Heart Failure

Heart Failure: Excerpt from In A Page: Pediatric Signs and Symptoms

Heart failure exists when adequate cardiac output cannot be maintained either at rest or with activity. It can be either acute, chronic, or an acute decompensation of the chronic state, and represents a wide range of anatomic and pathophysiologic conditions. The three main categories are increased afterload, left-to-right shunt lesions, and intrinsic myocardial disease.

Differential Diagnosis

Increased afterload

• Most common in the neonate due to left-sided obstructive lesions, which present acutely
• Aortic coarctation is most common
  –Increased pulse/BP in right arm
  –Decreased pulse/BP in lower extremities
• Critical aortic stenosis
  –Poor pulses, loud murmur
• Hypoplastic left heart syndrome, aortic arch interruption

Left-to-right shunt lesions
• Normal cardiac muscle funtion but overcirculation of lungs due to a congenital connection between the right and left side of the heart and low PVR
• Usually presents at 1–2 months of age
  –PVR drops and systemic resistance becomes higher than PV
  –Blood shunts from left to right (systemic circulation to pulmonary circulation)
  –Pulmonary overcirculation and poor systemic output (poor peripheral perfusion, low urine output)
• Ventricular septal defect (most common)
• Atrioventricular septal defect (AV canal, endocardial cushion defect), associated with Down syndrome
• Patent ductus arteriosus
• Atrial septal defect (usually asymptomatic)

Intrinsic myocardial disease
• More common cause of heart failure in older children and adolescents
• Myocarditis
  –Acute inflammation and dysfunction of cardiac muscle, usually postviral
  –1/3 remain stable, 1/3 return to normal cardiac function, and 1/3 deteriorate
• Cardiomyopathy
  –Dilated most common, but also hypertrophic and restrictive
  –Multiple genetic and metabolic causes, often positive family history, some represent old, “burned-out” myocarditis
• Myocardial infarction (rare)
  –Kawasaki disease
  –Congenital coronary abnormalities (anomalous left coronary artery)

Workup and Diagnosis

• Neonate
  –Consider left-sided obstructive lesions in any neonate with poor or differential pulses/perfusion
  –Often have respiratory distress, hepatomegaly, and metabolic acidosis
  –Critically ill requiring supplemental O2 and ventilatory support; transfer to tertiary care ICU

• Infants/children
  –History: Activity tolerance, poor feeding, diaphoresis, respiratory symptoms (wheezing or frequent infections due to pulmonary overcirculation), weight gain (poor due to increased metabolic demands or excess due to activity intolerance and edema), dyspnea on exertion for older patients
  –Physical exam: Vital signs (tachypnea, tachycardia), perfusion/pulses, edema (especially of face/eyes for infants), increased work of breathing/retractions, hepatomegaly, increased jugular venous distension

• Chest X-ray often reveals nonspecific cardiomegaly and pulmonary venous congestion
• ECG: Evaluate for ventricular hypertrophy (left-to-right shunt lesions, hypertrophic cardiomyopathy); low QRS voltage (myocarditis, dilated cardiomyopathy)
• Echocardiography and/or cardiac catheterization to further define anatomy and function
• Serum electrolytes, BUN/creatinine, and LFTs (including total protein and albumin) to further define current metabolic state before therapy

Treatment

• Increased afterload due to left-sided obstructive lesion
  –Use prostaglandins to open ductus arteriosus to relieve the obstruction, and/or use the right ventricle for systemic circulatory support
  –Inotropic support (dopamine/dobutamine) if very ill
  –Surgical intervention depending on specific anatomy

• Left-to-right shunt lesions
  –Diuretics to decrease lung fluid and improve respiratory mechanics
  –Inotropic support with dopamine/dobutamine for critically ill, digoxin for chronic use
  –Systemic afterload reduction with ACE inhibitors if systemic BP adequate
• Myocardial disease
  –Diuretics and inotropes for afterload reduction
  –β-blockers and ACE inhibitors
  –Mechanical circulatory support and cardiac transplantation for advanced heart failure

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Heart conditions

• Back to disease: Heart conditions: Introduction
• Next Book Extract About Heart conditions: MURMURS (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: MURMURS (Differential Diagnosis in Primary Care)

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