Heart failure

Question 1

What is CHF?

Answer 1

CH 442: CONGESTIVE HEART FAILURE (CHF)
- Syndrome in which the heart is unable to pump blood
to the body to meet its needs, or to dispose of
pulmonary/venous return adequately

Question 2

What are the causes of CHF?

Answer 2

Causes
- Usually secondary to volume/pressure overload

1. Congenital heart disease
   - MC cause of CHF in infancy
   - Volume overload lesions (VSD, PDA, OCD): MC cause of
   CHF in the 1st 6 MOL
   - ASD rarely cause CHF in pedia
   - Large L-R shunt lesions (VSD, PDA) do not cause CHF
   before 6-8 weeks
   o Due to inc PVR at this time
2. Acquired heart disease
   - Dilated cardiomyopathy: MC cause of CHF beyond
   infancy. Usually idiopathic
   - Myocarditis sec. to Kawasaki disease in 1-4yo
   - Viral myocarditis more common <1yo
   - Acute rheumatic carditis
   - Rheumatic valvular heart ds (MR, AR) usually in older
   children
3. Miscellaneous
   a. Metabolic (hypoxia, acidosis, hypogly,
   hypoCa)
   b. Hyperthyroidism
   c. Severe anemia (Hgb <6)
   d. Acute systemic HTN (PSGN)

Question 3

What is the pathophysio?

Answer 3

Pathophysio
- Cardiac output is determined by: HR x SV
- SV is determined by 1.preload, 2.afterload 3.Contractility

1. Preload – volume before systole
   - Frank Starling Law: inc preload, the healthy heart inc
   CO until a maximum is reached. At maximum point, CO cannot be further inc –> LV end diastolic pressure reaches a certain point, pulmonary congestion develops (tachypnea, dyspnea)
2. Afterload – volume after systole
   - Dec SV, dec EF from inc afterload
3. Wall stress – Laplace law: wall P = P x ½ radius x wall thickness
   - 2 most impt points:
   o The bigger the LV and higher radius, higher
   wall stress
   o At any LV size: inc P = higher wall stress
   - Thus, dilated ventricles require more O2 demand

Compensatory mechanisms
- Activation of SNS and RAAS
1. Inc epi/NE –> inc sympathetic tone –> inc HR, inc
contractility –> inc CO
- However, chronic bad because: inc afterload, inc
metabolism, inc arrhythmogenesis, inc myocardial
toxicity
- Dec B adrenergic receptors on myocardial cell
(maladaptive)
2. Oliguria –> inc renin –> inc angiotensin II –> constrict arterioles, inc reabsorption of salt and water -> inc myocardial fibrosis –> hypertrophic response in
attempt to restore wall (maladaptive)
- Thus, tx for CHF = beta blocker, ACEI to block maladaptive roles

Question 4

Hallmark of CHF

Answer 4

Hallmark of CHF:
a. Tachypnea
b. Tachycardia
c. Cardiomegaly

Question 5

Clinical manifestations of CHF

Answer 5

CM
1. Hallmark of CHF:
a. Tachypnea
b. Tachycardia
c. Cardiomegaly
d. Edema + organomegaly

2. Infants – poor feeding, tachypnea during feeding, poor weight gain, cold sweat, puffy eyelid
3. Older child – SOB, easy fatigability, bipedal edema
4. Compensatory responses – tachycardia, gallop rhythm,
   weak thready pulses, cardiomegaly, inc sym. Activity (growth failure, perspiration, cold sweat)
5. L-sided failure – pulmonary venous congestion: tachypnea (common and early), exertional dyspnea (poor feeding in infants), orthopnea, wheezing & pulmo crackles
   - Pulsus alterans – beat-to-beat oscillation in strength of
   cardiac muscle contraction at a constant HR (severe
   CHF) due to LV dysfunction.
   Dec EF –> dec SV –> inc
   LVEDV
6. R-sided HF – systemic venous congestion: hepatomegaly, puffy eyelids (infant), distended neck
   veins, dependent edema (sacral (infant), back)
7. Anginal sx – due to dec EF, dec CO to coronary sinus

