Congestive Heart Failure
Congestive Heart Failure: Excerpt from The 5-Minute Pediatric Consult
Jondavid Menteer, MD
Congestive Heart Failure - BASICS
Congestive Heart Failure - description
- CHF is the pathophysiologic state in which the heart is unable to pump sufficient blood to meet the metabolic demands of the body.
- The chronic CHF state involves not only deficiency of heart output, but also a complex interplay of neurohormonal and inflammatory activation.
Congestive Heart Failure - general prevention
- Intravenous immunoglobulin (IVIg) for myocarditis or Kawasaki disease
- Limited use of anthracycline chemotherapeutic agents in cancer therapy, or cardioprotection with dexrazoxane (Zinecard)
- Prompt treatment of streptococcal pharyngitis to prevent rheumatic fever
- Antibiotic prophylaxis, when indicated, to prevent infective endocarditis
Congestive Heart Failure - pathophysiology
- Basic mechanisms:
- Diminished ejection from the systemic ventricle
- Cardiomyopathy
- Pressure load (hypertension, pulmonary hypertension, outflow obstruction coarctation)
- Normal to increased ejection with diminished systemic output:
- Severe atrioventricular (AV) valve or semilunar valve regurgitation
- Left-to-right shunt (atrial septal defect [ASD], ventricular septal defect [VSD], patent ductus arteriosus [PDA])
- Arteriovenous malformation (AVM)
- High cardiac output CHF:
- Anemia and other noncardiovascular causes
- Neurohormonal activation:
- CHF leads to activation of the renin–angiotensin–aldosterone system.
- Vasoconstriction, intended to raise BP, leads to increased oxygen consumption and workload on the heart.
- Angiotensin II receptors are involved in cardiac myocyte apoptosis pathway.
- Fluid retention, intended to raise preload and improve cardiac contractility by Frank-Starling mechanism, is ineffective at restoring normal blood flow.
- Aldosterone activates fibroblasts, causing collagen deposition, which can lead to worsening diastolic function.
- Sympathetic nervous system activation
- Right vs. left heart failure:
- Left ventricles are sensitive to acute volume loads and ischemia.
- Right ventricles are compliant, but sensitive to pressure loads.
Congestive Heart Failure - etiology
- Classification:
- Structural heart disease vs. myocardial disease
- Acquired vs. congenital:
- Acquired: Myocarditis, Kawasaki disease, rheumatic heart disease, polyarteritis nodosa, other transient conditions
- Congenital: Heart defects, cardiomyopathy, inborn errors of metabolism
- In utero (hydrops):
- Arrhythmias: Supraventricular tachycardia (SVT), ventricular tachycardia (VT), complete heart block (CHB)
- Volume overload: AV valve regurgitation, AVM
- Primary myocardial disease: DCM, HCM, myocarditis
- Anemia: Rh isoimmune disease, thalassemia, twin–twin transfusion
- Premature closure of the ductus arteriosus or foramen ovale
- In neonates:
- Myocardial dysfunction: Asphyxia, sepsis, myocarditis, hypoglycemia, acidosis, DCM, HCM, ischemia (anomalous left coronary artery from the pulmonary artery), metabolic defects (carnitine deficiency, other inborn errors of metabolism)
- Outflow obstruction: Aortic stenosis, coarctation of the aorta
- Volume overload: Large ASD, large VSD, moderate to large PDA, truncus arteriosus, aortopulmonary window, total anomalous pulmonary venous return, AVM
- Arrhythmias: SVT, VT, or CHB
- Left heart inflow obstruction: Mitral stenosis, cor triatriatum, pulmonary venous obstruction
- In infants:
- Myocardial dysfunction: DCM, HCM, restrictive cardiomyopathy, metabolic disease, mitochondrial disease, glycogen storage disease, myocarditis, Kawasaki disease, anomalous left coronary artery from the pulmonary artery
- Outflow obstruction: Right or left heart
- Volume overload: ASD, VSD, PDA, common AV canal defect, partial anomalous pulmonary venous return
- Secondary causes: Renal disease, hypertension, hypothyroidism, sepsis
- Arrhythmias: SVT, VT, or CHB
- Pericardial effusion owing to systemic lupus erythematosus (SLE), juvenile rheumatoid arthritis (JRA), other inflammatory diseases, postpericardiotomy syndrome
- In childhood and adolescence:
- Unrepaired congenital heart disease (CHD) with volume and/or pressure overload
- Repaired CHD with a residual defect that results in volume and/or pressure overload
- Acquired heart disease: Pericarditis, myocarditis, endocarditis, rheumatic fever
- Cor pulmonale: Pulmonary hypertension, Eisenmenger syndrome, pulmonary disease
- Cardiomyopathy: Primary or secondary (anthracyclines, sickle cell anemia, etc.)
