Page 9 - Heart Failure Guidelines
P. 9

Pediatric Heart Failure Guidelines

               beta blockade, followed by aldosterone inhibition.  However this can be altered based on
               individual patient characteristics, disease state, side effect concerns or other patient factors.

               The majority of anti-heart failure medications lower blood pressure and/or lower heart rate.
               Concern for low blood pressure and/or low heart rate often lead to delays in dose escalation.
               The general approach will be to continue to advance anti-heart failure medications as long as
               the patient is asymptomatic (dizziness, syncope, lightheadedness, etc.) from hypotension or
               bradycardia, or the degree of bradycardia/hypotension is severe enough to cause harm (end-
               organ dysfunction, arrhythmias, syncope).  The degree of bradycardia and hypotension will
               depend upon each individual.

               ACE-Inhibitors
               ACE inhibitors are common first line medications used in the treatment of heart failure. Captopril
               is usually used to initiate therapy if patient is hospitalized, otherwise Enalapril is the first line
               ACE-I. Lisinopril is a daily dose and useful in older patients.

                     Indications: include symptomatic heart failure, asymptomatic left ventricular or systemic
                       ventricular dysfunction, hypertension and systemic semilunar or atrioventricular valve
                       regurgitation.
                     Side Effects: include hypotension, hyperkalemia, angioedema, dizziness, syncope,
                       anemia, and cough.
                     Special Considerations: Patients should have a recent serum K+ and Cr prior to
                       starting an ACE-I; follow up serum K+ and Cr should be obtained after starting an ACE-I,
                       timing should depend upon the clinical situation; initiation of ACE-I in unstable,
                       hospitalized patient will preferably be done with captopril.

               Angiotensin Receptor Blockers
               Angiotensin receptor blockers (ARBs) have a mechanism of action similar to the ACE-inhibitors
               and have been shown to have similar effects on adult heart failure but there is limited pediatric
               heart failure data on ARBs. Losartan is the most frequently used. Valsartan is a component of
               Entresto but can be used alone.

                     Indications: ARBs are similar to ACE-inhibitors and are typically used when a patient is
                       not able to tolerate an ACE-inhibitor (typically for cough).
                     Side Effects: include hypotension, angioedema, dizziness, syncope & anemia.
                     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
               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.






               Updated 9/21/2018                                                                       page 9
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