Question 6

Modified Ross classification of HF in children

Answer 6

Modified Ross classification of HF in children
I – asymptomatic
II – mild tachypnea with feeding diaphoresis
III – marked tachypnea, diaphoresis during feeding
IV – tachypnea, grunting, retractions, diaphoresis at rest

Question 7

Diagnostics for CHF

Answer 7

Dx
1. ECG – ID cause of CHF, least helpful in CHF
2. CXR – cardiomegaly, pulmonary edema, congestion
3. 2D echo – most helpful non-invasive study that
confirms CHF and estimates severity of HF; useful in
determination of efficacy of Tx
- Ejection fraction NV = 55-70%
4. Cardiac catheterization – endomyocardial biopsy
5. CBC,BUN, Crea, ABG, e’s, BCS

Question 8

Management of CHF

Answer 8

Mgt
Goals:
1. Elimination of underlying cause – most desirable approach

2. Treatment of contributing causes
3. Control of HF state
   The required calorie intake of infants = 150-160 kcal/kg/d
4. Preload unloaders
   a. Diuretics – principal tx to control pulmonary
   and systemic venous congestion and salt and water retention
   - Decrease preload (no effect on CO/myocardial contractility)
   - SE: hypoK (except spironolactone), hypochloremic alkalosis (due to loss of Cl ions –> inc HCO3 levels),
   hypotension
   - Hydrochlorthiazide 2-4mkd BID/TID (non popular)
   - Furosemide 1mkdose IV or 2-3mkdose po BID or TID:
   DOC, most potent
   - Spironolactone 1-3mkd po BID or TID: anti-aldosterone
   and K sparing effect. Good to combine with
   furosemide.
5. Inotropes
   a. Rapidly acting inotropic agents – inotropic, vasodilating for acute situations
   - For critically-ill infants with renal dysfunction, post op pxs with HF
   - SE: HTN, arrhythmia, vasodilation, tachycardia
   - Epinephrine 0.1-1 ug/kg/min IV (rare)(a>B1>B2)
   - Dobutamine 2-8 ug/kg/min IV (B1>B2)
   - Dopamine 5-10 ug/kg/min
   o Dose related CV effects:
   § 2-5: renal vasodilation
   (dopaminergic R)
   § 5-8: inotropic (B & dopa R)
   § >10: mild vasoconstriction (a
   adrenergic R)
   § 15-20: vasoconstriction
   o Onset of action: 1 min
   b. Digitalis glycosides (digoxin) – inc CO; diuretic and PSY (slows HR, inhibits AV conduction) properties
   - SE: shortening of QTc (earliest sign), slowing of HR
   - CM: anorexia, nausea, vomiting, diarrhea, restlessness, drowsiness, fatigue, visual disturbance
   - Half-life: 36-48h (N renal fxn); 3-5d (impaired renal fxn)
   - Toxicity: PR interval prolongation à 2nd degree HB, profound sinus bradycardia, SVT and ventricular
   arrhythmia, PVC
   - Dosage: infants and children require larger dose

Age Total digitalizing
dose (ug/kg) Maintenance dose
(ug/kg/d)
PT 20 5
FT 30 8
<2yo 40-50 10-12
>2yo 30-40 8-10

Question 9

How to digitalize?

Answer 9

How to digitalize?
o LD given over 12-18h followed by MD
§ Results to pharmacokinetic
steady state in 3-5d
o Baseline ECG and serum e’
§ ECG: rhythm and PR
§ E’s: hypoK, hyperCa predispose
to digitalis toxicity
o Calculate total digitalizing dose
o Give ½ TDD à ¼ à ¼ q6-8h intervals
o ECG again – start MD 12h from final part of
TDD

Question 10

• Monitoring toxicity

Answer 10

Monitoring toxicity
o Best determined by ECG monitoring during
the 1st 3-5d after digitalization
§ Prolonged PR interval
§ Profound sinus bradycardia/ SA
block
§ SV arrhythmia – atrial/nodal
ectopic beat
§ Ventricular arrhythmia -isolated
PVC
o Serum digoxin levels: therapeutic range = 0.8-2 ng/ml
§ Blood should be collected >6h
from last dose
§ Drugs that inc levels: quinidines,
verapamil, amiodarone, B
blockers
§ Drugs that dec levels: rifampicin,
neomycin, cholestyramine

