label your referrals with the stat or asAP if you feel that deserves to be seen. We also have people on call in our division that can help you if you have an infant that is not looking good and need to be evaluated at ASAP. So how do we evaluate these murmurs or what are what are the things that can trigger a sooner or later referral is obviously the timing of the murmurs. Historic murmurs tend to be more benign. The diastolic diastolic murmurs tend to be uh pathologic. So if you have a diastolic murmur, considerable, assumed that could be pathologic continuous murmurs. Also in infants could be related to doctors are theriot sis venus. Homes also can give you some sort of continued murmur and is considered a nine murmur but the timing is important. The grade of course grade wanted to maybe not that urgent, A harsher or a louder murmur in the in the 3rd, 4th or fifth degree sex to be. Then you should prefer these patients with certain emergencies. They're not necessarily a benign murmur when you can hear it very easy on level three, the pitch in um cardiology. If we hear anything that is high pitched, musical by battery type of murmur tend to be or we tend to think this is more benign. Anything that is low pitch or hard is considered pathologic. So those are the things that you can evaluate in your practice and decide who needs to be seen sooner. Also location and radiation. And I'm going to just put a little quick slide where you just orient yourself in terms of what the anatomical things are you listening to when you school creating a different areas of the chest, the right over um uh spot is for more of a generic type of disease. I already called insufficiency and aortic valve stenosis. You also have gonna have radiation of these murmurs to different spots left for personal borders pulmonary disease. Most of the time related to pulmonary stenosis. The left lower sternal border you can hear VSD. Is there you can also hear um track us about disease. Like because without regurgitation or stenosis which is the diastolic murmur. And then a place called facilitation was going to talk more about mitral disease. I'm gonna put my glasses because if not I can read some of these uh slides. So this is just information. And when you if you get to review this lecture later then you can use this as a reference for having an idea where what is the structure that could be affected and depending on the place what you hear the murmur and that will indicate a more urgency or less urgency in terms of referral. Ah And this is like we're talking about the type of memory and this is about the timing. We tend to think the systolic ejection murmurs tend to be more innocent but they also can be obviously related to stenosis of the era or the permanent evolve if you hear a whole historical pants systolic murmur, they tend to be due to evaluate meditation. V. S. Ds. Are in this category then early diastolic is considered a relic. Regurgitation might mean diastolic is mitral trikus speed or tractable valve stenosis. And this is just a guide. It's very hard to time and murmur in an infant that has a heart rate of 1.40. Um so you know if you have an idea at least in the older kids you can have a more um a better a better understanding of how soon this patient needs to be seen. We'd like to see, like I said infants less than one month in and start that way. The next diagnosis is palpitations. What is important to know is what is the duration of these events and the patient if we can get the history from the patient. And if there is any symptoms associated with these palpitations, if there is any dizziness, if the patient has any changes in color to pale or if there is any syncope associated with the palpitations. A good physical exam, it's important to see if there is any murmurs associated any clicks or any new rocks, for example announced quotation and if you can do in your office and E. K. G. That will be very important. It's going to take away a bunch of urgent diagnosis of possibilities in the differential that you you can actually take out and if you do have an E. K. G. And you have findings and you want advice I more than welcome for myself to give you a help with these matters. You can try to get this to one of our offices and we if there is a cardiology there we can maybe do a preliminary reading for you. So like I said when the communities that I work and serve I'm very available and um we like to see these patients depending on what are the finance on the E. K. G. If these patients symptoms are associated with things like syncope e changes in color and really these patients need to be kind of busy in kind of soon. If you find also a murmur or something on their physical exam associated to the cardiovascular system then you definitely need to be sooner. Ah And as you remember the duration and presentation of palpitations. The most common arrhythmias in young people is going to be S. V. T. And the presentation is actually sudden sudden starting sudden end when they are reentry. Tachycardia. So that is an important part of the questionnaire that you can or the questions that you can ask your patients to try to decide how soon this patient needs to be seen. The palpitations and arrhythmia go together like I mentioned to you uh duration is not the same to have a patient that refer rhythms