Heart failure in children

In the literature and clinical practice, the notion of "circulatory insufficiency" is widely used, in fact it is a circulatory disturbance associated with two main factors:

• decreased myocardial contractility;
• weakening the tonic stress of peripheral vessels.

The weakening of the tonic tension of peripheral vessels is, by definition, vascular insufficiency. It is found isolated most often in practically healthy individuals with vegetative dystonia phenomena with reduced sympathetic support and relative predominance of parasympathetic influences, i.e. At asympathicotonia, as well as in individuals with a primary true prevalence of the parasympathetic influence of the vegetative section of the central nervous system. Of course, vascular insufficiency can be secondary and manifested in acute and chronic infections, endocrine pathology, chronic course of non-infectious diseases, including those with cardiovascular pathology.

Leading clinical signs of vascular insufficiency are paling, possible dizziness, in extreme situations - loss of consciousness (vaso-vagal syncope), as a result of lowering blood pressure with low peripheral vascular resistance. Vascular insufficiency is not accompanied by shortness of breath, tachycardia; never notice a liver enlargement, there are no peripheral edema and other signs of stagnant phenomena. The boundaries of relative cardiac dullness are not expanded, heart sounds can be more loud due to insufficient filling of the chambers of the heart. In the vascular form of circulatory failure, the contractile function of the heart is not impaired. In individuals with organic cardiac pathology, vascular insufficiency is a consequence of heart failure. The combination of vascular and cardiac forms of circulatory insufficiency is called cardiovascular insufficiency.

The very concept of heart failure can be defined as follows:

• a condition caused by violation of intracardiac and peripheral hemodynamics, associated with a decrease in the contractility of the myocardium;
• a condition caused by the inability of the heart to translate the venous influx into an adequate cardiac output.

Actually, the latter definition is the hemodynamic basis of the clinical signs of heart failure.

There are two forms of heart failure: acute and chronic. Acute heart failure occurs with myocardial infarction, acute failure of the mitral or aortic valve, rupture of the walls of the left ventricle. Acute congestive heart failure may complicate the course of chronic heart failure.

Since more often we are talking about chronic heart failure, we give one more definition: chronic heart failure is a syndrome that develops as a result of various diseases of the cardiovascular system, leading to a decrease in the pumping function of the heart (although not always), chronic hyperactivation of neurohormonal systems and manifested by dyspnoea , palpitation, increased fatigue, restriction of physical activity and excessive fluid retention in the body.

ICC codes 10

According to the ICD 10, heart failure is classified as grade IX: diseases of the circulatory system. Code 150: congestive heart failure - 150.0, left ventricular - 150.1.

Epidemiology of heart failure

The need to address this problem is dictated by the following reasons:

• poor prognosis of the syndrome;
• the risk of sudden death is 5 times greater than in the population;
• 5-year survival of patients with chronic heart failure is less than 50%;
• the number of patients with asymptomatic course (asymptomatic left ventricular dysfunction) significantly exceeds the number of patients with clinically significant chronic heart failure.

The presented positions concern the adult contingent of patients. Precise statistics on the number of patients, and even more children with chronic heart failure in Ukraine does not exist.

Causes of heart failure

In the age aspect, the etiological factors of heart failure may be the following:

• the period of the newborn: congenital heart defects, as a rule, at this age complex, combined and combined;
• Infant age:
  • Congenital heart defects, congenital myocarditis - early (fibroelastosis of the endocardium and myocardium) and late;
  • acquired valvular heart disease, at this age - as a consequence of infective endocarditis;
  • acute myocarditis.

Causes of heart failure

Pathogenesis of heart failure

In this work we are talking about chronic heart failure. This is due to the fact that, strictly speaking, acute heart failure without a previous long-term heart disease is not often met in clinical practice. An example of such a state may be, probably, acute myocarditis of rheumatic and non-rheumatic origin. More often, acute heart failure occurs as a complication of chronic, perhaps against a background of some intercurrent disease and is characterized by the rapid development and severity of certain symptoms of heart failure, thereby demonstrating decompensation.

