cardiac failure in children

1. Heart Failure in Children
Definition, Types, Patho-physiology, Etiology,
Clinical Features, Complications, Management
Prognosis
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. Al Quran surah Al Shuaraa 26:88-89
On the day of judgement, wealth or family will not be of any benefit;
only the person who comes with a pure heart will be successful

3. Heart
• Human heart beats 115,000
times each day
• Human Heart pumps 7500
liters of blood in 24 hours
• Human Heart supplies
nutrients to each cell of the
body through blood vessels
which are 100,000 km long

4. Cardiac Failure
• Definition: Failure of cardiac output to meet metabolic
needs of the body
• Cardiac Failure results in inadequate oxygen delivery to
body tissues
• Compensated Heart Failure: compensatory mechanisms
increase the cardiac output and the oxygen delivery
• Decompensated Heart Failure: compensatory mechanisms
start failing and cardiac output starts falling

5. Cardiac Output
• Cardiac Output = Heart Rate X Stroke Volume
• Stroke volume is dependent on three factors:
• • Preload - (blood volume overload, End Diastolic Volume)
• • Afterload - resistance (pressure) against which the heart
must pump blood, systemic vascular resistance
• • Contractility of heart - Cardiac Performance

6. Volume overload increases contractility of Heart

7. Compensatory Mechanisms in Heart Failure

8. Types of Heart Failure
• Compensated Heart Failure –
• compensatory mechanisms are successful
- increased heart rate and force of contraction (chronotropic and
ionotropic effect)
- stroke volume increased
- cardiac output maintained
• Decompensated Heart Failure –
• compensatory mechanisms fail
- cardiac contractility low
- cardiac output decreased
- venous congestion
- edema

9. Decompensated Heart Failure

10. Pathology
• Cardiac Hypertrophy
• Pulmonary edema
• Venous congestion
• Dependent edema (pitting edema)

11. Etiology
• Volume overload - L to R shunts in heart, Fluid overload,
Severe anemia
• Decreased Contractility - Myocarditis, Cardiomyopathy,
Hypoxia, Hemosiderosis
• Pressure overload – Systemic Hypertension, Pulmonary
Hypertension (cor-pulmonale)
• Diastolic Dysfunction – Pericardial effusion

12. Heart Failure in Children
• Congenital Heart Disease – VSD, ASD, PDA
• Rheumatic Fever, Rheumatic Heart Disease - MR
• Cardiac Arrhythmia - SVT, VT
• Severe anemia
• Pericardial effusion
• Hypertension – Renal diseases (Acute glomerulonephritis,
CKD)
• Pulmonary hypertension (cor-pulmonale)
• Cardiomyopathy

13. Clinical Features

14. Clinical Scenario
• A 3 months old baby presents to the OPD with complaints of
frequent cough and cold for the last 2 months.
• Baby is on mother feeding, but takes feeding for a short time
only. He remains fussy and cries often
• Weight of the infant is 4 kg.
• On examination, his heart rate is 150/min and respiration is
60/min.
• Chest examination: apex beat at 5th intercostal space 1 cm left to
mid-clavicular line. A pan-systolic murmur is audible at left lower
sternal border.
• Abdominal examination shows enlarged liver palpable by 4 cm
below the right costal margin
• What is your diagnosis ?

15. Symptoms
• Infants :
• Feeding problems, sweating
• Oliguria
• Growth failure
• Older children:
• Exertional dyspnea
• Fatigue
• Edema
• Palpitation
• Pain abdomen

16. Signs
• Tachycardia (fast heart rate)
• Tachypnea (fast breathing )
• Cardiomegaly (shifted apex)
• Hepatomegaly
• JVP raised
• Edema – pulmonary, systemic
• Growth failure

17. Diagnosis
• X – ray Chest (cardiomegaly)
• ECG – (ventricle hypertrophy)
• Echocardiography –
• Low Ejection Fraction (N = 55-65%)
• Oxygen saturation (Pulse oximetry) – low in
pulmonary edema

18. Other Investigations
• CBC
• Electrolytes
• Cardiac Biomarkers – increase in ventricular dilation
- Brain natriuretic peptide (BNP) - more than 100 pg/mL
- N -terminal prohormone BNP (NT-pro BNP)
• Liver Function Tests
• Renal Function Tests

19. Complications
• Cardiac Arrhythmia
• Thrombo-embolism
• Repeated chest infections
• Pulmonary edema
• Liver dysfunction
• Renal failure
• Electrolyte Imbalance
• Failure to thrive – low weight and height

20. Management

21. Supportive Management
• Comfortable environment
• Rest
• Position
• Feeding
• Fluid restriction
• Anemia – iron supplements
• Blood transfusion

22. Specific Management
• Diuretics
• Digoxin
• ACE inhibitors (ACEI, ARB)
• Neprilysin inhibitors
• Beta-blockers
• Treat the cause of Heart Failure

23. Prognosis
• Etiology of HF
• Severity of HF
• Response to treatment

24. Clinical Assessment of Severity in Adults

25. Clinical Assessment of Severity in Children

26. Medical Profession