Digitalis toxicity
o Stop drug immediately then resume MD after 3-5d
o Correct hypoK/hyperCa
o Treat arrhythmia with anti-arrhythmic drug

Question 11

Management

Answer 11

3. Afterload reducing agents – facilitate ventricular emptying by dec wall tension and inc CO

• augments SV w/o damage in contractile state (no inc in O2 consumption)
• SE: dizziness, syncope, hypotension
  a. Arteriolar vasodilator: Hydralazine 0.1-0.2 mkdose q4-6h IV (max 2 mg/kg q6h), 0.75-3
  mkd BID-QID (max 200mg/d)
  b. Mixed vasodilator: Captopril – vasodilator of choice due to AgII suppressing effect
  § NB: 0.1-0.4 mkdose OD-QID po
  § Infant: 0.5-6mkd OD-QID
  § Child: 12.5 mg/dose OD-BID
  c. Mixed vasodilator: Nitroprusside 0.5-8
  ug/kg/min IV
  d. Mixed: Prazosin5 ug/kg (1st dose) –> 25 ug/k/d QID po
  e. Venodilator: Nitroglycerin 0.5-1 ug/kg/min IV

4. Other drugs
   a. B blockers – prevent LV remodeling and myocardial fibrosis
   - SE: dizziness, headache, hypotension
   - Metoprolol 0.1-0.2 ug/kg/dose BID then slow inc to 1.1 mkd over weeks
5. Surgical mgt – consider if no improvement in sx after medical tx
   - Cardiac transplant – progressively deteriorating cardiomyopathy despite maximal medical tx
6. Supportive mgt – semiFowler position, oxygen, hypoNa and hyperK supplementation, enhance physical and
   metabolic requirements (inc pH, glu, Ca, Hgb), control HR, e’ and metabolic balance, peritoneal dialysis and mech vent

Question 12

What is myocarditis?

Answer 12

CH 439: MYOCARDITIS
- Inflammation of the myocardium
- Cell-mediated immunologic reaction of myocardium:
soft, flappy, pale with areas of scarring

Question 13

Etiology of myocarditis

Answer 13

Etiology
1. Infections – enterovirus (MC), Coxsackie A&B, adenovirus, parvovirus, EBV, CMV, HIV, HepC, Dengue, HSV, Infuenza, VZV, MMR, rabies, HepB
- Bacteria (rare): C.diphtheria toxin, MTb, Streptococcus, Mycoplasma, C.perfringens, Salmonella
- Fungal, protozoal, parasites

2. Immunologic: ARF, Kawasaki, RA, SLE
3. Drugs: sulfonamides, penicillin, phenytoin,
   Carbamazepine
4. Toxins/chem: radiation, drugs, Ca, Hc, Hg, lead

Question 14

Pathophysio of myocarditis

Answer 14

Pathophysio
- Pathogens/causative agent: infectious/ non-infectious
- Immune response –>
o Innate: activate cytolytic T cells, apoptosis,
dec T cell regulatory function, inc inflamm
mediators (cytokines, interferon)
o Acquired: further T cell and subsequent Bcell activation, Ab against endogenous
epitopes (cross-reaction)
- Myocardial inflammation: direct damage by causative agent, additional injury may be caused by immunologic mechanisms, inflammatory cell infiltrates, myocyte
necrosis and degeneration –>
- Resolution or persistence:
o Resolution: eradication of pathogen,
dampened immune response
o Persistence: viral persistence and/or
continuous immune activation; myocardial
fibrosis, cardiac remodeling

Question 15

What are the clinical manifestations of myocarditis?

Answer 15

CM
1. Infant/young child: hx of preceding URTI/GIT infection,
fever, poor feeding, irritability, lethargy, vomiting,
pallor, diaphoresis (fulminant, severe s/sx)
2. Older child: recent Hx of flu-like illness, headache,
muscle pain, diarrhea, sore throat, rashes, chest
discomfort, exertional dyspnea, syncope/nearsyncope
3. CHF signs (RD, tachypnea, tachycardia, hepatomegaly)
soft systolic murmur (MR due to dilated MV annulus),
gallop rhythm (poor ventricular compliance),
arrhythmia (universal sx), cardiomegaly, poor
peripheral perfusion, hypotension

Question 16

Diagnostics for myocarditis?

