Heart failure

I50.9

DESCRIPTION

Clinical syndrome reflecting the inability of the myocardium to meet the oxygen and nutritional/metabolic requirements of the body.

Causes include:

  • volume overload:
    • L-R shunt lesions
    • mitral/aortic regurgitation
  • pump failure:
    • myocarditis/cardiomyopathy
  • high output failure:
    • septicaemia
    • severe anaemia

DIAGNOSTIC CRITERIA

Clinical

  • Acute cardiac failure may present with shock. See Shock .
  • History of recent onset of:
    • poor feeding,
    • poor or excessive weight gain,
    • tachypnoea,
    • breathlessness,
    • sweating,
    • cough.
  • Physical findings:
    • tachycardia,
    • cardiomegaly,
    • hypotension,
    • cold extremities,
    • weak pulses,
    • reduced urinary output,
    • gallop rhythm with/without a cardiac murmur,
    • pulmonary venous congestion and fluid retention:
      • tachypnoea,
      • dyspnoea,
      • orthopnoea,
      • recession,
      • wheezing,
      • coarse crepitations,
      • cyanosis;
    • systemic venous congestion:
      • hepatomegaly,
      • periorbital oedema - not seen in infants,
      • abnormal weight gain,
    • signs and symptoms of underlying condition/disease.

Investigations as appropriate for the possible underlying cause

  • Chest X-ray: cardiomegaly is almost always present.
  • Electrocardiogram may show evidence of hypertrophy/enlargement of one or more heart chambers and/or dysrhythmias.

HEART FAILURE, ACUTE WITH PULMONARY OEDEMA

I50.9

GENERAL AND SUPPORTIVE MEASURES

  • Treat the underlying disorder/condition. Where the primary cause of acute pulmonary oedema is renal failure treat as per renal failure. See Acute Kidney Injury .
  • Restrict fluids, beware of IV fluids.
  • Place patient in an upright or semi-upright sitting position.
  • Intubation and ventilation may be required in an ICU setting.

MEDICINE TREATMENT

  • Oxygen 100%, administered via face mask or nasal cannula.

Treat the underlying condition:

  • Furosemide, IV, 1 mg/kg, 8 hourly.
  • If response is inadequate, change to an IV infusion 0.1-1mg/kg/hour.
  • Switch to oral furosemide as soon as patient condition allows.
    • Monitor clinically and biochemically for, and avoid, overdiuresis.
    • Monitor for hypokalaemia and other electrolyte disturbances.

LoEIII [3]

If response still inadequate consider:

  • Hydrochlorothiazide, oral, 1 mg/kg/dose, 12 hourly in consultation with a paediatric cardiologist.

LoEIII [11]
LoEIII [12]

Manage severe hypotensive or refractory failure in an ICU setting.

Inotropic support may help to stabilise patients with severe myocardial dysfunction and hypotension.
May be lifesaving in severe myocarditis or cardiogenic shock.

  • Dobutamine, IV infusion, 2–15 mcg/kg/minute.
    • Continue until myocardial function and blood pressure improve.

If no response to dobutamine, consider adrenaline (epinephrine) infusion. Ensure adequate renal function.

Once patient stable and maintaining blood pressure wean the inotrope and introduce:

  • ACE inhibitor, Note: ACEI should be avoided in patients with obstructive heart lesions.
  • e.g.:
  • Captopril, oral.
    • Initial dose: 0.5 – 1 mg/kg/24 hours in 3 divided doses (8 hourly) for 24–48 hours.
    • Increase by 0.5 mg/kg/24 hours every 24–48 hours until maintenance dose of 3–5 mg/kg/24 hours is reached. Monitor blood pressure and renal function.
    • Continue for as long as needed to control the cardiac failure and allow myocardial recovery.

LoEIII [13]

HEART FAILURE, MAINTENANCE THERAPY

I50.9

GENERAL AND SUPPORTIVE MEASURES

  • Recognise and treat the underlying condition, e.g. infection, hypertension, cardiac tamponade, fluid overload.
  • Fluid restriction (75% of daily requirements) – not at the expense of adequate caloric intake.
  • Ensure adequate nutrition, tube-feeding may be necessary.
  • Monitor blood potassium levels, urea and electrolytes.

MEDICINE TREATMENT

  • Oxygen 100%, administered via face mask or nasal cannula.

Combination drug therapy is usually indicated, i.e. start with diuretic, then add an ACE inhibitor.

Diuretic therapy

  • Furosemide, oral, 1-2 mg/kg/dose 12 hourly. Titrate dose against clinical response. Potassium supplements are necessary if furosemide is used without an aldosterone antagonist, i.e. spironolactone.
  • Monitor for response.

LoEIII [14]

If response still inadequate consider:

  • Hydrochlorothiazide 1 mg/kg/dose oral, 12 hourly in consultation with a paediatric cardiologist.

LoEIII [11]
LoEIII [12]

AND

ACE inhibitor

Note:
ACE inhibitors are contraindicated in bilateral renal artery stenosis, coarctation of the aorta, aortic stenosis and mitral stenosis.

  • Captopril, oral.
    • Initial dose: 0.5-1 mg/kg/24 hours in 3 divided doses (8 hourly) for 24–48 hours.
    • Increase by 0.5 mg/kg/24 hours every 24–48 hours until maintenance dose of 3–5 mg/kg/24 hours is reached. If < 1 year do not exceed 4 mg/kg/day.
    • Continue as long as needed to control the cardiac failure and allow myocardial recovery.

LoEIII [13]

OR

  • Enalapril, oral, 0.2–1 mg/kg/day as a single dose or 2 divided doses. Start at the low dose and increase by 0.2 mg/kg/day at 1-2 day intervals.

In still symptomatic add:

  • Spironolactone, oral, 1–3 mg/kg/dose once daily. May be divided 12 hourly.

In those patients that are refractory, refer to paediatric cardiologist for consideration of beta-blockers and digoxin.

REFERRAL

  • For determination of the underlying cause, where this is not known and review of treatment after stabilisation.
  • Deterioration despite adequate treatment.