Pediatric Heart Failure: Principles for Primary Care Presented by Tricia Brown, MSN, APRN, CPNP, CCRN

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CONGENITAL HEART DISEASE

What is Pediatric Heart Failure?

What is Pediatric Heart Failure?

What is Pediatric Heart Failure?

Causes of Heart Failure Infancy Congenital heart disease Childhood Cardiomypathy Acquired disease: myocarditis, Kawasaki disease Adolescence Acquired disease: myocarditis Palliated congenital heart disease

“Enlarged Heart” Disease Cardio My What? “Enlarged Heart” Disease

Myo Huh?

Myo Huh?

Medical Therapies

Renin-Angiotensin-Aldosterone System Fibrosis Blood Pressure  Salt Retention Inflammation Vasoconstriction  Bradykinins & nitric oxide Aldosterone Angiotensin II Salt Retention Angiotensin converting enzyme LV Remodeling Salt Retention Angiotensin I Renin Angiotensinogen (from the liver) Blood Pressure 

ACE Inhibitor: Enalapril Fibrosis Blood Pressure  Salt Retention Inflammation Vasoconstriction  Bradykinins & nitric oxide Aldosterone Angiotensin II Salt Retention Angiotensin converting enzyme LV Remodeling Salt Retention Angiotensin I Enalapril Renin Angiotensinogen (from the liver) Blood Pressure 

Medical Therapies Enalapril Classification: antihypertensive Therapeutic effects: decrease afterload Side Effects: Orthostatic hypotension, dizziness Hyperkalemia Renal dysfunction Cough Adverse reaction: angioedema Counseling: Good hydration

Beta Blocker: Carvedilol

Medical Therapies Carvedilol Classification: nonselective beta blocker, antihypertensive Therapeutic effects: block CNS activation Side Effects: Hypotension Bradycardia Adverse effect: exacerbation of heart failure with initiation and up-titration Counseling: Good hydration

Medical Therapies digoxin Classification: cardiac glycoside Therapeutic effects: Increase intracellular calcium within the myocardium – increased contraction Side Effects: Hyperkalemia Bradycardia Adverse Effects Arrhythmias, including heart block Toxicity: GI symptoms, vision disturbances

Medical Therapies spironolactone (Aldactone) Classification: aldosterone antagonist Therapeutic effects: anti-fibrotic Side Effects: Hyperkalemia Gynecomastia

Diuretics Loop-diuretics Lasix, Bumex Thiazide diuretic Diuril Low cardiac output, Elevated pressures Congestion Fluid Retention Loop-diuretics Lasix, Bumex Thiazide diuretic Diuril

Medical Therapies Diuretics Therapeutic effects: fluid removal Side Effects: Electrolyte derangement Dehydration Renal impairment

Care of the Child with Complex Heart Disease

Care of the Child with Complex Heart Disease They get common childhood illnesses. Prescribe antibiotics judiciously.

Care of the Child with Complex Heart Disease Fontan Physiology: The Blood Goes Where?

Care of the Child with Complex Heart Disease Fontan Physiology: Is there a hole or no?

Care of the Child with Complex Heart Disease Fontan Physioogy: Unique Complications Protein Losing Enteropathy C/O diarrhea, malodorous Plastic Bronchitis C/O productive cough – white casts, rubbery, branch-like Wheezing not improved with albuterol Heart Failure

When in doubt, call!

References Canter, CE & Simpson, KE. Diagnosis and treatment of myocarditis in children in the current era. Circulation. 2014, 129: 115-128. Hollander, SA, et al. Abdominal complaints as a common first presentation of heart failure in adolescent dilated cardiomyopathy. Am J of Emerg Med. 2013, 31: 684-686. Kantor, P., et al. Presentation, diagnosis, and medical management of heart failure in children: Canadian cardiovascular guidelines. Canadian Journal of Cardiology. 2013, 29 (12); 1535-1552. Park, MY. Park’s Pediatric Cardiology for Practitioners. 6th Ed. 2014. Tsu, DT, & Canter, CE. Dilated cardiomyopathy and heart failure in children. Heart Failure Clin. 2010, 6: 415-532. Tsu, DT, & Pearson, GT. Heart failure in children part I: History, etiology, and pathophysiology. Circ Heart Fail. 2009, 2: 63-70. Tsu, DT, & Pearson, GT. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Heart Fail. 2009, 2: 490-498. Wolters Kluwer Clinical Drug Information, Inc. Lexicomp. 2017, version: 3.0.1