Congestive Heart Failure - associated conditions
- Muscular dystrophies (Becker, Duchenne)
- Inborn errors of metabolism (infants)
- Heart failure due to tamponade can be the presenting symptom of JRA, SLE, and other vasculidities.
- Endocarditis
- Rheumatic fever, Kawasaki disease, infantile polyarteritis nodosa
- CHD
Congestive Heart Failure - DIAGNOSIS
Congestive Heart Failure - signs & symptoms
- Right heart failure:
- Hepatomegaly
- Jugular venous distension
- Edema
- Right-sided ventricular/parasternal heave
- Left heart failure:
- Tachypnea
- Pulmonary edema
- Orthopnea
- Shock/poor systemic perfusion
- Diffuse or displaced point of maximal impulse (PMI)
- Nonspecific manifestations:
- Exercise intolerance
- Poor feeding
- Gastrointestinal symptoms
- Heat intolerance
Congestive Heart Failure - history
- Infants and neonates:
- Prolonged feedings associated with tachypnea, retractions, and diaphoresis
- Emesis, inadequate caloric intake, and failure to thrive
- Irritability with feeding and frequent respiratory infections
- Orthopnea: Distress when supine
- Family history of heart failure or sudden unexpected death at a young age
- Childhood and adolescence:
- Exercise intolerance with exertional dyspnea
- Palpitations or chest pain
- Chronic cough, wheezing, orthopnea, fatigue, weakness, anorexia, nausea, and edema
- Weight loss secondary to anorexia, nausea, and increased metabolic demands
- Weight gain secondary to fluid retention
- Family history of heart failure or sudden unexpected death at a young age
Congestive Heart Failure - physical exam
- Tachycardia, low BP
- Gallop
- Murmurs (quality/location)
- Systolic ejection click
- Abnormal S2 (fixed split, loud PTachypnea, wheezing, rales
- Nasal flaring, grunting, retractions
- Abdominal or cranial bruit
- Hepatomegaly and/or splenomegaly
- Edema
- Cool and/or mottled extremities
- Poor capillary refill
- Weak pulse (throughout or in legs only)
- Pulsus alternans; pulsus paradoxus
Congestive Heart Failure - tests
Electrocardiograph:
- Rhythm
- Ischemia
- Hypertrophy (cardiomyopathy, CHD, storage disease)
- Heart block (1st, 2nd, and 3rd degree) or tachyarrhythmia
- Identify diagnoses with characteristic electrocardiograph findings, such as anomalous left coronary artery from the pulmonary artery (lateral Q waves and T wave inversion, acute ischemic changes), pericarditis (diffuse ST segment changes), Pompe disease (huge voltages).
Congestive Heart Failure - lab
- Blood gas: Metabolic acidosis, high lactate
- Chemistry: Hyponatremia, either dilutional or as a result of chronic diuretic therapy
- Blood counts: Anemia, leukocytosis, or leukopenia (viral myocarditis)
- ESR elevation (rheumatic fever, Kawasaki disease, etc.)
- B-type natriuretic peptide (BNP) elevation: NT-proBNP has longer serum half-life.
- Urine: Proteinuria, high urine specific gravity, microscopic hematuria
- Evaluation as to the cause of cardiomyopathy may also include ammonia level, amino acid quantification, urine organic acids, carnitine, selenium, acylcarnitine, liver function tests, mitochondrial DNA analysis, viral studies, etc.
Congestive Heart Failure - imaging
- Chest radiograph: Cardiomegaly, increased pulmonary vascular markings, hyperinflation, pleural effusion, Kerley B lines
- ECG: Rule out CHD, identify coronary artery origins, assessment of cardiac function (both systolic and diastolic)
Congestive Heart Failure - diag proced-surgery
- Cardiac catheterization: Delineation of cardiac hemodynamics and anatomy (used only in selected cases)
- Cardiac biopsy may be helpful in the diagnosis of myocarditis, storage disease, or cardiomyopathy.
- Electrophysiology study to identify arrhythmia
Congestive Heart Failure - TREATMENT
Caution: Care must be used during the administration of oxygen to the infant with undiagnosed heart disease which may include “unprotected” pulmonary blood flow (e.g., hypoplastic left heart syndrome, truncus arteriosus, large VSD). Oxygen can cause excessive pulmonary blood flow and decreased blood flow to the systemic circulation.
- Establish IV access for fluids, inotropes, antiarrhythmics, or other meds.
- Oxygen is usually indicated.