or arrhythmias and palpitations for 10 15 minutes. The one that said he's been doing it for two hours. Um Also it's not the same. The patient that refers symptoms of syncope, dizziness, pallor sweating or chest discomfort with the symptoms that the ones that are not present any symptoms on it as well as the findings on the physical exam and E. K. G. So if you have a patient that present to you with the symptoms and you find um you know your physical examination shows you some sort of arrhythmia on exportation or the findings on the E. K. G. Suggest that this patient can have a reentry tachycardia then feel more than welcome to send this patient on us that matter for us to evaluate and treat. I just put a couple of EKGs of normal things that can be found in in regular practice. One of the most common um referrals that I get sinus arrhythmia. They were arrhythmia throw people off when there is that reading on the EKGs and sinus arrhythmia is normally is something normal. It has the changes of the heart rhythm with respirations. So there's nothing that you need to worry about this and you can actually corroborate this in the office. If you have an E. K. G. Machine make your patient to hold the breath and see how they have already slowed down. But Germany is not that benign but it could be sometimes benign. We need to see what kind of Pvcs are. Those are more and more people more fake And we also want to know what is the duration of the, by gemini rhythm and how many of the PVcs are present during the 24 48 hour timing. So if you have a patient with my gemini, definitely somebody that we want to see, it could be a reflection of something more dangerous like a cardiomyopathy or prison disturbance. Pc very common in young people and this era is the area of caffeine. Unfortunately our teenagers are drinking 345 cups of coffees a day uh in the matter of shakes, energy drinks, so keep an eye on and those habits. So if you have a patient that have a P A. C Don't forget to ask for the ingestion of caffeine, if he's a teenager, otherwise they tend to be benign if they are present in an infant. We like to think that this is just transitory. They tend to result in the first 7 to 10 days of life is the most common arrhythmia and fiddle, you know medicine. Now, if it's an older patient you may want these patients to be evaluated just to make sure this is not the beginning of something else. And also to have an idea of how many of these beads are throw in a day. So these are patients that we like to see. Not necessarily urgently, but if they do have associated CinCO P or you find anything in the physical examination, then at least you know sooner than later for a normal EKGs and this is when I put up normal is all those EKGs that get red maybe in the E. D. By an adult physician or maybe in a screening place that they did the E. K. G. We want to know if there is any associated symptoms or if there's any physical exam findings that support the findings on the E. K. G. But always if you have doubts that piece feel free to get an official reading from any of us in the group that we would be more than welcome to help you with. That. Do not necessarily need to refer the patient right away if you don't find any symptoms or anything on the physical exam unless it's something that obviously looks abnormal on the E. K. G. Like W. P. W. Or other findings. Otherwise you can send the E. K. G. And see if we can help you with a reading uh W. P. W. S. Or you probably all remember his. The shortening of the P. R. Interval with delta wave and prolongation of the Q. R. S. Um is a pre excitation type of problem. You have given us SPT due to reentry tachycardia. And these patients presentation could be S. V. T. Short of paroxysmal SV. T shirt episodes of palpitations with or not associated with pallor dizziness. The patient usually refer that the heart comes up to their throat they feel their heart coming out of the throw is not necessarily associated with any activity. These patients can have complications for WP WP. And these need to be taken care treated and managed long Q. T. Is one of those things that you may found because the patient presents with symptoms like sink copy uh maybe associated with seizure like activity. And you do an E. K. G. And find that the kids have a prolongation of the QT. C. For girls in the 15 to 16 years. We tolerate up to 4 55 milliseconds for younger boys. We like it in the 4 50 range. Anything that is above that should be considered um you know borderline or Miley prolonged. If you again has any doubts, please let us know to take a look at the E. K. G. Is different. If you find this with an asymptomatic patient that if you have this on a patient that had a single bee episode, either exercising after exercise or even at rest so long QT can be very insidious in presentation may not have a clear picture. But if you find it on the E. K. G. You should refer these patients ASAP L. B. H. Um As you know there is multiple criteria for L. B. H. And you can use in different um whatever you feel more comfortable doing. If you have a patient that is an athlete and those five hours of exercise a day and have a L. B. H. Maybe a normal finding. But if you have somebody who doesn't exercise then you may have to send this a patient for evaluation form of cardiomyopathy. Rbgh. What