Management of Congestive Heart Failure by Christina VanderPluym, MD, for OPENPediatrics
Management of Congestive Heart Failure by Christina VanderPluym, MD, for OPENPediatrics
In this video, Dr. Christina VanderPluym reviews goals of therapeutic intervention, components of therapy, and preventing morbidity and complications in cases of congestive heart failure.
Initial publication: May 18, 2016
Last reviewed: November 23, 2020.
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Content
27.5 -> Management of Congestive Heart Failure, by
Christina VanderPluym.
33.48 -> My name is Christina VanderPluym. I'm the
Director of the Ventricular Assist Device
36.82 -> Program at Boston Children's Hospital. And
today I'm going to speak about heart failure
40.61 -> in children, focusing on management strategies.
43.29 -> In our first section, we discussed the pathophysiology
and diagnosis of heart failure. And in the
47.41 -> subsequent session, we're going to discuss
management of congestive heart failure. When
51.62 -> thinking about the management of heart failure,
we first must consider what are the goals
55.19 -> for therapeutic intervention? And following
this, we'll then look into the components
58.989 -> of therapy, be it either surgical or catheter
based therapies, pharmacological and non pharmacological
65.379 -> therapies. And then we will focus on preventing
morbidity, or complications related to heart
69.95 -> failure. Specifically, intracardiac thrombus,
arrhythmias, and nutritional and growth deficiencies.
75.45 -> Let's begin with the goals of therapeutic
intervention. The goals of therapy for heart
80.119 -> failure include relieving symptoms of heart
failure, such as congestion and low cardiac
84 -> output, decreasing morbidity, such as those
related to intracardiac thrombi and arrhythmia,
89.68 -> and including the risk of hospitalization
itself. To slow, or even potentially reverse
94.59 -> the progression of heart failure, to improve
patient survival, and importantly, improve
100.27 -> patients' quality of life.
101.229 -> Next we move on to
the components of therapy. Management of heart
106.6 -> failure depends firstly on the etiology and
pathophysiology of heart failure. This was
111.159 -> further described in our first section, but
broadly consists of pump dysfunction, volume
116.95 -> overload, or pressure overload. Many children
presenting in heart failure may have a combination
122.1 -> of these types of dysfunction, be it either
pump dysfunction with volume or pressure overload,
127.479 -> or one of these in isolation.
130.56 -> We must also consider the severity of heart
failure. We can classify severity using a
135.04 -> multitude of different classification systems
including New York Heart Association classification,
140.09 -> which has been most widely described and used
in adults, the Ross classification, which
144.22 -> is most commonly used in children, as well
as staging of heart failure from stage A to
148.98 -> D, with stage A consisting of those patients
with no symptoms and otherwise normal cardiac
154.65 -> function, but who may be at risk of cardiac
dysfunction, and stage D, those with end stage
159.01 -> heart failure refractory to maximum medical
management.
162.26 -> Another consideration of management therapies
in children is how do they present with their
167.87 -> symptoms? For patients who present with symptomatic
heart failure, treatment must also be focused
173.51 -> at what type of symptoms they present with,
be it either congestion or low profusion,
177.95 -> or a combination of both. The ideal patient
is that person who presents well-profused
183.76 -> with no evidence of congestion, and ultimately,
no treatment is warranted at that time. This
189.18 -> is in converse to patients who may present
with good profusion, however with evidence
194.08 -> of congestion-- be it either pulmonary edema,
peripheral edema, or ascites-- and these patients
199.819 -> may benefit from non-pharmacological therapies,
such as fluid restriction, or pharmacological
205.08 -> therapy, such as intravenous or oral diuretics.
208.39 -> There are also those patients who present
with evidence of low profusion secondary to
212.099 -> poor cardiac output. They may also present
with signs or symptoms of congestion or no
218.209 -> congestion. And in the setting of a patient
being cold and dry, they may benefit from
222.379 -> fluid resuscitation, plus or minus the addition
of inotropic intravenous medications.
