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heart failure
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HEART FAILURE IN CHILDRENPresented by :
Dena Karina F
Luhur Pribadi
Muammar Riyandi
Departement of Child Health RSCMFaculty of Medicine University of Indonesia
Pendahuluan
Gagal jantung pada pediatrik etiologi yang beragam berbagai macam presentasi klinis
Mempunyai patofisiologi yang sama tidak terobati mempercepat kematian
Penyakit jantung pada anak gagal jantung penyumbang 50 % transplantasi jantung
Boucek MM, et al .Registry for the International Society for Heart and Lung Transplantation: seventh official pediatric report–2004. J Heart Lung Transplant. 2004
Definisi
Prevalensi
Gagal jantung di USA 900.000 masuk rumah sakit selama setahun 250.000 meninggal pertahunnya
Sebagian besar gagal jantung terjadi pada saat dewasa
Pada anak Pediatric Cardiomyopathy Registry annual incidence 1.13 kasus cardiomyopathy pada setiap 100.000 anak
Lipshultz SE, Sleeper LA, Towbin JA, et al. The incidence of pediatric cardiomyopathy in two regions of the United States. N Engl J Med 2003
ETIOLOGI
Infant Child n’ Adolescent
Congenital Aritmia Dys
ventrikelNon
cardiacSepsi
s
VSDASDPDATruncus
Cardiomyopathymyocarditis
Renal FailureHypotyroidism
Unoperated
Post operated
Acquired
Non Cardiac
•Mitral regurgitasi•Aortic regurgitasi•Ebstein anomaly•Eisenmenger Syndrom
• Residual Shunt•Mitral regurgitasi•Aortic regurgitasi•Residual obstruction
• Rheumatic heart disease•Infective endocarditis•Myocarditis•Cardyomyopathy•Aritmia
• Marfan syndrom•Renal failure•Pulmonary Hypertension (primary or secondary)
Moss and Adam’s Heart Disease in Infant, Children, and Adolescent-including the fetus and young adults , 7th ed, LWW, 2008
Patofisiologi
Principles of DiagnosisNo single test is specific for CHF
• Physical findings and cardiomegaly on a chest film is nearly a prerequisite sign of CHF
• Echocardiographic confirm the diagnosis of heart failure and estimate the severity of heart failure, help identify the cause of heart failure.
• ECG the least important test for the diagnosis of CHF
• BNP levels can distinguish between cardiac and pulmonary causes of respiratory distress in neonates and children
History
Physical Examination
Chest x-ray films
Echocardiographic studies
ECG
Laboratory1 Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27. Mosby; 2008.
Clinical manifestation
Because HF has multiple causes, it has a variety of age-dependent clinical presentations.1
1 Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498.2 Madriago E, Silberbach M. Heart failure in infants and children. Pediatr Rev. 2010;31(1):4-12.
3 Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27. Mosby; 2008 .
Infants Children
Physical Examination
Infants• Hepatome
galy• Puffy
eyelids
Compensatory Mechanism
Left sided failure (Pulmonary Venous
Congestion)Infants
• Tachypnea• Respirator
y distress (retractions), grunting
Children • Dyspnea
on exertion • Orthopnea• Wheezing
and pulmonary crackles
• Tachycardia, gallop rhythm, and weak and thready pulses
• Signs of increased sympathetic discharges (e.g., growth failure, perspiration, cold and wet skin)
Right sided failure (systemic Venous
Congestion)Children
• Decreased exercise capacity
• Hepatomegaly
• Distended neck veins
• ankle edema• ascites,
and/or pleural effusions.Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27.
Mosby; 2008
Clinical Classification
The Ross Heart Failure Classification was developed to provide a global assessment of heart failure severity in infants, and has subsequently been modified to apply to all pediatric ages.
Hsu DT, Pearson GD. Heart failure in children part I: History, etiology, and pathophysiology. Circ Hear Fail. 2009;2(1):63-70
ACC/AHA for HF staging
The ACC/AHA staging identifies patients at risk for HF who require early intervention to prolong the symptom-free state;
It also delineates patients who require aggressive management of symptoms once they become manifest.
Rosenthal D, Chrisant MRK, Edens E, et al. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant. 2004;23(12):1313-1333.