we see most often associated these patients that have obesity and sleep apnea and then develop our B. H. Two to increase pulmonary pressures. So R. V. H. Or L. V. H. And E. K. G. Is not a normal finding. Uh and it needs to be um refer unless you have an explanation um Like you know it's an obese patients with the diagnosis of um sleep apnea. I still needs to have a cardiovascular evaluation for pulmonary hypertension and a patient that is not athletic and has significant L. V. H. And E. K. G. Then still needs to be evaluated for cardiomyopathy. This is just a few pictures of what we see in echo. For patients with cardiomyopathy. Hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy has is the number one cause of sudden death in young adults uh and athletes. So it's something that you want to make sure you're not dealing with. And if you are then we need to see these patients very very very soon. Um those are the E. K. G. Findings on how come and as you can see you have Q. Wakes I have a whole life that shows all the findings on the patients with how come um And then you can go through this when you review this lecture but also I want to mention that W. P. W. Could be a presentation of Hong kong in the E. K. G. So 33% of patients with Hong kong. You'll end up having W. P. W. Chest pain. And syncope is a very very common um cardiovascular symptom uh and a very common reason for referring patients to us. We want to know in chest pain and seem to be what was the timing is different to have a patient that actually have a chest pain or seem to be doing exercise. And this is the bottom of my slide please if you do have one that have an exertion all sink copy or exceptional chest pain. We do want to see this patient's asap because can be a sign our symptoms of something something more um um dramatic like hypertrophic cardiomyopathy or coronary abnormalities or other type of cardiovascular disease. So timing is important. And we said if it's exceptional it's definitely um an emergency. If it is addressed tend to be more um you can just maybe wait a little longer for these patients to be seen. Duration is also important if it's something that is happening and it's lasting 10 15 minutes and it's happening three hours. And also for how long these symptoms are presented. I do have patients that when you ask the question how long they said all that's been happening for two years in the last three hours five times a week and you get you know. So I always tell them probably it's not your heart because if not I will have no no organ to check at this point. You know? So it's different than when you have a patient who is me telling you that this is reason is having this chest discomfort for 10 15 minutes more like a pressure. Like and it's something new or if there is any symptoms associated like fever. Um But now with the peri myocarditis presentation of the covid vaccine which is very unlikely. It's one in five millions. But anyway we still have to keep an eye on these patients adolescents boys. So we can um make sure that the symptoms you know are related or not to the vaccine or if you have any other trigger for cardiomyopathy or myocarditis, A pericarditis. So physical exam again it's going to be important. You want to make sure you can hear the heart sounds and you don't hear any erupts and E. K. G. Is also going to be helpful in making that decision. If this is a real chest pain originating from the heart, it is a non cardiac chest pain always have in the back of your head. That um G. R. D. Is one of these very common. Also pleural disease or pleural effusions. I had a couple of patients that were you referred to me for chest pain and end up having um pleural effusions for insidious things like mycoplasma pneumonia is one of those that we see once in a blue moon with atypical pneumonia and end up having a pleural effusion and chest pain. And if we want to see. So we want to see these patients on first available. The ones that are not associated with any symptoms and are not associated with exercise. Hypertension is becoming a much more common referral for cardiology these days when I train um that we didn't necessarily see these patients. We just see the hypertension patients that were associated with anatomical issues like um A patients with their deportation but is defined as a systolic blood pressure and diastolic blood pressure more than 90% with co morbidity factors over three visits. And welcome orbit will be um you know obesity diabetes hyper epidemiologists or three visas with more than 95% for uh sex, age, sex and height. The time frame is what is usually first available but we will really appreciate if there is some workout you can do in your office. Probably send some lap work including cmp cbc title function. Uh Mobile in a one c there is a question about diabetes lipid panel and renal workout. So those things are very helpful that you can do in your office before you refer the patient. And um we will definitely see this patient um You know as soon as we have an available time. You also can recommend these patients to decrease the amount of sodium that they take daily ah And you know drinking more water and start doing more exercise until we get to see them. The american Academy of Pediatrics and the american Heart association usually recommend these patients