The Canadian Cardiovascular Society is the first in Canada to issue guidelines aimed at helping primary care and emergency physicians, as well as specialists, recognize and manage heart failure in children. The guidelines were released today at the Canadian Cardiovascular Congress.
Pediatric heart failure is often fatal and occurs in about 3,000 children annually in North America. Worldwide, the problem is far greater and the causes are diverse. To date there has been little guidance to assist practitioners who deal with children with heart failure.
"The previous guidelines, produced in 2004 by the international Society for Heart and Lung Transplantation, are now dated and were not designed for front-line practitioners who deal with these children at the first encounter," says Dr. Paul F. Kantor, who chaired the guidelines and is head of pediatric cardiology at the Stollery Children's Hospital, University of Alberta.
"Providing guidance in this area may help to solve one of the biggest challenges we have: that children with heart failure are usually not recognized early and treated effectively. When heart failure presents late in the disease course, it is more dangerous and can be fatal."
Heart failure in children is far more likely to cause death than cancer, but the problem is not nearly as well recognized, says Dr. Kantor.
About half of the children who present with obvious heart failure will die, or require a heart transplant within five years. Unfortunately, awareness regarding organ donation is still relatively low among Canadian doctors and patients, and a heart transplant is not always available.
"We try our best to treat them with medication and we also use advanced devices such as the Berlin Heart and other ventricular assist devices to keep them alive. Occasionally recovery occurs and some patients will be fortunate enough to receive a transplant," Dr. Kantor says.
"The biggest issue we face is that our patients are often presenting very late and with advanced disease. The earlier they are diagnosed, the more likely it is that we will be able to offer effective treatment."
The new guidelines will provide a framework for early recognition and treatment.
The key recommendations for early recognition are:
Cardiomyopathy, or heart muscle disease, is one of the main causes of heart failure in children and should be excluded when a child presents with unexplained rapid heart rate or rapid breathing. This may be a familial condition caused by one of several gene abnormalities.
Myocarditis, a viral infection of the heart muscle, may be present when children present with abdominal pain and vomiting and have signs of poor circulation.
Specialized pediatric echocardiography is required to exclude heart failure and should be obtained in children with unexplained symptoms and signs of abnormal circulation.
"Often children are brought to the emergency room with shortness of breath and some cough and are thought to have asthma, when in fact they have very severe heart failure," says Dr. Kantor. "The clues of a very unusually fast heart rate and low blood pressure are sometimes overlooked and these children will be sent home with a 'puffer' for their breathing problems, which are actually due to heart failure."
In the same way, he says, teenagers who come to the emergency room with nausea and vomiting and abdominal pain may be thought to have gastroenteritis but may actually have myocarditis. "This is one of the earlier considerations that people in the emergency department should make, since the earlier this is diagnosed, the better the outcome."
Pediatric echocardiography is a specialty in its own right and is different from adult echocardiography. Unfortunately, echocardiography is sometimes done in a non-expert setting, which can lead to misdiagnosis and delay in starting the correct treatment, Dr. Kantor emphasized.Key recommendations for management after diagnosis are:
"We strongly recommend the use of diuretics, which are very effective in an emergency setting," says Dr. Kantor. "We also strongly recommend rescue treatment with inotropic drugs, such as epinephrine and milrinone, to restore the circulation, followed later on by ACE inhibitors, which are effective heart failure treatment in adults and appear to be effective in children as well."
For myocarditis, the experts recommend supportive care, to allow the heart to recover on its own. This can mean giving the patient drugs to support blood pressure, circulation, and occasionally, use of a ventricular assist device, to improve the circulation while the heart recovers, giving it a chance to rest.
These guidelines will benefit practitioners in the field by standardizing practice across institutions, and allowing patients to benefit regardless of where they are cared for.
"Canadian Cardiovascular Society guidelines are an invaluable resource that establish best practices in patient care," says Dr. Michelle Graham, chair of the CCS Guidelines Committee. "These guidelines are important references for our healthcare practitioners in Canada and they are recognized and used by practitioners around the world."
A family's story Tim and Theresa Miller from Delaware, Ont., lost their teenage son to heart failure in 2003.