CHEST X-RAY
www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html
CHD and Pulmonary Function
Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of Congenital Heart Disease. Paediatric Respiratory Reviews, 13(1), 10–15.
CHF & RRTI
Anak PJB seringkali mengalami infeksi saluran napas dan bila terkena lebih lama sembuh dibanding anak yang normal, gagal jantung memperburuk keadaan tersebut.
Faktor yang dianggap menyebabkan lamanya infeksi tersebut adalah :
adanya kompresi bronkus besar oleh atrium kiri atau arteri pulmonalis yang membesar akibat hipertensi pulmonal defek pada bersihan jalan nafas
Terjadinya edema paru menjadi nidus infeksi untuk saluran nafas bawah
Terjadinya atelektasis (akibat kompresi ekstrinsik oleh malformasi vascular atau defek restriktif dari edema paru), hipoksemia pulmonal dan hypoplasia jalan napas
Wilar, R., & Wantania, J. M. (2006). Beberapa Faktor yang Berhubungan dengan Episode Infeksi Saluran Pernapasan Akut pada Anak dengan Penyakit Jantung Bawaan. Sari Pediatri, 8, 154–158Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of Congenital Heart Disease. Paediatric Respiratory Reviews, 13(1), 10–15. Sadoh, W. E., & Osarogiagbon, W. O. (2013). Underlying congenital heart disease in Nigerian children with pneumonia. African Health Sciences, 13(3), 607–612.
ECHOCARDIOGRAPHY
Echocardiography, the primary imaging modality in pediatric cardiology, provides excellent structural and functional detail in children.
Although not useful for the evaluation of HF, which is a clinical diagnosis, echocardiography is essential for identifying :
Causes of HF such as structural heart disease, ventricular dysfunction (both systolic and diastolic)
Confirm enlargement of ventricular chambers Serial evaluation of the efficacy of therapy
Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498
congestive heart failure itself is not an echocardiographic diagnosis; therefore, the underlying etiology is best identified by means of detailed history taking and physical examination and often by means of chest radiography.
Madriago, E., & Silberbach, M. (2010). Heart failure in infants and children. Pediatrics in Review / American Academy of Pediatrics, 31(1), 4–12.
Laboratory BNP and NT-pro BNP
A BNP level > 300 pg/mL has been shown to predict death, transplantation, or heart failure hospitalization and was more strongly correlated with poor outcome than symptoms or echocardiographic findings.1
Auerbach, S.et al : In children with moderately symptomatic HF, BNP > 140 pg/mL at higher risk for worse outcome
Chun-wang Lin. Et.al : Optimal cutoff values of plasma NT-proBNP for the diagnosis of HF were 502 ng/L (0-1 year), 456 ng/L (1-3 years), 445 ng/L (4-7 years), and.355 ng/L (8-14 years).
Lin C-W, Zeng X-L, Zhang J-F, Meng X-H. Determining the optimal cutoff values of plasma NT-proBNP levels for the diagnosis of heart failure in children of age up to 14 years. J Card Fail. 2014;20(3):168-173.
Guidelines for the use of brain natriuretic peptide (BNP) and N-terminal pro-BNP levels in adult patients are not generalizable to children, because the type of ventricular impairment, underlying cardiac morphology, age, gender, and assay method may affect the reference values for these markers.1 Auerbach SR, Richmond ME, Lamour JM, et al. BNP levels predict outcome in pediatric heart failure patients post hoc analysis of the Pediatric Carvedilol Trial. Circ
Hear Fail. 2010;3(5):606-611
1 Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498
Heart Failure with Preserved Ejection Fraction in Children(HFpEF)
HFpEF does exist in children.
Prevalence is rare (only 0.5% of all cohorts with possible and diagnosed cardiovascular diseases compared to prevalence: 1.1–5.5% in adult)
the underlying pathophysiology of HFpEF in children represented by concentric hypertrophy, diastolic dysfunction and possibly ventricular systolic and arterial stiffening
The diagnosis of HFpEF requires :
(1) signs or symptoms of HF
(2) normal or mildly abnormal systolic left ventricular (LV) function
(3) evidence of diastolic LV dysfunction.
Nakagawa, M. (2013). Clinical Characteristics of Heart Failure With Preserved Ejection Fraction in Children. Circulation Journal, 77(9), 2249–2250
Management
McMurray JJ et al. European Heart Journal (2012) 33, 1787–1847
Elimination of the underlying causes
Treatment of the precipitating or contributing causes
Control of the heart failure state.
Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008
Treatment Of Underlying Causes Or Contributing Factors
Surgery if feasible Treat the contributing factor (hypertension, infection fever, anemia, etc)
Antiarrhythmic agents or cardiac pacemaker therapy if indicated.
If hyperthyroidism is the cause of heart failure, this condition should be treated.
Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008
Control of the heart failure state
Diuretics are usually used with inotropic agents.
Afterload-reducing agents, such as ACE inhibitors, have gained popularity because they can increase cardiac output without increasing myocardial oxygen consumption.
Rapid-acting inotropic agents (dopamine, dobutamine) are used in critically or acutely ill infants and children.
Recently, lowdose β-adrenergic blockade has been added to the treatment of dilated cardiomyopathy with encouraging results.
Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008
β-Adrenergic blockers
Carvedilol, The initial dose was 0.09mg/kg twice daily and the dose was increased gradually to 0.36 and 0.75 mg/kg as tolerated, up to the maximum adult dose of 50 mg/day.
Metoprolol. The starting dose was 0.1 to 0.2 mg/kg per dose twice a day and was slowly increased over a period of weeks to 1.1 mg/kg/day (range 0.5 to 2.3 mg/kg/day).
Park MK, Pediatric Cardiology for Practitioners, Elsevier 2008
Device Therapy For Heart Failure
One study in seven children with congenital heart disease and a right bundle branch block pattern found that resynchronizaton therapy resulted in small but statistically significant acute improvement in cardiac output and right ventricular.
Although still controversial there are guidelines for the use of ICD in children some of which has been extrapolated from adult trials.
Walsh EP. Pacing Clin Electrophysiology 2008;31(suppl1):S38-S40Sia MJ Bar Cohen Y. Circ Arrhythm Electrophysol 3008;1:298-306
Dubin AM feinstein JA, Reddy VM, et al. Circulation 2003;107:2287-89
Nutrition and Exercise in PediatricHeart Failure
Significant nutritional “cost” to infants who are trying to both grow and cope with the increased metabolic demands of heart failure symptoms.
Sodium restriction is not recommended in infants and young children
Regular physical activity can result in sustained improvements in physical functioning even in children with complex congenital heart disease.
Hsu, DT. Pearson DG. Circ Heart Fail. 2009;2:490-498
References
Boucek MM, et al .Registry for the International Society for Heart and Lung Transplantation: seventh official pediatric report–2004. J Heart Lung Transplant. 2004
Moss and Adam’s Heart Disease in Infant, Children, and Adolescent-including the fetus and young adults , 7th ed, LWW, 2008
Madriago, E., & Silberbach, M. (2010). Heart failure in infants and children. Pediatrics in Review / American Academy of Pediatrics, 31(1), 4–12.
Park M. Congestive Heart Failure. In: Pediatric Cardiology for Practitioners. 5th ed. Chapter 27. Mosby; 2008.
Hsu DT, Pearson GD. Heart failure in children part I: History, etiology, and pathophysiology. Circ Hear Fail. 2009;2(1):63-70
Hsu DT, Pearson GD. Heart failure in children part II: Diagnosis, treatment, and future directions. Circ Hear Fail. 2009;2(5):490-498
www.radiologyassistant.nl/en/p4c132f36513d4/chest-x-ray-heart-failure.html
Rosenthal D, Chrisant MRK, Edens E, et al. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant. 2004;23(12):1313-1333.
Wilar, R., & Wantania, J. M. (2006). Beberapa Faktor yang Berhubungan dengan Episode Infeksi Saluran Pernapasan Akut pada Anak dengan Penyakit Jantung Bawaan. Sari Pediatri, 8, 154–158
Healy, F., Hanna, B. D., & Zinman, R. (2012). Pulmonary Complications of Congenital Heart Disease. Paediatric Respiratory Reviews, 13(1), 10–15.
Sadoh, W. E., & Osarogiagbon, W. O. (2013). Underlying congenital heart disease in Nigerian children with pneumonia. African Health Sciences, 13(3), 607–612.
McMurray JJ et al. European Heart Journal (2012) 33, 1787–1847
THANK YOUHAPPY EID MUBARAK
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