MEDICAMENTOS USADOS NO TTO DA INSUF. CARDÍACA

Table 1: Standard pharmacotherapy of chronic compensated heart failure in children

Standard dose
Mechanism of action
Comments
Diuretics

Relieve congestive symptoms; Do not change the long-term outcome
Excess use of diuretics can reduce the preload and cardiac output, resulting in neurohormonal activation and fluid retention- a vicious cycle
1. Furosemide
1 mg/kg dose BID up to max 6 mg/kg/day

2. Chlorothiazide
10 mg/kg dose BID up to max 2 gm/day
3. Metolazone
0.1 mg/kg dose BID up to max 20 mg/day
Digoxin
3 to 4 mcg/kg dose BID
Increases inotropy; Attenuates neurohormonal activation; No effect on mortality
No relationship between serum digoxin level and worsening heart failure, change in left ventricle ejection fraction and exercise tolerance in adults
Angiotensin converting enzyme inhibitors

Decrease mortality and morbidity; Blocks the conversion of angiotensin I to II and activates bradykinin and kallidin; Cause vasodilation and natriuresis; Reduce afterload >
Mitigate the process of angiotensin-mediated maladaptation to heart failure; Decrease Qp:Qs and improve weight gain in children with left to right shunts
1. Captopril
0.1 mg/kg dose TID up to max 2 mg/kg/dose

2. Enalapril
0.1 mg/kg dose BID up to max 0.5 mg/kg/day
Beta-blockers

Decrease morbidity and mortality; Carvedilol has vasodilatory, antioxidant, antiproliferative and anti apoptotic properties, Reversing cardiac remodeling
Dosing is extrapolated from adult data, extreme caution should be used because there could be exacerbation of heart failure
1. Metoprolol
0.1 mg/kg dose BID up to max 1 mg/kg dose

2. Carvedilol
0.05 mg/kg/dose BID up to max 0.4 mg/kg/dose
Aldosterone antagonist Spironolactone
1 mg/kg dose BID up to max 200 mg/day
Decreases mortality and morbidity; Improves endothelial vasodilator dysfunction; Suppress vascular angiotensin conversion.
Should be used with caution in patients with hyponatremia, renal insufficiency, hyperkalemia and hepatic disease
(BID=twice daily, TID= three times daily, max=maximum, Qp: Qs=pulmonary to systemic blood flow ratio, LVEDP=left ventricular end- diastolic pressure, mg/kg = milligram per kilogram)