How to Evaluate and Manage Children With Acute Decompensated Heart Failure

For the first time, experts have published comprehensive guidance on how to evaluate and manage pediatric patients with acute decompensated heart failure.

The guidance has been needed due to the rising number of children living longer with repaired or palliated congenital heart disease or cardiomyopathy, explains Shahnawaz Amdani, MD, Section Head of Pediatric Heart Function and Transplant at Cleveland Clinic.

“Thanks to medical advances, we have more children living with heart disease and, therefore, more children coming into an emergency department or being hospitalized with heart failure,” he says. “Research shows that once children get admitted for heart failure, they are much more likely than adults to need advanced cardiac therapies or die. And, while readmission rates have steadily declined in adults with heart failure — largely thanks to improved interventions and management practices — readmission rates have not changed for pediatric patients.”

Management of children and adolescents with decompensated heart failure can involve pediatric, emergency, intensive care, cardiac surgery and cardiology specialists and other providers, notes Dr. Amdani. Because this multidisciplinary teamwork is essential, standardizing care may help improve patient outcomes.

As a result, the American Heart Association (AHA) recently published a scientific statement, “Evaluation and Management of the Child With Acute Decompensated Heart Failure,” in Circulation.

“The guidance is supported by scientific evidence,” says Dr. Amdani, who is senior author of the statement and is the chair of AHA’s Young Hearts Heart Failure and Transplant Committee. “So, anyone involved in caring for young people with acute decompensated heart failure can go to one place to read the latest comprehensive, evidence-based information on how to evaluate, manage and discharge these patients successfully.”

Highlights from the statement

The AHA statement first discusses the diverse etiologies of acute decompensated heart failure (e.g., cardiomyopathy, congenital heart disease, cardiac transplant graft dysfunction or rejection) and their diagnostic challenges.

Then it outlines guidelines for managing patients in the:

• Emergency department. “It is critical to have a high index of suspicion for decompensated heart failure because the presenting symptoms and signs mimic a lot of pediatric diseases,” Dr. Amdani says. “If patients have sepsis, for example, they may have hypotension, tachycardia and low perfusion. However, if you provide the standard treatment for sepsis, such as rapid fluid administration, it could have a detrimental effect on myocardial function in patients with heart failure. Instead, emergency physicians should be empowered to use diuretics and inotropes in these patients, to help prevent progression to cardiogenic shock and the need for extracorporeal membrane oxygenation [ECMO] or other advanced therapies.”
• Intensive care unit. Various inotropes — such as milrinone, dobutamine, epinephrine and dopamine — can be used in patients with decompensated heart failure. Some of these medications may be more beneficial than others in certain circumstances, as outlined in the statement. Inotrope selection depends on the patient’s clinical presentation, perfusion and blood pressure. The statement also offers guidance on hemodynamic monitoring, respiratory management, and enteral or parenteral nutrition.

Access to mechanical circulatory support has expanded in the past decade. As such, the AHA statement offers strategies for peripheral and central cannulation for ECMO, recommending when to select each.

It then outlines decompression strategies for the left ventricle, which often arises in patients on ECMO. One of the more recent strategies involves using microaxial flow pumps to decompress the left ventricular myocardium. The statement also provides guidelines for managing myocardial recovery or transitioning patients from temporary to durable ventricular assist devices.

Finally, the statement addresses transitions of care and best practices, including behavioral health management.

“Standardized discharge planning for patients admitted with decompensated heart failure has not gotten a lot of attention in pediatrics,” Dr. Amdani says. “Our statement also raises awareness of the mental health burden of these patients and their families. A multidisciplinary team, including behavioral health and sometimes pediatric palliative experts, can help provide family-centered care.”

A call for more pediatric heart failure research

Decades of work has been done to advance the science of adult heart failure medicine, notes Dr. Amdani. The result has been standardized guidelines and management practices that have improved outcomes for adults with heart failure. Pediatric patients need the same.

“Kids are not just small adults. There are unique differences between pediatric and adult heart failure,” Dr. Amdani says. “We need to have pediatric guidelines and best practices that are derived from rigorous science and then implemented at the patient level to improve outcomes. Our new AHA statement is a start, but there still are many knowledge gaps that we need to fill.”

The AHA statement lists several topics recommended for future research, including:

• Developing a cardiogenic shock staging system for pediatric patients
• Determining the best vasoactive agent suited to the presenting hemodynamic profile
• Identifying the best time and method of ventricular decompression

“Children facing acute decompensated heart failure are at significant risk for severe outcomes, including repeat hospitalizations and death,” Dr. Amdani says. “It will take a global effort by clinicians, researchers and patient families to develop a unified strategy to close knowledge gaps and enhance care for these vulnerable patients.”