Answer 16

Dx
1. Myocardial biopsy (Dallas criteria) – gold standard but low Sn (patchy infiltrates), invasive: (+)myocyte necrosis, degeneration, inflammation
2. ECG always abN
- Sinus tachycardia/bradycardia
- Arrhythmia (premature ectopic beat, SVT, VT, AV blocks)
- Low QRS complex (<10mm in chest; <5mm in limb)
- Nonspecific ST-T wave changes
- Prolonged QT interval
3. CXR – cardiomegaly (most impt sign), pulmo congestion/edema, pleural effusion
4. 2D echo
- Depressed ventricular function (dec LV contractility)
- Cardiomegaly (esp LVH)
- Valvular regurgitation (MR, TR)
- Pericardial effusion
5. Others
- elev ESR, CRP, SGOT, CK-MB, LDH (low sn, low sp)
- Troponin T and I (more sp): cardiac markers, degree of elevation proportional to degree of myocardial damage
o NV= 0.052 ng/ml
o Start elevating in 3-12h, Peak in 24-48h,
remain elevated for 5-14d
- antiviral titers
- contrast cardiac MRI: localized and patchy myocardial damage, can guide biopsy)

Question 17

Management of myocarditis

Answer 17

Mgt
1. anti-CHF – to augment CO, minimize metabolic
demands
a. diuretics (Furosemide)
b. oxygen
c. bed rest, high back rest
d. IV inotropic agents (Dobutamine,
dopamine)
e. Vasodilators (ACEI, nitroglycerin)
f. Inodilators (milrinone)
g. Cautious digitalization – predispose to
arrhythmia

2. mgt of arrhythmia – cardioversion, pacemaker
3. maintain adequate BP
4. supportive measures
   a. fluid and caloric maintenance
   b. correction of acid-base disturbance
   c. correction of e’ imbalance
   d. T control
   e. Correction of anemia
5. treat other associated medical conditions

Question 18

Prognosis of myocarditis

Answer 18

prognosis
- mild ds recover w/o long term sequelae
- NB: 75% mortality
- Acute myocarditis –> chronic myocarditis, dilated cardiomyopathy

Question 19

What is pericarditis?

Answer 19

CH 440: PERICARDITIS
- Inflammation of the pericardium
- Usually with pericardial effusion

Question 20

etiology of pericarditis

Answer 20

Etiology
1. Pyogenic infection (S.aureus, S.pneumoniae,
pneumococcus, leptospirosis)
2. ARF (MC in general)
3. TB (MC in PH)
4. Viral, uremia, collagen ds (RA, SLE)
5. Postpericardiotomy syndrome
6. Others: fungal, parasitic, idiopathic, systemic
inflammatory ds, metabolic, malignancies, pericardial
tumor, radiation tx
7. Infectious pericarditis – virus: entero, influenza,
adenovirus, RSV, parvovirus; purulent (bacterial):
S.aureus, S.pneumonia; TB
8. Non-infectious – autoimmune, rheumatic and CT
disorders may result in serous pericardial effusions,
neoplastic ds, CRF or hypothyroidism, JRA

Question 21

Pathophysiology of pericarditis

Answer 21

Patho
- When the amount of fluid in the nondistensible pericardial space becomes excessive, pressure within the pericardium increases and is transmitted to the
heart resulting in impaired filling –> fluid accumulation causes abrupt impairment of cardiac filling –> cardiac
tamponade —> shock, death

Question 22

What are the clinical manifestations of pericarditis?