to have changed on the life. Is that for six months before treatment needs to be done if they don't have any comorbidities or nothing in the lap work or a lab panel So make sure that your cough with is 40% of the child's arm. Uh circumference and the length is 80 200% of the circumference. So they are so it's very important that you are having a actual accurate measurement. I do have patients that still have elevated blood pressures when they come to the office. I let them chill and relaxed. Start talking about other things and then redo the blood pressure just to make sure that it's as elevated as maybe it was some presentation. Just remember that we still have the white coat syndrome even though that we tend to think that it's not only white coat is probably more often than that. But you always want to make sure that this is something really not just an event that happened due to stress A. D. H. D. Happened to be a common diagnosis these days. And um still a lot of pediatricians and um psychologists psychiatrists that are doing EKGs before they do uh management for these patients. And if they present in a normal E. K. G. We want to see these patients just to make sure this thing cardiovascular that we need to take care of. We will see it on first availability if the patient is asymptomatic. I got a nice slice here that tells the type of medications the mechanism action and what are the cardiac effects. So you have an idea that all these medications will cause elevation of the heart rate and blood pressure. Even the ones that said they're not stimulants. So this is something to consider when you have a patient that is on treatment and needs and um is having elevated blood pressure or tachycardia. They don't supposed to cause any changes on the E. K. G. With the exception of the spinning this be the medium in which caused prolongation of the QT. C. And this is a patient. They have borderline Q. T. C. Or anticipation that have family history of Q. T. C. You may I want to stay away from that medication or if you have a patient that um had you know have a change on the E. K. G. After you started on medication. And it is a significant prolongation. Then you may want to stay away from that medication in particular in my personal experience, I know that these patients have specific cocktails that work for them and it's very personal. The type of treatment is not one formula that fits at all. So I understand that there is a balance between what these patients need to be functional in society and what are the risks that we take giving them these medications but monitoring the blood pressure, the heart rate is not a bad idea. You can do an E. K. G. If you want to and if you have the ability to do it but prior to start treatment and maybe six months six months after you start the treatment to see if there is anything that you wanted to to to check as you can see that it's not really anything that you're going to see on the E. K. G. O. S. That is developing of left ventricular hypertrophy or prolongation of the QT. C. Kawasaki disease is part of the acquired cardiovascular disease. Um We see these patients usually in counselors and in patients if it's uncomplicated and there is no or trans and coronary artery ecstasy for minimal kardian involvement. Then we see these patients two weeks and six and eight weeks post concept of the illness. Just to check for coronary aneurysms. If it's complicated then you probably will have a much more extensive consultation of or involvement of cardiology in the hospital. And it will be determined by the necessity of the consultant and the consultant will decide when I want to see these patients depending on the findings and the complications. This is just as like to remind what the Kawasaki would be will shows up like um usually you know, you have injected content drivers so very um tone with cracked lips in injected mucosa, Hand and feet, edema and rush. Also a diffuse erythema, those rights and the rush on the genital area. These are the manifestation of Kawasaki disease. As you can see the heart involvement start maybe between one week and it can take up to five weeks Um to um actually go away the answer, Christmas present later on, it's been 3-6 weeks and that's what we want to see them. Usually at that time, just remember the other part of the presentation. I love this life. Just to give an idea what I would should be looking like. Um from the moment the patients start having fevers, I have to add to this casa que no covid. Unfortunately we're using the some of the criteria of Kawasaki to follow on patients who had involvement of the heart by covid disease. So if there is any affection of the coronaries then we will follow these patients after they get discharged from the hospital, genetic disorders. Uh well, as you know, there is a bunch of genetic disorder that have involvements of the heart. These are the most common disorders marked from Turner's down the George, Noonan and muscular dystrophy. Uh I know that if you work in areas where their rural patients or migrant workers, you may have patients that are first come to your office and they look like they may have a syndrome that you may don't know what exactly is going on because they don't have genetic confirmation. But if you suspect any of these in terms you need to make sure