39. Acute and chronic heart failure.

Question 1

Etiology of heart failure in children?

Answer 1

Congenital:
Volume overload
: left to right shunting

Pump failure 
Aortic stenosis
Coarctation of aorta 
Pulmonary stenosis
Inflammatory- viral myocarditis , Chagas’ disease , 
Dilated cardiomyopathy 
Arythracyclin toxicity 

Acute rheumatic carditis

Cardiomyopathy with muscular dystrophy and fredrichs ataxia

Myocarditis - Kawasaki disease

Question 2

What are the symptoms of heart failure ?

Answer 2

Neonates 
Poor weight gain 
Difficulty feeding - Tacypnea / gets worst with feeding
Cold sweat on forehead 
Restlessness and irritability 
Tachycardia
Tachypnea 

Older children 
Dyspnea 
Fatigue
Persistent cough
Puffiness of face 
Pedal edema
Diaphoresis

Question 3

What are the symptoms specific for right and left sided heart failure ?

Answer 3

Hepatomegaly
Facial and pedal edema
Engorged jugular veins

===

Left sided 
Tachypnea
Tachycardia 
Cough 
Wheezing
Rales

Question 4

What is the classification of heart failure in children .

Answer 4

Modified ross heart failure classification

Class 1 asymptomatic

Class 2 Mild tachypnea and diaphoresis with feeding infants, Dyspnea on exertion with older infants

Class three- marked tachypnea or diaphoresis when feeding infants, marked dyspnea on exertion

Class for- symptoms at rest

Question 5

In diagnostics what is key in diagnosing the probability of what the ethology may be

Answer 5

Age
1st week - hypoglycaemia ,hypocalcemia, sepsis
Aortic stenosis severe , coarctation of aorta
obstructed total anomalous pulmonary venous connection (TAPVC),
the great arteries (TGA) with intact ventricular septum (IVS),
and hypoplastic left heart syndrome

2nd week - truncus arteriosus

4-6 week Left to right shuntsEndocardial cushion defect

Beyond two years - rheumatic fever with carditis, myocarditis, cardiomyopathies , rhythm disturbances

Question 6

How do you diagnose heart failure?

Answer 6

Chest x ray - cardiomegaly ( left to right shunts, dilative CM, TGa, snowman -TAPC

Electrocardiography
Systolic dysfunction - LESS THAN 55 percent

ECG - sinus tachycardia most common, LV. Hypertrophy, myocardial infarction

Biomarkers - BNP high and NT- proBNP more for HF prognosis

Acute rheumatic fever -antistreptolysin O and crp

CMRI-T2 - for myocarditis and cardiomyopathy

Endomyocardial biopsy - myocarditis
Cardiomyopathy

Question 7

What is the treatment for heart failure?

Answer 7

For systemic and pulmonary congestion - diuretics
ESP loop diuretics
Furosemide - given intravenously at a dose of 1–2 mg/k
Diuretic induced hypokalemia and hyponatremia are rare in children
But spironolactobe - 1 mg/kg

Digoxin

Acei- captopril and enalopril

Betablockers for moderate to severe systolic dysfunction
- carvedilol
Metoprolol
Used for long term treatment

Ionotropes
Dopamine and domaine
Phosphodiesterase inhibitors- milrinone
(Not recommended)

Pacemaker
CRT cardiac resynchronisation therapy

Cardiac transplantation hypoplastic heart syndrome
Viral infections - cmv, ebv