In the early stages of impaired cardiac function or heart failure, peripheral circulation remains adequate to the needs of the tissues. This is facilitated by the connection of primary adaptation mechanisms already at early, preclinical stages of heart failure, when there are still no obvious complaints and only an attentive examination makes it possible to ascertain the presence of this syndrome.

Pathogenesis of heart failure

Classification of heart failure

Acute and chronic heart failure may be left ventricular and right ventricular, however, both ventricles often develop simultaneously, i.e. Total heart failure. Currently in our country two classifications are used in assessing heart failure in adults.

Classification of N.D. Strazhesko and V.Kh. Vasilenko assumes the following stages.

• I stage - latent heart failure, detected only with physical exertion.
• Stage II - marked prolonged heart failure (stagnation in a small and / or a large circle), the symptoms are expressed in rest:
  • II A - violations of hemodynamics are poorly expressed, in one of the divisions (in a large or small circle of circulation):
  • II B - deep violations of hemodynamics - the end of the long stage, the involvement of large and small circles of circulation:
• III stage, the final - dystrophic changes in organs with severe hemodynamic disorders, persistent changes in metabolism and irreversible changes in the structure of organs and tissues.

Classification of heart failure

Symptoms of heart failure

One of the earliest and most characteristic signs of left ventricular heart failure is shortness of breath. At first, shortness of breath occurs only with physical activity, fast walking, running, climbing stairs, etc. In the future, it also arises at rest, intensifying with a change in the position of the body, during conversation and eating. Shortness of breath, due to heart disease, increases in the horizontal position of the patient. Therefore, children with heart failure accept forced semisid position (orthopnea), in which they feel relief.

Right ventricular failure is also characterized by such subjective symptoms as fatigue, weakness, sleep disturbances, etc. Cough, dyspnea, cyanosis are usually expressed in varying degrees and often do not correspond to the severity of stagnant phenomena in the large circulation. They often depend on the nature of the underlying disease underlying the deficiency of the right divisions.

Symptoms of heart failure

Diagnostics

Diagnosis of left ventricular failure is also based on data from instrumental survey methods. So, the most informative in this respect are the ECG data: the size of the cavity of the left atrium, the left ventricle, the size of the ejection fraction. With left ventricular failure, these indicators can vary significantly. The pronounced enlargement of the left atrial cavity, as a rule, reflects a high degree of overload of the small circle of blood circulation and coincides with the clinical signs of pulmonary hypertension. The enlargement of the left atrium is in some cases more important than an increase in the left ventricular cavity.

When assessing the severity of heart failure, one should not forget about the general methods of physical examination, in particular about the characteristics of blood pressure. The indices of arterial pressure in heart failure may indicate the severity of the patient's condition. Thus, a decrease in cardiac output leads to a decrease in systolic pressure.

Diagnosis of heart failure

Treatment of heart failure

Treatment of heart failure is aimed at increasing the contractility of the myocardium, the elimination of stagnant phenomena (fluid retention), the normalization of the functions of internal organs and homeostasis. Of course, a prerequisite is the treatment of the underlying disease that caused heart failure.

General tactics and principles of treatment of chronic heart failure

The goals for the treatment of chronic heart failure are as follows:

• elimination of symptoms of the disease - shortness of breath, palpitation, increased fatigue, fluid retention in the body;
• protection of target organs (heart, kidneys, brain, blood vessels, musculature) from defeat:
• improving the quality of life;
• decrease in the number of hospitalizations:
• improved prognosis (prolongation of life).

Treatment of heart failure

Complications of heart failure

Complications can be associated at different stages of heart failure. As the degree of heart failure increases, complications occur more often and occur more severely. Some complications can become the direct cause of death.

True hyponatremia develops with prolonged use of diuretics against a background of a salt-free diet. In this case, the sodium content in the serum is less than 130 mmol / l. There is a painful thirst, a decrease in appetite, dryness in the mouth, vomiting, etc.

On the ECG, AB-conduction may be shortened, the end part of the ventricular complex may be changed.

Complications of heart failure

[1], [2], [3], [4]