Page 10 - Heart Failure Guidelines

Pediatric Heart Failure Guidelines

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
weeks.

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
II–IV) with a resting heart rate ≥70 bpm and are either on a maximally β-blocker dose or
β-blocker is contraindicated.
• Side Effects: include fetal toxicity, atrial fibrillation, bradycardia, sensitivity reactions e.g.
angioedema.
• Special Considerations: Bonnet et al. J Am Coll Cardiol 2017;70:1262–72

Calcium Channel Blockers (Non-dihydropyridine)
The non-dihydropyridine calcium channel blockers act upon the peripheral calcium channels as
well as the calcium channels in the myocardium decreasing inotropy and chronotropy.
Therefore, they are typically avoided in pediatric heart failure, but can be utilized in hypertrophic
cardiomyopathy. Diltiazem is the principle drug used.

• Indications: Hypertrophic Cardiomyopathy

Updated 4/22/2019 page 10