228.769 -> And then there are those patients who present
with evidence of poor profusion, as well as
233.26 -> evidence of congestion, and these patients
may benefit from fluid restriction, diuretic
238.409 -> therapy, as well as inotropic medication.
As you can see, the treatment strategies for
243.14 -> heart failure it can be very varied, and one
must always consider not only the pathophysiology
249.08 -> or the severity, but the symptoms that we
are trying to target.
252.65 -> In addition to heart failure therapy, we must
also try to identify and correct all non-cardiac
257.729 -> factors that may be contributing to cardiac
dysfunction or poor perfusion. These include
262.36 -> sepsis, or active infection, metabolic derangements,
such as acidosis, anemia that may be impairing
268.62 -> oxygen delivery to end organs and renal failure.
Renal failure and heart failure are two significant
274.65 -> problems that sometimes require very different
treatment strategies. While heart failure
279.669 -> requires low systemic arterial pressures and
lower volumes, renal failure, unfortunately,
285.949 -> requires the opposite, with higher systemic
arterial pressures and more volume. As such,
291.06 -> this can be a significant challenge to the
treating physician.
294.96 -> Also we must consider any surgical or catheter
based therapies that may correct either volume
300.38 -> loading or pressure loading anatomical defects.
Let's move on to pharmacological heart failure
306.02 -> therapies. These therapies are used in patients
with either pump dysfunction, otherwise known
311.1 -> as systolic dysfunction, with a goal to improve
function and/or stabilize or relieve symptoms
316.36 -> of poor output. It can also be used for patients
with poor ventricular relaxation, otherwise
322.19 -> known as diastolic dysfunction with the goal
to improve pump compliance and relieve symptoms
327.75 -> of congestion. And lastly, can be used in
patients with normal pump function in the
332.509 -> setting of symptoms of congestion.
335.11 -> Most add-on heart failure medication has
come from studies in adult patients, with
338.86 -> only very small trials conducted in children.
This is due to the fact that we are unable
343.44 -> to conduct large trials in children because
the prevalence of heart failure in children
347.33 -> is relatively low as compared to our adults.
Additionally, there are many different causes
352.25 -> of heart failure in children, resulting in
significant heterogeneity for large studies.
358.03 -> Let's begin with drugs for mild to moderate
heart failure, stages B and C. There's a large
363.699 -> armamentarium of medications that can be used
for symptomatic heart failure in the setting
367.68 -> of poor ventricular function or congestion.
These include diuretics, with the goal to
372.479 -> reduce filling pressures and reduce symptoms
of congestion, to digoxin to increase inotropy,
378.62 -> or contraction of the ventricle. Angiotensin
converting enzyme inhibitors to reduce afterload
384.47 -> and decrease the LV workload. Beta blockers
to reduce the maladaptive sympathetic activation
391.229 -> of the heart to reduce heart rate and allow
for more diastolic filling time. And lastly,
397.12 -> pulmonary vasodilators that decrease pulmonary
vascular resistance and decrease the workload
402.35 -> of the right ventricle.
403.979 -> Let's begin with diuretics. Diuretics decrease
preload by promoting natriuresis and relieve
410.38 -> symptoms of volume overload, be it other pulmonary
or peripheral edema. They are generally used
415.509 -> in children with stage C and D heart failure.
This is symptomatic heart failure secondary
421.53 -> to ventricular dysfunction, or end-stage heart
failure refractory to other medical managements.
427.81 -> There are multiple different classes of diuretics.
And these include loop diuretics that inhibit
432.31 -> sodium and chloride reabsorption in the thick
ascending loop of Henle. These include furosemide,
438.59 -> bumetanide, and torsemide.
441.38 -> Next are thiazide diuretics that inhibit reabsorption
of sodium and chloride in the convoluted tubules
446.72 -> of the kidney. These include chlorothiazide,
hydrochlorothiazide, and metolazone. And lastly,
453.449 -> aldosterone antagonists that decrease sodium
reabsorption and potassium excretion in the
458.759 -> collecting ducts of the kidney, including
spironolactone and eplerenone. These medications
464.84 -> are used in conjunction with loop and thiazide
diuretics, and they have been shown to reduce
469.349 -> mortality and morbidity in patients with heart
failure, in addition to standard medications.