the heart is okay. Where um we'll see these patients on first available if they are asymptomatic but they do have a huge murmur or a failure to thrive or any other symptoms would like to see them sooner. It is just a slide to show some of the associations of the congenital heart abnormalities with these specific syndromes. As you can see, try 17 18 is gonna probably have heart issues. Down syndrome will be between 40 to 50%. Then you have the other syndromes like Degeorge which is up to 75% of cardiovascular findings. If you do have patients with any of those syndromes already confirmed, don't don't forget to send this revelation of the heart. This is more of these single gene defects and Noonan's Costello chopper allergy pills. And I again, I respect a lot of the pediatricians that are in the community dealing with patients that may have this diagnosis but they never have been confirmed. So if you do have a patient that may have some of these or genetic disorders. Don't forget to give us a call and we'll be more than welcome to help you to evaluate this and we maybe can do an enjoyment with genetics right. Uh the typical thing in the community is having a premature that went to the niCU and ended up being diagnosed with an ASD VSD. Or a P. D. A. And then to get discharged and we try to see these patients if they are asymptomatic, 1 to 2 months after discharge the patient's symptomatic then we want to see them sooner and it will be determined by the in house consoles. Sometimes if you didn't have any house console then we want to see them soon. If the patients are symptomatic. Uh I'm sorry if the patient and symptomatic if they have any failures to drive for Pds, remembers your continuous murmur but it could be also just as historic murmur. A stds may give you or not a systolic ejection murmur in the level of personal border. For Bs Ds will be a hollis. Systolic murmur. The presentation usually is heart failure and they can present with difficulty feedings, poor weight, gain sweating with feedings and troubled growing. This is just as like to remind you where these defects are. Um stds are defecting NHL substance produced left to right, shunting at the level of the HN with volume overload of the right atrium, right ventricle and ordinary circulation BSD is the facts in the ventricular septum with left to right shunting at the level of the ventricular of the ventricle with um volume overload into the pulmonary circulation left atrium and left ventricle and the P. D. A. Has a very similar type of um physical pathology with the left to right shunt at the level of the great quantities and increased volume into the pulmonary circulation. Left atrium and left ventricle hyper embodiments. Again it is hand to hand with hypertension in the epidemic of obesity. We need to screen patients age 2 to 10 years. If there is family history of this lipid e. Mia's, it's important to ask the parents um or if there is cardiovascular disease in less than a male with less than 55 years old or a female less than 65. If you have a patient with A B. M. I. Between the 85th and 95th percentile or obese with B. M. I. Is above 95th percentile. If there is hypertension or if you have diabetes you have we have the editorial causes of hyper epidemiology. Like familiar hypercholesterolemia, familiar combined and this better lipoprotein anemia. So when you order the labs for lipids just required remember to just get a segmental or a um all the lips including the L. D. L. B. L. B. L. D. L. And um not necessarily kyla microns. But if you can please get all not just the total cholesterol's to give an idea of what could be happening. Ah These patients some of these patients will need pharmacology therapy on top of the diet and the and the exercise. So feel free to please call if you have any questions with the patient and needs to be seen for hyper epidemiology with serious patients in combination with other specialties. Unfortunately we cardiologists be dealing with hyper lipid even in non alcoholic fatty liver um representation of obesity. So we now need to get some experience on the management of these patients. Um genetics also should be involved in the if the patients have some sort of familiar Editori cost of hyper epidemiology. Um also referred to cardiology. If you try to listeners are over 300 if you B. M. I. Is over 90 L. E. L. Over 1 60 Um with story of cardiovascular disease or the LDL is more than 1:30 with family history of early cardiovascular disease also have a vascular disease. So those are the criteria of when we like to see these patients in the cardiology clinic you can do these labs in your office and definitely start the the management of the patients with dietary guidance and exercise. We do use pharmacology therapy for the treatment of Hyperloop Idema. And some of these patients they need to be over 10 years of age and they have to have an L. D. L. Uh in those ranges for us to start pharmacological therapy. Otherwise we would recommend just diet and exercise. So again we have what is susceptible borderline and high and I the the little picture with the child and all the complications of obesity is something that I carry in my phone as a cardiologist at the clinical cardiologist, I've been seeing a lot of patients with obesity and a lot of problems related to that. I try to present