Hospital pediatrics. Chronic heart failure in children. Clinic, diagnosis, treatment (lecture notes)

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Hospital pediatrics. Chronic heart failure in children. Clinic, diagnosis, treatment (lecture notes)

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LECTURE No. 5. Chronic heart failure in children. Clinic, diagnosis, treatment

Heart failure is a condition in which the heart, despite sufficient blood flow, does not meet the body's blood supply needs. Causes of chronic circulatory failure: direct effects on the myocardium (toxic, infectious, traumatic), cardiovascular diseases.

Classification. Classification of chronic heart failure (according to Strazhesko-Vasilenko). Stage I. Compensated. Stage IIA. Decompensated-reversible. IB stage. Decompensated-slightly reversible. Stage III. Terminal.

International classification of chronic heart failure.

I functional class.

II functional class.

III functional class.

IV functional class.

Pathogenesis. The pathogenesis of chronic heart failure is manifested by a decrease or increase in blood supply, blood flow and/or pressure in the central or peripheral parts of the circulation. These changes arise as a mechanical consequence of a violation of the pumping function of the heart and as a result of inadequacy of adaptive reactions. These reactions include tachy- and bradycardia, changes in vascular peripheral and pulmonary resistance, redistribution of blood supply, hypertrophy and expansion of individual chambers of the heart, fluid and sodium retention. Hemodynamic disturbances lead to pathological changes in the heart, blood vessels and other organs and systems.

Clinical manifestations.

clinical forms.

1. Congestive left ventricular failure occurs more often with mitral disease. An increase in pressure in the pulmonary veins leads to filling of the left ventricle and preservation of cardiac output. Congestive changes in the lungs disrupt the function of external respiration and are a factor aggravating the patient’s condition with congestive left ventricular failure. Clinical manifestations: shortness of breath, orthopnea, upon auscultation there are signs of pulmonary congestion (dry rales below the level of the shoulder blades, migrating moist rales) and radiological changes, cardiac asthma and pulmonary edema, secondary pulmonary hypertension, tachycardia.

2. Left ventricular failure is characteristic of aortic disease, ischemic heart disease, and arterial hypertension. Clinical manifestations: cerebrovascular insufficiency manifested by dizziness, blackout, syncope, coronary insufficiency and echocardiographic signs of low output. In severe cases, Cheyne-Stokes breathing, presystolic gallop rhythm (pathological IV tone), and congestive left ventricular failure appear.

3. Congestive right ventricular failure manifests itself with mitral, tricuspid disease or constrictive pericarditis. More often it is associated with congestive left ventricular failure. Clinical manifestations: swelling of the neck veins, increased venous pressure, acrocyanosis, enlarged liver, peripheral and cavitary edema.

4. Right ventricular failure is observed with pulmonary stenosis and pulmonary hypertension.

Clinical manifestations of chronic heart failure.

Stage I of chronic heart failure (I f. to.).

Complaints of weakness. On objective examination, the skin is pale. Signs of heart failure only during heavy physical activity: shortness of breath, tachycardia. Hemodynamics are not affected.

Stage IIA of chronic heart failure (II stage) Complaints: sleep disturbance, increased fatigue. Signs of heart failure at rest:

1) left ventricular heart failure, shortness of breath (no cough), tachycardia;

2) right ventricular heart failure, liver enlargement and pain, pastiness in the evening on the lower extremities (no edema).

Stage 11B of chronic heart failure (II stage) Complaints: irritability, tearfulness. All signs of heart failure at rest: icterus, cyanotic skin, pronounced LVHF and PZHF, decreased diuresis, expansion of the borders of the heart, dull tones, arrhythmia.

Stage III of chronic heart failure (IV f.c.) Cachexic circulation, emaciation, light tan skin. Edema-dystrophic blood circulation (thirst, edema, cavitary edema (pulmonary edema)). The progression of chronic heart failure is manifested by oliguria and hepatosplenomegaly.

Treatment.

Principles of treatment.

1. Cardiac glycosides.

2. Diuretics.

3. ACE inhibitors

4. β-blockers.

Treatment tactics for chronic heart failure. Stage I - (I f.k.) basic therapy of the underlying disease. Stage IIA (II f.k.) - diuretics.

CB stage (III stage) - diuretics, cardiac glycosides. Stage III (IV f.k.) - diuretics, cardiac glycosides, peripheral vasodilators.

In stage I, it is necessary to observe a work-rest regime and moderate physical exercise. In severe stages, physical activity should be limited, bed rest or semi-bed rest should be prescribed. Complete, easily digestible food, rich in proteins, vitamins, and potassium. If there is a tendency to fluid retention and arterial hypertension, moderate restriction of table salt is indicated. In case of massive edema, a short-term strict salt-free diet is prescribed. Cardiac glycosides are not prescribed for obstructive hypertrophic cardiomyopathy, severe hypokalemia, hyperkalemia, hypercalcemia, atrioventricular heart block, sick sinus syndrome, ventricular extrasystoles, and paroxysms of ventricular tachycardia. Cardiac glycosides are prescribed in doses close to the maximum tolerated. First, a saturating dose is used, then the daily dose is reduced by 1,5-2 times. For glycoside intoxication, unithiol is prescribed (5% solution 5-20 ml IV, then 5 ml IM 3-4 times a day). According to the indications, antiarrhythmic therapy is carried out. The patient and his relatives must be familiarized with the individual treatment regimen for cardiac glycosides and the clinical signs of their overdose. Digoxin is prescribed 2 times a day in tablets of 0,00025 g or parenterally 0,5-1,5 ml of a 0,025% solution (saturation period), then 0,25-0,75 mg (maintenance dose) per day . The use of the cardiac glycoside digoxin requires special caution. The dosage of cardiac glycosides should be selected in a hospital. Diuretics are used for edema, liver enlargement, and congestive changes in the lungs. The minimum effective doses are used during treatment with cardiac glycosides. The treatment regimen is individual, which is adjusted during treatment. Complications of diuretic therapy are hypokalemia, hyponatremia, hypocalcemia (loop diuretics), hypochloremic alkalosis, dehydration and hypovolemia. Hypotazide is used in tablets of 0,025 g, loop diuretic furosemide or Lasix in tablets of 0,04 g or parenterally. Peripheral vasodilators are prescribed in severe cases when cardiac glycosides and diuretics are ineffective. With stenosis (mitral, aortic), as well as with systolic (blood pressure reduced from 100 mm Hg. Art. and below) they should not be used. Mainly venous dilators, nitro drugs reduce the filling pressure of the ventricles in case of congestive insufficiency; the arteriolar dilator hydralazine 0,025 g is prescribed 2-3 tablets 3-4 times a day, as well as the calcium antagonist nifedipine, Corinfar. Venuloarteriolar vasodilators: captopril in a daily dose of 0,075-0,15 g. The use of venulo-arteriolo-dilators together is used in severe heart failure, refractory to cardiac glycosides and diuretics, with significant dilatation of the left ventricle. Potassium preparations can be prescribed together with cardiac glycosides, diuretics and steroid hormones. Potassium preparations are prescribed for ventricular extrasystoles, hypokalemia, tachycardia refractory to cardiac glycosides, and flatulence in seriously ill patients. It is necessary to meet the need for potassium through the diet (prunes, dried apricots, apricots, peach, apricot, plum juice with pulp). Potassium chloride is usually poorly tolerated by patients; prescribed orally only in a 10% solution, 1 tbsp. l.

Author: Pavlova N.V.

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