Management of heart failure in children

B dvances in our understanding of the pathophysiology and molecular basis of diseases offer new, challenging, controversial, and sometimes, counterintuitive forms of therapy. This is especially true with regard to the syndrome of heart failure. Therapeutic approaches to heart failure in adults have evolved rapidly during the past decade. Unfortunately, as with many other aspects of medicine, our concepts of heart failure in the pediatric population have been reduced to a simple extrapolation of the adult model. Pediatricians know that a child is not a small adult. Consequently, heart failure is perhaps a far more complex entity in the pediatric population with regard to pathophysiology and the possible courses of action. In this review we summarize recent advances in heart failure research in adults and attempt to integrate these findings in a pediatric context. The basic paradigm of hemodynamic derangement and the consequent symptoms have dominated our approach to congestive heart failure for most of this century (Fig 1). Despite constraint by this narrow viewpoint, the normalization of hemodynamics has an immediate positive effect on symptomatic improvement. Multiple clinical trials were conducted in the adult population with a variety of pharmacologic strategies aimed at enhancing systolic performance only. The clinical outcome of these trials was disappointing because of adverse effects on the heart in the long term, since the initial improvement in the standard measures of heart failure severity (such as exercise tolerance, symptoms, and hemodynamics) was not sustained. 1,2 Application of information available from recent heart failure research enables us to go beyond the concept of the heart as a simple pump and formulate a more comprehensive understanding of the syndrome of heart failure (Fig 2). We are now beginning to recognize the