these um picture to my patients. People think that obesity is just vanity sometimes. And this has um much more broader uh spectrum of disease with affection in the brain and the lungs and the you know, gastrointestinal system, endocrine, muscular and cardiovascular obviously, but please We know that it is hard to send patients with obesity and complications of obesity to cardiology. But this is something that needs to be taking care. Um you can do a lot of changes in in um in your practice uh and help to start early before patients come with £100. But if you have patients that are definitely difficult and you can manage it needs some more help then remove more than welcome to help you treating these patients. Remember the cholesterol some comes from deliver some comes from the food and the food that usually associated is anything that comes or deactivate from animals, fat, animals. So just um or animal fat. So just remember to talk to your patients about that. The south economia or pots is the newest uh more common reason for seeing these patients in cardiology clinic is a form of Ortho statics intolerance and it can present in a very different type of of symptoms. These patients can have cardiovascular symptoms like dizziness and syncope e related to decreasing the blood pressure or palpitations due to the tachycardia related to the reflects tachycardia due to the auto static hypertension. The diagnosis is when the heart rate increased 30 beats per minute or more over 120 with the 1st 10 minutes of standing. So you get your patient laying down, tell them to stand. And if the heart rate goes up to over 1 20 or more than 30 beats, it could be a patient with the south economia or pots. Um, The revised standard set 40 beats per minute. Uh and we usually use the tail table to make the final diagnosis is a very gruesome type of test. I'm not sure. I like to send my patients for the tables for diagnosis of positive. I do have the suspicious I um just do some maneuvers in the office and try to confirm the diagnosis. If I have doubts, then is when we send these patients folding tables, um, they can be done beside and I try to do that with the patient. But if you do have an adolescent symptoms from multiple systems, including lack of concentration, abdominal pain, diarrhea, constipation, auto static hypertension. Then start thinking that this could be the Salvation Army and parts and it's definitely a diagnosis that we treat in cardiology clinic. As you know, this is not a cardiovascular disease. Unfortunately, there is a lot of symptoms associated with the cardiovascular system. So, as you know, can present fatigue, headaches, like headaches and concentration. Like I said, it's a very broad uh picture of symptoms. These patients usually go from specialist to specialist um to somebody's put everything together and said, oh, that's what you got. Um We definitely have a diesel genomic clinic um that we do with neurology and UCSF Fresno. It's a combined neuro cardio clinic and sometimes we actually involved G. I for some of these patients, I know some of my colleagues not to soil for see a lot of these these autonomic patients in the East Bay too. So it's something that we see some neurologists do have also this autonomy clinics as part of their practice. The history was coined in 1993 in Mayo Clinic, but it's something that probably has been going around for many, many years before that with different names. We have gained a lot of insight to this in the last 20 years. When we actually start putting together that this is more an issue of the autonomic nervous system. It just means information and inspiring of the autonomic system and that's why we have these um, all these, you know, different types of symptoms, what causes. We don't know, there is some triggers definitely that related to systemic infections. Um because you present with so many other symptoms, we don't really necessarily going to find the cause, but I do have, if we find the cause, then we treat the cause and try to get away with it. I have um here some of the most common suspects like Epstein Barr for example, also of autoimmune disease like lupus or Sjogren's genetic disorders, Ehlers Danlos becoming very popular on this, vitamin deficiency, anemia, reconditioning and other things like acute infections, tumorous cancers. So it's very very um it's a very, very a number of amount of diagnosis that can be triggered of these symptoms. The treatment depending of what is the most predominant cardiovascular symptoms, at least in my patients. Some of them and flew the court is um some of them and just water and salt intake. Some of them are you need to have my um my true dream for low heart rates and low blood pressure. So there is also vitamins and dietary changes that can be used and all theirs. If they go to neurology, they may use other types of medications. So this is what I tell my patients that come to clinic with obesity, hypertension and hyperlink piggy mias. And uh I do appreciate your time. And if you have any questions then we go directly to that. This is our panel of our team of pediatric cardiology in venue and here is the information that you need if you want to send us a patient. Like I said, we can also take care of some of the emerging questions to the person that is on call on the L. A basis