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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Chronic Heart Failure

Rossano, Joseph W. MD; Cabrera, Antonio G. MD; Jefferies, John L. MD; Naim, M.P.H. Maryam Y. MD; Humlicek, Timothy PharmD

doi: 10.1097/PCC.0000000000000624

Objective: Heart failure is a serious complication that can occur in patients with a variety of congenital and acquired disorders including congenital heart disease, cardiomyopathy, and myocarditis. Furthermore, heart failure patients comprise an increasing number of ICU admissions. Thus, it is important for those caring for patients with critical cardiovascular disease to have a thorough understanding of the medications used for the treatment of heart failure. The aim of this review is to provide an overview, rationale, indications, and adverse effects of medications used in the treatment of chronic heart failure.

Data Sources: PubMed, Medline, Cochrane Database of Systemic Reviews.

Study Selection: Studies were selected on their relevance for pediatric heart failure. When limited data on pediatric heart failure were available, studies in adult patients were selected.

Data Extraction: Relevant findings from studies were selected by the authors.

Data Synthesis: The rationale for the efficacy of most heart failure medications used in pediatric patients is extrapolated from studies in adult heart failure. Commonly used medications for chronic heart failure include β-receptor antagonists (e.g., carvedilol and metoprolol), and medications aimed at blocking the renin-angiotensin-aldosterone system (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists). In addition, diuretics are useful for symptoms of fluid overload. For patients with impaired perfusion, inotropic agents are useful acutely, but may be associated with worse outcomes when used chronically. Newer medications that have been recently approved in adults (e.g., serelaxin, ivabradine, and neprilysin inhibitor [angiotensin receptor blocker]) may prove to be important in pediatric heart failure.

Conclusions: Heart failure patients are in an important population of critically ill children. The pharmacologic approach to these patients is aimed at treating symptoms of congestion and/or poor perfusion and improving long-term outcomes.

1Cardiac Center, Perelman School of Medicine at the University of Pennsylvania, Children’s Hospital of Philadelphia, Philadelphia, PA.

2Division of Cardiology, Department of Pediatric Medicine, Baylor College of Medicine, Texas Children’s Hospital; Houston, TX.

3Division of Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Dr. Cabrera disclosed off-label product use: angiotensin-converting enzyme inhibitors β-blockers inotropes including levosimendan. Dr. Humlicek disclosed off-label product use: the pharmacotherapy discussed in the article includes medications not specifically labeled for the patient population discussed. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies