Page 9 - Heart Failure Guidelines






Page 9 - Heart Failure Guidelines
P. 9

Pediatric Heart Failure Guidelines

                   •  Special Considerations: Patients should have a recent serum Cr prior to starting an
                       ARB; follow up serum Cr should be obtained after starting an ARB, timing should
                       depend upon the clinical situation.

               Entresto is a combination of sacubitril and valsartan. Sacubitril is a neprilysin inhibitor. It blocks
               the enzyme neprilysin, which breaks down naturetic peptides (e.g. BNP). Naturetic peptides
               decreases vascular tone and adjusts sodium and water balance. Valsartan is an ARB. In adult
               trials, it has been shown to reduce mortality and hospital admissions. The pediatric trial is
               currently recruiting.

               Aldosterone Inhibitors
               Spironolactone is an aldosterone inhibitor that has been shown to improve heart failure
               outcomes in adult heart failure.  There is limited pediatric data on use. Eplerenone has a smaller
               incidence of gynecomastia and is more frequently used in adolescents and adults.

                   •  Indications: include symptomatic heart failure, asymptomatic left ventricular or systemic
                       ventricular dysfunction, hypertension and hypokalemia.
                   •  Side Effects: include hyperkalemia & uremia.
                   •  Special Considerations: Serum K+ and Cr should be obtained prior to starting and be
                       rechecked after initiation; should be avoided during acute renal insufficiency.

               Beta Blockade

               Carvedilol is a non-selective beta blocker with additional alpha-1 blocker qualities and is a
               commonly used heart failure medication in adult heart failure.  There is evidence that supports
               its use in certain pediatric heart failure populations. Other Beta Blockers have been studied in
               adult heart failure and been shown to improve outcomes. However, head to head trials indicate
               Carvedilol is the superior beta blocker in heart failure. Metoprolol is commonly used in older
               patients. Atenolol and Propranolol are more usually used in hypertrophic cardiomyopathy.

                   •  Indications: include symptomatic heart failure, asymptomatic left ventricular heart
                       failure and possibly restrictive physiology.  Non-carvedilol beta blockers are often used
                       in hypertrophic cardiomyopathy.
                   •  Side Effects: include fatigue, bradycardia, depressive symptoms, dizziness, malaise.
                   •  Special Considerations: Conflicting evidence exists upon the use of carvedilol in
                       patients with congenital heart disease, especially those with single ventricles, therefore
                       use in this population should be done with careful consideration; titration up to target
                       goal should be done slowly to minimize side effects, typically increasing dose every 2-4

               Sinus Node Blockade

               Ivibradine is the only drug in the class with limited pediatric experience.

                   •  Indications: Ivabradine is used to reduce the risk of hospitalization for worsening adult
                       heart failure with stable, symptomatic, mild to severe chronic heart failure (NYHA class

               Updated 7/31/2018                                                                       page 9
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