Answer 22

CM
1. Hx of previous RTI, fever
2. Chest pain – MC sx, main sx. Sharp, stabbing, poststernal radiating, worse with inspiration and supine, relieved by sitting up/leaning forward
3. Shoulder and neck pain
4. Cough, dyspnea
5. abdominal pain, vomiting
6. pericardial friction rub (cardinal sign) – pathognomonic
of small pericardial fluid, LSB, lean forward
7. quiet hypodynamic heart
8. venous engorgement
9. RUQ pain/ hepatomegaly
10. tachycardia
11. Signs of cardiac tamponade – Beck’s triad: inc CVP, distant heart sounds, hypotension
- Narrow pulse P, low CO
- Tachycardia, hepatomegaly, venous distention
- Pulsus paradoxus: exaggeration of N reduction of systolic P during inspiration (>10mmHg) because of compromised LV diastolic filling

Question 23

What are the diagnostics for pericarditis?

Answer 23

Dx
1. ECG – low voltage QRS complexes (damping effect of significant fluid), ST changes (initial ST elevation then T wave inversion)
- Electrical alterans: changing QRS complex amplitude (some tall, some short) since the heart moves within a fluid-filled pericardial sac

2. CXR – varying degrees of cardiomegaly, flaskshaped/ water-bottle heart with large effusion (upright, hallmark of massive PE), dec/N pulmonary vasculature
3. 2D echo – most sn diagnostic tool
   - Assess fluid in pericardial space, compression and collapse of RA and RV (cardiac tamponade)
4. Pericardiocentesis – ID etiology
5. CBC (infection), ESR (marker of inflamm)

Question 24

Management of pericarditis

Answer 24

Mgt
1. Tx of primary ds
2. IV Abx – for fulminant cases for 4-6 wks
Vancomycin 60mkd q6 + Ceftriaxone 100mkd q12-24
3. CS – for severe rheumatic carditis, post pericardiotomy syndrome, TB pericarditis
4. NSAIDs, salicylates – Aim is resolution of chest pain and inflammation
5. Pericardiocentesis – detect etiology, emergency for cardiac tamponade/significant effusion (life saving)
6. Urgent surgical drainage for supportive pericarditis – to prevent cardiac tamponade
7. Supportive measures
8. Pericardiectomy – for bacterial and TB pericarditis, to prevent constrictive pericarditis.

Question 25

What is cardiac tamponade?

Answer 25

CARDIAC TAMPONADE - Cardiac emergency! - Cardiac decompensation from rapid accumulation of >100ml pericardial fluid

Question 26

Clinical manifestations of cardiac tamponade

Answer 26

CM - varies according to rapidity in which effusion develops 1. Beck’s triad - Distant/muffled heart sounds - Hypotension - Elevated central venous pressure with jugular venous distension 2. PE: distant or diminished heart sounds, tachycardic with regular rhythm, usually no murmur, neck vein engorgement, hepatomegaly, narrow pulse P, pulsus paradoxus 3. Kussmaul’s sign – small volume pulse which disappears on inspiration 4. Rapid accumulation: tachypnea, cough, abdominal pain due to hepatomegaly

Question 27

Diagnostics of cardiac tamponade

Answer 27

Dx 1. ECG – low voltage complexes, widespread T wave inversion 2. CXR – enlarged cardiac silhouette (water bottle/ Erlenmeyer flask sign), dec/N pulmo BF 3. Echo – echo-free space around heart with collapse of R heart

Question 28

Management of Cardiac tamponade

Answer 28

Mgt 1. Fluids: 20 ml/kg PNSS or LR bolus 2. Pericardiocentesis/ tube pericariostomy – life-saving bedside procedure. Anesthetize puncture site --> G18 or 19 on 10-15ml syringe at subxiphoid (1cm inferior to bottom rib)/ xyphocostal angle (45 degrees angle, direct toward L shoulder) --> advance needle until fluid reached, aspirate slowly à limit acute drainage to <1L. 3. Treat underlying cause

Question 29

What is cardiomyopathy?

Answer 29

CH 439: CARDIOMYOPATHY - Heterogenous group of myocardial abnormalities which cause myocardial dysfunction - Some secondary cardiomyopathy: doxorubicin, systemic disease, peripartum, Kawasaki, HTN - Most unknown etiology (idiopathic)

Question 30

Types of Idiopathic cardiomyopathy

Answer 30

Types of idiopathic cardiomyopathy 1. dilated (congestive) CM - MC 2. hypertrophic obstructive 3. Restrictive CM 4. Arrhythmogenic RV dysplasia