Management of heart failure in children

Current evidence for pharmacologic therapy following stage 1 palliation for single ventricle congenital heart disease

INTRODUCTION

Infants with single ventricle congenital heart disease are vulnerable to complications between stage 1 and stage 2 of palliation. Pharmaceutical treatment during this period is varied and often dependent on institutional practices as there is little evidence supporting a particular treatment path.

AREAS COVERED

This review focuses on medical management of patients following stage I palliation. We performed a scoping review of the current literature regarding angiotensin converting enzyme inhibitors and digoxin treatment in the interstage period. In addition, we discuss other medication classes frequently used in these patients.

EXPERT OPINION

Due to significant heterogeneity of anatomy, rarity of disease, and other confounding factors, there is limited evidence to support most commonly used medications within the interstage period. Digoxin is associated with improved mortality within the interstage period and should be considered; however, no large randomized controlled trial exists supporting its use. Prevention of thrombotic complication with aspirin is also associated with improved outcomes and should be considered unless a contraindication exists. The addition of other prescriptions in this patient population should be considered only after an evaluation of the risks and benefits of each medication, recognizing the burden and risk of polypharmacy in this fragile patient population.

Cardiovascular health supervision for individuals affected by Duchenne or Becker muscular dystrophy

Duchenne muscular dystrophy is the most common and severe form of the childhood muscular dystrophies. The disease is typically diagnosed between 3 and 7 years of age and follows a predictable clinical course marked by progressive skeletal muscle weakness with loss of ambulation by 12 years of age. Death occurs in early adulthood secondary to respiratory or cardiac failure. Becker muscular dystrophy is less common and has a milder clinical course but also results in respiratory and cardiac failure. The natural history of the cardiomyopathy in these diseases has not been well established. As a result, patients traditionally present for cardiac evaluation only after clinical symptoms become evident. The purpose of this policy statement is to provide recommendations for optimal cardiovascular evaluation to health care specialists caring for individuals in whom the diagnosis of Duchenne or Becker muscular dystrophy has been confirmed.

[Chronic heart failure in children: recent contributions of physiopathology and therapeutic implications]

The treatment of chronic heart failure has made remarkable progress over the past ten years. Recent advances in our understanding of the pathophysiologic mechanisms involved in heart failure syndrome have led to changes in our approach to the treatment of children. The goals of the therapy have shifted from purely hemodynamic manipulation to a combination of hemodynamic and neurohumoral modulation. As for adults, three therapeutic classes have recently emerged: conversion enzyme inhibitors, spironolactone and beta-blockers. Pediatricians know that a child is not a small adult and we have to think about heart failure on the basis of etiology, the age of the patient, and circulatory physiology and maturation.