"We got Daniel to hospital twice on a Monday, and then on the Wednesday. He had all the classic signs that they talk about in these guidelines and they were not recognized as heart failure," says Tim Miller. "Finally, they were trying to resuscitate him and the doctor said, 'It doesn't look good. He probably has myocarditis.' But by then it was too late. He had been in hospital for almost two full days."
"He was 17," adds Theresa Miller. "He was a normal, healthy, bright kid. He'd just finished his application for university, and then, just out of the blue, he got this case of the flu, but he was sicker than we had ever seen him. It was different from any other flu he'd ever had."
"It's the regular physician on the floor that needs to be aware of these guidelines to get the patient on the right track," adds Tim. "The guidelines talk about unusually high heart rate, and that was one of Daniel's symptoms. When he went in that first day, the doc came back and said, 'Wow, his heart rate is really high.'"
"And it was at that moment in time, if these guidelines were in place and had sparked that doctor to recognize the symptoms of myocarditis, that was Daniel's chance. And he was at a tertiary care facility, all the experts were there, but they looked at him as someone having the flu and never thought to look at him broadly enough and treat him in the way that he needed to be treated," says Theresa. "We think these guidelines could be hugely helpful because they give logical steps of what needs to happen if we are going to give these kids a chance.""This was totally out of the blue, that on a Saturday you have a son, and by Thursday, you don't."
The Heart and Stroke Foundation (heartandstroke.ca), a volunteer-based health charity, leads in eliminating heart disease and stroke and reducing their impact through the advancement of research and its application, the promotion of healthy living and advocacy.
Healthy lives free of heart disease and stroke. Together we will make it happen.
For more information and/or interviews, contact the CCC 2012 MEDIA OFFICE AT 416-585-3781 (Oct 28-31)
ORDiane Hargrave Public Relations
Jane-Diane Fraser | EurekAlert!
Unique brain 'fingerprint' can predict drug effectiveness
11.07.2018 | McGill University
Direct conversion of non-neuronal cells into nerve cells
03.07.2018 | Universitätsmedizin der Johannes Gutenberg-Universität Mainz
For the first time ever, scientists have determined the cosmic origin of highest-energy neutrinos. A research group led by IceCube scientist Elisa Resconi, spokesperson of the Collaborative Research Center SFB1258 at the Technical University of Munich (TUM), provides an important piece of evidence that the particles detected by the IceCube neutrino telescope at the South Pole originate from a galaxy four billion light-years away from Earth.
To rule out other origins with certainty, the team led by neutrino physicist Elisa Resconi from the Technical University of Munich and multi-wavelength...
For the first time a team of researchers have discovered two different phases of magnetic skyrmions in a single material. Physicists of the Technical Universities of Munich and Dresden and the University of Cologne can now better study and understand the properties of these magnetic structures, which are important for both basic research and applications.
Whirlpools are an everyday experience in a bath tub: When the water is drained a circular vortex is formed. Typically, such whirls are rather stable. Similar...
Physicists working with Roland Wester at the University of Innsbruck have investigated if and how chemical reactions can be influenced by targeted vibrational excitation of the reactants. They were able to demonstrate that excitation with a laser beam does not affect the efficiency of a chemical exchange reaction and that the excited molecular group acts only as a spectator in the reaction.
A frequently used reaction in organic chemistry is nucleophilic substitution. It plays, for example, an important role in in the synthesis of new chemical...
Optical spectroscopy allows investigating the energy structure and dynamic properties of complex quantum systems. Researchers from the University of Würzburg present two new approaches of coherent two-dimensional spectroscopy.
"Put an excitation into the system and observe how it evolves." According to physicist Professor Tobias Brixner, this is the credo of optical spectroscopy....
Ultra-short, high-intensity X-ray flashes open the door to the foundations of chemical reactions. Free-electron lasers generate these kinds of pulses, but there is a catch: the pulses vary in duration and energy. An international research team has now presented a solution: Using a ring of 16 detectors and a circularly polarized laser beam, they can determine both factors with attosecond accuracy.
Free-electron lasers (FELs) generate extremely short and intense X-ray flashes. Researchers can use these flashes to resolve structures with diameters on the...
13.07.2018 | Event News
12.07.2018 | Event News
03.07.2018 | Event News
16.07.2018 | Physics and Astronomy
16.07.2018 | Life Sciences
16.07.2018 | Earth Sciences