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Why is heart failure in pediatric age group imperative. Although heart failure is more usual in elderly people and it is increasing in prevalence and incidence in adult population1, however, it is one of the common causes of childhood mortality and morbidity in developing countries2. Pediatric heart failure is also economic and social burden, because when a child takes admission in hospital for heart failure, the economic costs are comparatively higher than adult as it requires repeated need for surgical based intervention. The stipulated medical care can scrimmage the family structure and negatively affect parental economic productivity. If a child dies of heart failure, the economic cost is enormous for the number of potential productive year loss per death. Therefore, heart failure in pediatric age group is a solemn public health concern.
The most common cause of heart disease among children is congenital heart disease. Although, there has been an raising awareness regarding the necessity of early referral of newborn with heart failure to special centers and advancement of technology and training in pediatric cardiology and pediatrics in developed countries, conversely, in Bangladesh there is still lack of awareness regarding pediatric heart failure make the detection of congenital heart disease difficult. Incidence of heart failure due to Rheumatic heart disease is gradually reducing due to appropriate cases management and preventive major against Rheumatic fever5 in industrialized nations; however, it is extensively prevalent in developing countries including Bangladesh.
Heart failure has many etiologies. In evaluating patients with heart failure it is important to identify not only the underlying but also the precipitating causes. A systemic search for the precipitating causes should be made in every patient which will reduce the mortality and morbidity of heart failure1.
The purpose of the study was to identify the risk factors regarding underlying and precipitating causes of heart failure, to find out the relationship between underlying and precipitating cause and finally to observe the prognosis of the hospitalized children. It may help to find out better preventive procedures and therefore give the affected children and their parents hope of a better life.
MATERIALS AND METHODS
This study is a prospective?? or case series study was carried out over a period of nine months among the admitted children in the Department of Paediatric and Cardiology department of BSMMU and National Institute of Cardio Vascular Disease (NICVD), located in Dhaka. A total 60 patients were included in this study age ranging from newborn to 15 years with heart failure. After admission, detailed history of the sixty patients was captured for knowing their clinical presentation. physical examination, investigations including X-chest ,ECG, echocardiography and blood gas were also done and daily follow up was given during hospitalization and their outcome were recorded.
After checking, data were analyzed using the Statistical Package for Social Science (SPSS) for windows version 11.5. Potential prognostic variables were tested for association with the outcome.
The total number of patients suffering from Congenital heart disease was 30 which is (50%) followed by Rheumatic heart disease (33.3%), dilated cardiomyopaty (5%), AGN (8.3%) and anaemia (3.3%) (table, 1). Out of 30 patient with congenital heart disease, majority (25%) were under 1 year of age group followed by (16.7%) patients were 2 years of age group and (8.3%) patients were found between 3-5 years age group(table, 2). On the other hand, out of 20 patients with rheumatic heart disease, majority (25%) were in 11-15 years age group followed by (8.3%) patients were in 6-10 year of age group. No patient was found below the age of 6 years (table, 3).
The commonest form of congenital heart disease was VSD (30%) followed by ASD (8.3%) and PDA (8.3%). 3.3% of cases had both VSD & ASD. (table, 4). Among the rheumatic heart diseases, rheumatic valvular heart disease was (21.7%), rheumatic fever with carditis was (1.6%) and (10%) of patient had both the problem(table, 5).
Major clinical presentations were dysponea (100%), fatigue (93.3%), cough (81.7%), growth failure (58.3%) and repeated chest infection (43.3%), Tachycardia (95%), tachypnoea (93.4%), cardiomegally (93.4%), basal crepetation (76.7%), hepatomegally (98.4%), oedema (61.7%). Among them, hepatomegally was the most common signs of heart failure in this study (table, 6). Precipitating factors in heart failure were non compliance to preventive treatment of rheumatic heart disease (35%), malnutrition (58.9%), respiratory tract infection (26.7%) and septicaemia (20%) and in (15%) of cases no precipitating factors was identified (table,7).
The socioeconomic conditions of the patients were divided arbitrarily into three classes: poor, middle and rich according to family income per month. Monthly family income of less than Tk. 3000 was taken as poor, Tk 3000-6000 as middle and above Tk. 6000 as rich. Most of the patients (65%) were in poor, (26.7%) were in middle and least (8.3%) were in rich group. (table,8). Nutritional status of the patient was done by anthopometric measurement. In this study (58.3%) of patients were wasted.
The commonest from of valvular disease was mitral regurgitation (23.3%) (table, 9).
In this study, the most common radiological findings of heart was cardiomegally (91.7%) followed by enlarged left ventricle (58.3%), enlarged left atrium (55%). However the most common radiological findings of the lung was prominent vascular marking (46.7%) then pulmonary venous congestion (30%), interstitial oedema (25%) and consolidation of lung (16.7%). (table 10 and table 11). The Common ECG findings were sinus tachycardia (76.7%), normal axis (63.3%), and left ventricular hypertrophy (60%) (table 12).
Out of 60 cases, 10 patients had low blood pH, 12 had low bicarbonate and 12 had low carbondioxide.
In this series, (13.3%) patients were fully recovered, (71.7%) had clinical improvement and (1%) succumbed. Here full recovery means complete cure, clinical improvement means signs symptoms of the heart failure has subsided but underlying diseases were present and complications were cardiogenic shock, septicemic shock and metabolic acidosis (table 14). On the other hand, (10%) patients died during the study period. (table ,15)
Case fatality was equal in both sexes. 3 (5%) patient died in 2 year of age group and 2 (2.5%) patient in 3 years of age group and 1 (1.7%) patient in 11-15 years of age group.