475.41 -> Let's move on to digoxin. Digoxin has a positive
inotropic effect, mediated by the sodium potassium
481.75 -> ATPase pump and increases intracellular calcium.
Intracellular calcium is imperative to increase
488.389 -> the squeeze or the contraction of the ventricle.
Additionally, it has a negative chronotropic
493.62 -> effect that slows the atrial conduction and
vagotonic properties that counter the sympathetic
499 -> upregulation, which is maladaptive for heart
failure. This ultimately decreases heart rate,
505.44 -> and allows for more time for the ventricle
to fill. It's generally used in infants and
510.4 -> children with stage C heart failure for symptomatic
relief. Benefits of digoxin can be actually
516.94 -> seen at much lower doses than traditionally
thought, with trough levels of only 0.5 to
522.02 -> 1 nanogram per mL, resulting in lower risk
of adverse effects, such as arrhythmias.
528.1 -> Next are renin-angiotensin-aldosterone inhibition.
The renin-angiotensin-aldosterone system is
533.949 -> a very active system in heart failure. It
leads to increased sympathetic tone, which
539.1 -> is a compensatory for low cardiac output in
the short term, but becomes maladaptive over
544.76 -> time, resulting in tachycardia, fluid retention,
and hypertension. Inhibition of this system
550.72 -> are target medications for heart failure.
And these include Angiotensin Converting Enzyme
555.64 -> inhibitors, otherwise known as ACE inhibitors,
and Angiotensin Receptor Blockers, or ARBs.
562.66 -> Angiotensin Converting Enzyme inhibitors inhibit
formulation of angiotensin II, which is a
567.1 -> potent vasoconstrictor that promotes myocite
hypertrophy and fibrosis. ACE inhibitors improve
573.589 -> survival in adults with symptomatic heart
failure in clinical trials, and reduce the
578.61 -> rate of progression of heart failure. However,
there are a limited small studies in ACE use
584.13 -> in children.
585.48 -> Experts suggest that use of ACE inhibitors
in children with pump dysfunction, such as
590.14 -> those with stage B or C heart failure, may
be of benefit. However, close monitoring of
595.38 -> blood pressure and renal function is imperative,
as ACE inhibitors will decrease patients' blood
600.47 -> pressure. And this may adversely affect already
tenuous renal function. Enalopril, which has
606.529 -> twice-daily dosing, is traditionally used
for larger children. And captopril, which
610.45 -> is three times daily dosing, is used for smaller
infants and children.
614.89 -> The next medication is Angiotensin Receptor
Blockers, otherwise known as ARBs. There is
620.22 -> limited data on the effectiveness for use
in children. However, there are smaller case
624.86 -> studies demonstrating its use as an alternative
to ACE inhibitors when there are significant
629.64 -> side effects or intolerance of ACE inhibition
due to ACE-induced cough or angioedema.
636.68 -> Beta blockers. Beta blockers counteract the
maladaptive effects of chronic sympathetic
641.2 -> activation. In adults, they improve survival,
reverse LV remodeling, and decrease myocardial
647.01 -> fibrosis. It should be noted that they should
only be added once stable on other heart failure
652.99 -> medications, including ACE inhibitors and
diuretics. Carvedilol is generally the recommended
658.92 -> beta blocker for use in children with LV dysfunction,
and dosing of carvedilol can be started very
664.279 -> low, generally at 1/8 of the eventual target
dose, at 0.05 milligrams per kilo per dose
670.43 -> twice daily, and increased cautiously every
two weeks to minimize side effects. Side effects
676.3 -> of beta blockers include dizziness, fatigue,
hypotension, bradycardia, and hypoglycemia.
