Management of heart failure in infants and children
- Rakesh K Singh, MD, MS
Rakesh K Singh, MD, MS
- Assistant Professor of Pediatrics
- University of California, San Diego
- TP Singh, MD, MSc
TP Singh, MD, MSc
- Associate Professor of Pediatrics
- Harvard Medical School
- Section Editors
- John K Triedman, MD
John K Triedman, MD
- Section Editor — Pediatric Cardiology
- Professor of Pediatrics
- Harvard Medical School
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
Heart failure is estimated to affect 12,000 to 35,000 children below the age of 19 years in the United States each year . It results from any structural or functional cardiac disorder that impairs the ability of the ventricle(s) to fill with or eject blood.
The management of children with heart failure will be presented here. The etiology, presentation, diagnosis, and initial evaluation of the pediatric patient with heart failure are discussed separately. (See "Etiology and diagnosis of heart failure in infants and children".)
Because heart failure is a common clinical condition in adults, there is a substantial amount of evidence-based data based on large, placebo-controlled clinical trials that guide management. Over the past 20 years, management of heart failure in adults has shifted based on observations that heart failure and left ventricular (LV) systolic dysfunction activate sympathetic nervous and renin-angiotensin systems. This response is initially physiologic (and compensatory), but persistent activation is maladaptive and contributes to progressive LV dilation and dysfunction (remodeling), and worsening heart failure. Data from clinical trials have shown that drugs targeted to block the effects of neuro-hormonal activation not only reverse LV remodeling but also improve survival in patients with heart failure.
However, the ability to conduct similar trials in children is not possible because the much lower prevalence rate of pediatric heart failure does not allow for a sufficient number of patients to replicate these studies. As a result, treatment of heart failure in children is based on results provided by adult studies. This approach is justifiable because children in heart failure have neuro-hormonal changes [2-4] and systemic ventricular remodeling similar to that described in adults with heart failure .
In 2004, the International Society of Heart and Lung Transplantation (ISHLT) published guidelines for the treatment of heart failure in children primarily based on the adult literature . Modifications for specific pediatric diagnoses were recommended based on expert consensus that was largely informed by clinical experience, small case series, and physiological studies. The management approach for this review is based on these guidelines and advances in heart failure therapy since the publication of these guidelines.
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- Goals of therapy
- Management approach
- - Etiology and pathophysiology
- - Severity of heart failure
- COMPONENTS OF THERAPY
- Surgical or catheter-based intervention
- Pharmacologic therapy
- - Overview
- - Diuretics
- - Digoxin
- - Renin-angiotensin-aldosterone system inhibition
- Angiotensin-converting enzyme inhibitors
- Angiotensin receptor blockers
- - Beta-blockers
- - Pulmonary vasodilators
- - Drug therapy for advanced heart failure
- - Catecholamines
- - Milrinone
- Nonpharmacologic interventions for advanced heart failure
- - Positive pressure ventilation
- - Mechanical circulatory support
- - Heart transplantation
- Nonpharmacologic therapy for chronic heart failure
- - Nutrition
- - Exercise rehabilitation
- Therapy to reduce complications
- - Thrombi formation
- - Arrhythmias
- - Ventricular dyssynchrony
- OUR APPROACH
- SUMMARY AND RECOMMENDATIONS