- Judicious use of fluids:
- Decompensated CHF is usually a volume overloaded condition.
- Lay patient supine if tolerated; 30° angle if orthopneic.
- Assess rhythm: Use AED if necessary (with appropriate-size pads).
Congestive Heart Failure - initial stabilization
- Judicious use of fluids
- Monitor vital signs and heart rhythm.
- CXR and EKG, basic blood testing
- Oxygen as indicated
- ECG and/or rhythm strip to assess rhythm
- PALS, airway control:
- Caution: The patient with heart failure and an arrhythmia may decompensate with the introduction of adenosine or other antiarrhythmics. Such maneuvers should only be performed under controlled conditions with emergency equipment available, preferably after consultation with a pediatric cardiologist.
- Drainage of pericardial effusion if tamponade physiology is present
- Initiation of inotropes if hypotension and fluid overload are present
Congestive Heart Failure - general measures
- Treatment of underlying cause:
- Arrhythmias: Antiarrhythmic medical therapy or catheter ablation therapy
- Congenital heart defect: Interventional cardiac catheterization (balloon dilation of aortic or pulmonary valve stenosis, coil embolization of PDA, device closure of ASD). Surgery if necessary
- Targeted medical treatment for endocarditis, myocarditis, anemia, acute rheumatic fever, Kawasaki disease, or hypertension
- Control of chronic inflammatory conditions, such as SLE or JRA
- Fetal: Administration of antiarrhythmic agents to the mother has been used to control CHF in the fetus secondary to an arrhythmia.
- Subacute management:
- Activity restriction, dietary management
- Oxygen as needed. Low oxygen saturation raises pulmonary vascular resistance, and may exacerbate heart failure.
- Inotropic agents (milrinone, dobutamine, dopamine)
- Diuretics (furosemide, spironolactone, bumetanide, metolazone)
- Nesiritide (BNP infusion) in refractory cases
Congestive Heart Failure - medication
Congestive Heart Failure - first line
- Beta-blockers (carvedilol, metoprolol)
- ACE-inhibiters (or angiotensin receptor blockers)
- Aldosterone antagonists
- Anticoagulants (ASA, Coumadin, LMW heparin, etc.),especially for severe dilated cardiomyopathy and restrictive cardiomyopathy
- Loop diuretics
Congestive Heart Failure - second line
Digoxin (falling out of favor)
Congestive Heart Failure - surgery
- Repair congenital heart defects
- Repair or replace damaged valves
- ECMO/VAD
- Pacemaker or AICD insertion
- Heart or heart/lung transplant
- Cardiac resynchronization therapy (pacing)
Congestive Heart Failure - patient monitoring
- ECG
- EKGs
- Holter (24-hour ambulatory EKG) monitoring
- 6-minute walk distance for patients with NYHA class II or greater CHF symptoms
- Exercise testing
- Serial evaluation of NT-proBNP
Congestive Heart Failure - bibliography
- Bristow MR. Beta-adrenergic receptor blockade in chronic heart failure. Circulation. 2000;101:558–569.
- Burch M. Dilated cardiomyopathy. Arch Dis Child. 1996;74:479–481.
- Kay JD. Congestive heart failure in pediatric patients. Am Heart J. 2001;142:923–928.
- Shaddy RE. Optimizing treatment for chronic congestive heart failure in children. Crit Care Med. 2001;29(suppl):S237–S240.
- Webber SA. Heart and lung transplantation in children. Lancet. 2006;368(9529):53–69.
Congestive Heart Failure - CODES
Congestive Heart Failure - icd9
422.91 Myocarditis
425.4 Dilated cardiomyopathy
437.8 Congestive heart failure
Congestive Heart Failure - FAQ
- Q: My child has a large VSD and is taking digoxin and furosemide. Should I take salt out of his diet?
- A: No. Excessive salt restriction is seldom enforceable and is not necessary. A no-added-salt diet is sufficient.
- Q: What is the importance of tachycardia and bradycardia in heart failure?
- A: Tachycardia limits diastolic filling time and may result in decreased cardiac output. However, bradycardia may be poorly tolerated in patients with heart failure and a relatively fixed stroke volume who are dependent on heart rate to maintain an appropriate cardiac output.
- Q: What are the major causes of death in heart failure patients?
- A: Ventricular arrhythmias are the most common cause of sudden death in children with ventricular dysfunction. Other causes include myocardial infarction owing to thromboembolism and progressive worsening of low cardiac output syndrome.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Congestive Heart Failure
More Medical Textbooks Online about Congestive Heart Failure
Review other book chapters online related to Congestive Heart Failure:
Medical Books Excerpts
- Cardiomegaly
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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