682.16 -> Pulmonary vasodilators. Pulmonary vasodilators
are used in the setting of right-sided heart
687.18 -> failure secondary to elevated pulmonary vascular
resistance. Pulmonary vascular resistance
692.25 -> may be increased due to a multitude of different
reasons, including abnormalities of the pulmonary
697.32 -> vasculature, such as idiopathic pulmonary
hypertension, or secondary to left heart failure
703.14 -> with subsequent elevated left-sided pressures
resulting in secondary pulmonary hypertension.
708.089 -> Phosphodiesterase-5 inhibitors, sildenafil,
is the most commonly used. And this has been
714.56 -> associated with improved LV function, functional
capacity, and quality of life in adults. There
719.93 -> are, to date, limited large studies in children.
However, there are a multitude of small studies
724.95 -> demonstrating its usefulness in a multitude
of different congenital anatomies, including
728.6 -> Fontan circulation.
730.45 -> Let's move on to drugs for advanced heart
failure-- namely, heart failure stage D. These
735.7 -> include inotropes, which are used for acute
exacerbations of heart failure with the goal
740.089 -> to increase cardiac output by contraction
and heart rate response. Catecholamines are
745.339 -> the most frequently used to improve myocardial
contractility. Generally we prefer the use
750.36 -> of dopamine in combination with milrinone
for decompensated heart failure due to the
755.279 -> fact that it not only improves myocardial
contractility and relaxation, but it also
759.98 -> reduces peripheral vascular resistance, resulting
in a decreased workload for the left ventricle.
766.1 -> Milrinone is a phosphodiesterase-3 inhibitor.
It increases contractility, reduces afterload,
772.73 -> and has no significant increase in myocardial
oxygen consumption. All of these features
777.839 -> make it very attractive for chronic use in
children who are awaiting transplantation.
782.51 -> Infusions of milrinone can commence at 0.25
micrograms per kilo per minute, up to 1 microgram
789.899 -> per kilo per minute. Additionally, this medication
has been shown to be effective and safe in
795.36 -> an outpatient setting.
796.92 -> Let's move on to non-pharmacological therapies
for heart failure, which are as equally important
801.63 -> as pharmacological therapies.
803.36 -> Nutrition. Growth failure, feeding intolerance,
and anorexia is a common complication, as
809.74 -> well as presenting symptom of children with
heart failure. Increasing caloric intake by
814.57 -> fortification with diet is generally necessary
in all children with significant symptomatic
819.8 -> heart failure. Additionally, the use of tube
feeds via nasogastric, nasojejunal, or direct
825.74 -> surgical gastric tubes may be necessary.
830.11 -> Another primary therapeutic intervention is
focused at fluid restriction. Fluid restriction
835.07 -> should be one of the first steps in non-pharmacological
treatment of heart failure with symptoms of
839.57 -> congestion. Heart failure may result in maladaptive
excessive thirst and water intake, leading
845.37 -> to electrolyte derangements such as hyponatremia
and symptoms of congestion and edema. Simply
851.37 -> by limiting fluid intake to high-caloric fluids
only and limiting total fluid intake may ameliorate
857.66 -> symptoms of congestion dramatically. They
may also limit the use of diuretics that may
863.31 -> have long-term negative effects on renal function.
867.329 -> While there is currently no recommended total
fluid intakes for children, general guidelines
873.06 -> suggest infants having around 100 cc's per
kilo per day, children weights 10 to 30 kilos
879.62 -> between 600 to 1 liter per day, and older
children and adolescents, between 1 to 2 liters
886.149 -> per day.
887.449 -> For more advanced forms of heart failure,
positive pressure ventilation may be necessary.
892.24 -> This may be delivered by invasive methods,
such as intubation, or noninvasive, such as
897.649 -> continuous positive pressure. Positive pressure
ventilation alleviates respiratory distress
903.529 -> from cardiogenic pulmonary edema. It has also
been shown to improve alveolar recruitment,
908.41 -> lung compliance, and decrease LV preload,
as well as afterload.
913.389 -> And lastly, for patients with end-stage heart
failure, refractory to maximal medical management,
918.5 -> mechanical circulatory support is an option.