Congenital heart disease by age and sex (n=60)
Aetiological pattern of heart failure (n=60)
Rheumatic heart disease
Rheumatic heart disease by age and sex (n=60)
Age group (year)
Types of congenital heart disease (n=60)
Congenital heart disease
Ventricular septal defect (VSD)
Atrial septal defect (ASD)
Both VSD & ASD
Patent ductus arteriosus (PDA)
Types of Rheumatic heart disease (n=60)
Rheumatic fever with carditis
Rheumatic valvular heart disease
Socio economic status of the patient (n=60)
Symptoms and signs of heart failure
Repeated chest infection
X-ray findings: Cardiac Shadows (n=60)
Normal cardiac shadow
Enlarged right atrium
Enlarged right ventricle
Enlarged left atrium
Enlarged left ventricle
Prominent aortic knob
Full pulmonary conus
Pattern of valvular diseases (n=60)
Types of valvular disease
Mitral regurgitation (MR)
Aortic regurgitation (AR)
Mitral stenosis (MS)
Both MR & AR
Both MR & MS
X-Ray findings: Lung Shadows (n=60)
Consolidation of right lung
Consolidation of left lung
Prominent vascular marking
Pulmonary venous congestion
Non specific finding
Increase interstitial markings
Pneumatocele of both lung
ECG findings (n=60)
Normal sinus rythum
Right bundle branch block
Prolonged PR interval
Right axis deviation
Left ventricular hypertrophy
Right ventricular hypertrophy
Right atrial hypertrophy
Left atrial hypertrophy
Low voltage ECG
Tall T wave
Diagnosis of death cases (n=6)
Outcome of heart failure (n=60)
Discharge on risk bond (DORB)
Arterial blood gas analysis of death cases (n=6)
Heart failure is common clinical syndrome and in its advanced stages have a grave prognosis. In this study 60 patient of heart failure admitted in paediatric department and cardiology department of BSMMU hospital and NICVD were included to find out risk factors and prognosis of heart failure. Among them (50%) belonged to congenital heart disease, rheumatic heart disease was2 (33.3%), cardiomyopathy was (5%) and (11.6%) were non cardiac causes. This finding is consistent with the findings of Herz21. This signifies that heart failure is more common in both congenital and acquired heart diseases.
The patients were included below the age of 15 years. (26.6%) patients were below 1 year, (26.6%) were between 11-15 years, (18.3%) were in 2 years age group and (63.3%) patients were in 0-5 yearââ‚¬â„¢s age group. This correlate with Smith22 study, where he showed that (87%) of heart failure was 0-5 yearââ‚¬â„¢s age group in same study (48.8%) were between 6-10 years and( 42.3%) were between 11-20 years age group. In this study, (51.6%) were male affected compare to (48.3%) were female. Male preponderance was shown by Smith22. Analyses of socioeconomic status of the patient of this study showed majority were from lower socioeconomic class (65%) which is similar to the findings from other developing countries24.
In this study, the risk factors of malnutrition, down syndrome, respiratory tract infection, septicaemia and cardiogenic shock were identified. Non compliance to drug was found to be an important precipitating factor in our study which is common in many studies25, 26.
In this study congenital heart disease was found to be the most common cause of heart failure in early years of life. The rheumatic heart disease is the second most common cause of heart failure in adolescent age group29, 31, and 23. In present study there was no sex differentiation was observed. Sex distribution of rheumatic heart disease tends to differ widely among different study. The insignificant difference in the prevalence of rheumatic heart disease by sex was reported in India23. Epidemiological studies by Khalil in Saudi Arabia and Sudan have reported higher rates of rheumatic heart disease among females32.
The most common valvular lesion in this study is mitral regurgitation. Regarding the pattern of valve involvement in present study of chronic rheumatic heart disease, mitral valve was one the top of the list 88%, aortic valve was the second in order. Shumpei et al. showed mitral valve involvement in 80%, aortice valve in 12% of cases33. This pattern of valve involvement also coincides with various studies from India34,35,36.
It is a heterogeneous group of myocardial disease characterized by cardiac dilation and impaired myocardial contractility37. Among 60 patients, 3 (5%) cases were diagnosed as dilated cardiomyopathhy (DCM) belonging to age group of 13-15 years. Among them 2 were male and 1 were female, 1 of them died due to cardiogenic shock.
Clinical features are the main tool to diagnosis of heart failure. Presentation were usual specific in this study the most common symptoms of heart failure were dyspnoea, cough of cases, history of repeated chest infections were common in younger age group who had congenital heart defect. Palpitation fatigue and chest pain were observed in older children.
During the study period (10%) patients died. Among them (8.3%) cases heart failure was due to congenital heart disease, (1.7%) patient had dilated cariomyopathy. Among 5 of congenital heart disease, 2 patient had Down syndrome, malnutrition and septacemia, 2 patient had malnutrition and septicaemia and 1 patient had bronchopneumonia. Dilated cardiomyopathy was associated with cardiogenic shock.
(13.3%) patients were completely recovered in this study. (71.1%) were clinically improved but they need surgical intervention for their complete recovery. 10 patients developed complications during this study period. Complications were cardiogenic shock, septic shock, arrhythmia, electrolyte imbalance with acidosis and they were referred to coronary care unit for specialized care. 1 patient left hospital by giving risk bond (DORB) during our study.
Congenital heart disease and rheumatic valvular heart diseases are curable by surgery. Rheumatic heart disease is preventable. Cheap and effortable treatment should be available for such patients. Proper public health interventions are needed to raise awareness about preventive and curative treatment of different types of heart diseases.