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Guidelines issued for diagnosis, treatment of HF in children
The Canadian Cardiovascular Society has issued guidelines on the presentation, diagnosis and medical management of HF in children.
The goal of these new guidelines is to assist practitioners in primary care departments or EDs who may have little practical experience with the presentation or management of HF in children, according to the document, written by the society’s Children’s Heart Failure Study Group in collaboration with the Canadian Pediatric Cardiology Association.
“The symptoms are dissimilar to those of adults, and are quite variable,” project leader Paul F. Kantor, MBBCh, of Stollery Children’s Hospital, University of Alberta, Edmonton, Canada, said in a press release. “Currently, our experience is that nearly all cases of new-onset HF are diagnosed only when the patient has reached a state of severe decompensation, and less than 50% of children who present with such symptoms of HF survive for 5 years without cardiac transplantation.”
Recommendations for diagnosis
The guidelines state that the NYHA/Ross classification is suitable for symptom stratification, but there is no tool for predicting mortality for children with HF based on status at presentation. Early and repeated CV examination is recommended for younger infants with feeding difficulties and growth failure, after ruling out gastrointestinal issues and other common causes.
A series of recommendations on which children should be evaluated for HF “place a high value on a comprehensive approach to history-taking, examination and differential diagnosis for children with suspected genetic or acquired [cardiomyopathy] and on a comprehensive approach to ongoing evaluation in suspected cases,” according to the document.
The study group recommended that chest radiography be a first-line investigation in children with suspected HF, and that at initial presentation of HF, assessment of electrolytes, acid-base status, urea and creatinine, hepatic transaminases and thyroid hormone levels should be performed, along with a complete blood count. A 12-lead ECG should also be performed at presentation to exclude features of ischemic or congenital heart disease, arrhythmia and pre-excitation.
Ambulatory ECG monitoring is not recommended as a primary diagnostic test except in certain cases, but may benefit certain classes of patients during follow-up.
Assessment of brain natriuretic peptide or NT-proBNP levels is recommended as a confirmatory test because they “are useful in distinguishing HF from respiratory or other noncardiac disease,” the authors wrote.
All pediatric patients presenting with HF should have a thorough personal health history and a three-generation family history taken, according to the guidelines. Metabolic laboratory testing in children with unexplained cardiomyopathy should be conducted according to clinical presentation, with assistance by specialist consultation. Further testing can be guided through consultation with genetic and/or metabolic services, the authors wrote.
In children who present with new-onset HF without a history of decreased functional capacity, a diagnosis of acute myocarditis should be considered, according to the guidelines. However, endomyocardial biopsy should only be performed if confirmation of the diagnosis will change the treatment plan, and should not be performed on infants weighing <10 kg or those who are hemodynamically unstable. Cardiac MRI can help to diagnose myocarditis, but its prognostic value is not known, the authors wrote.
Recommendations for treatment
The panel recommended that children diagnosed with HF and showing symptoms of congestion should receive a loop diuretic, such as furosemide. The recommended starting dose is 0.5 mg/kg to 1 mg/kg intravenously or orally every 6 to 12 hours.
Use of inotropic therapies, such as milrinone, dobutamine or low-dose epinephrine, may be an appropriate rescue strategy for children who present with HF due to reduced cardiac output with end-organ dysfunction, the guidelines stated. However, their use should be confined to those with distressed systolic function and clinical evidence of low cardiac output syndrome.
ACE inhibitors are recommended in patients with HF due to primary heart muscle disease of the systemic left ventricle, Kantor and colleagues wrote. If treatment for moderate-to-severe systolic dysfunction of a systemic left ventricle is required, a beta-adrenergic antagonist such as carvedilol, metoprolol or bisoprolol is recommended, the guideline stated.
Among children with chronic systolic HF, aldosterone antagonist therapy may be used if renal function is normal or mildly impaired, according to the document. If aldosterone antagonist therapy is co-administered with an ACE inhibitor, close monitoring of renal function and serum potassium levels is necessary.
Those with myocarditis should receive standard HF management, including inotropic support and diuretic therapy, but mechanical circulatory support should be considered for patients with fulminant myocarditis, according to the guidelines. Corticosteroids and IV immunoglobulin G are not recommended as routine myocarditis treatments.
Disclosure: Some members of the panel report financial ties with Actelion, Berlin Heart, Genzyme, Novartis and Sanofi.