There currently are many different forms of
923.38 -> mechanical circulatory support that can provide
both short and long-term cardio and cardiopulmonary
928.55 -> support. For short-term support, these include
Extracorporeal Membrane Oxygenation, otherwise
934.3 -> known as ECMO. And for long-term support,
it includes ventricular assist devices. These
939.61 -> can be used as a bridge to transplantation
or to stabilize patients with subsequent removal
944.899 -> of the mechanical circulatory support with
ventricular myocardial recovery.
948.49 -> Let's
move on to preventing morbidity or complications
952.089 -> related to heart failure. There are a multitude
of complications that can be related to heart
957.259 -> failure. These include thrombi formation.
Intra-cardiac clots can form in the setting
962.55 -> of severe RV or LV dysfunction, leading to
either pulmonary embolus, cerebral embolic
968.1 -> strokes, or any other arterial embolic events.
971.899 -> We suggest the use of anti-coagulation, be
it unfractionated or low-molecular heparin,
977 -> or an oral vitamin K antagonist for severe
RV or LV dysfunction. And we suggest the use
983.019 -> of an anti-platelet agent, such as aspirin,
in the setting of mild to moderate RV or LV
987.74 -> dysfunction. There are currently no clear
guidelines on what ejection fraction should
992.88 -> be used as the cutoff between the use of anti-coagulation
or anti-platelet therapy, however many adult
998.86 -> studies demonstrate that an LV ejection fraction
less than 30% should be treated with anti-coagulation
1005.839 -> to prevent intra-cardiac thrombi formation.
1009.07 -> Next is arrhythmias. Decreased ventricular
function can lead to ventricular and atrial
1013.75 -> enlargement that predispose to sustain atrial
and ventricular arrhythmias. As can be expected,
1018.759 -> atrial and ventricular arrhythmias can result
in significant hemodynamic compromise and
1024.149 -> destabilize already marginal patients. As
such, medication, ablation, or even implantable
1030.12 -> cardioverter-defibrillators are all recommended
depending on the severity of the heart failure
1035.8 -> and the frequency of arrhythmias.
1036.76 -> In summary, there are a multitude of approaches
to heart failure, and ultimately they all
1042.13 -> depend on the pathophysiology of the underlying
cause of the heart failure as well as the
1047.389 -> severity of the presentation. In considering
patients with heart failure, we must first
1053.02 -> consider any surgical or based cath correction
of structural heart disease that may be resulting
1058.1 -> or contributing to heart failure. Next, we
must focus on therapies that are tailored
1063.72 -> to the severity of the heart failure.
1066.2 -> For stage A patients-- those are those that
are at risk of heart failure but who currently
1070.39 -> have normal function-- no therapy is recommended.
For stage B-- these are patients who are asymptomatic
1076.87 -> with abnormal function-- simply an ACE inhibitor
may cause regression or remodeling of the
1083.97 -> ventricle and normalization of function. For
stage C-- patients with symptomatic heart
1089.72 -> failure in the setting of abnormal function--
there's a large armamentarium of medications
1094.289 -> recommended, such as ACE inhibitors, aldosterone
antagonists, beta blockers, digoxin, and diuretics.
1100.48 -> Utilization of these therapies must be tailored
at what symptoms the patient presents with,
1105.059 -> be it congestion or low perfusion. And lastly,
for stage D-- patients presenting with end
1111.24 -> stage heart failure refractory to oral medications--
the use of intravenous inotropes, diuretics,
1117.23 -> ventilation, mechanical circulatory support,
and lastly heart transplant are all warranted.
1123.34 -> Non-pharmacological therapy is also equally
important to pharmacological therapy, including
1128.77 -> nutritional support and exercise programs.
1131.96 -> And lastly, we must focus on prevention and
treating of complications related to heart
1136.64 -> failure, both thrombotic events and arrhythmias.
Thank you for watching this video on heart
1142.08 -> failure management in children.
1144.12 -> Please help us improve the content by providing
us with some feedback.
Source: https://www.youtube.com/watch?v=wvqCjLGweh8