Pediatric heart failure: A focus on low-income countries

Table 1 Factors leading to disparity in congenital heart diseases management between high- and low-income countries

High income countries	Middle/Low income countries[2,4,6]
Prenatal factors
Lower birth rate and less consanguinity	High birth rate and more consanguinity
Preconception folic acid	No routine folic acid supplements
Antenatal diagnosis (echocardiography)	Sparsity of antenatal echo
Immediate postnatal factors
Hospital delivery and postnatal examination	Home deliveries are common
Neonatal pulse oximetry screening	No neonatal pulse oximeter screening due to early discharge
Well baby clinic
School screening	Late diagnosis
Access to medical and interventional treatment
Timely access to interventions (cardiac catheterization and surgery)	Poor access to prostaglandins
Availability of technical settings and personnel for high-risk interventions	Poor access to timely interventions
Medical insurance coverage	Few neonatal interventions
	The majority of patients/procedures are not covered by insurance
Follow up
Access to timely follow up	Poor follow up rate
Access to medical and interventional treatment	Poor access to and compliance with medications
The burden of RHD
Low prevalence of rheumatic heart disease	High prevalence of RHD

RHD: Rheumatic heart disease.

Table 2 Medications used for pediatric heart failure

Drug/group	Evidence for pediatric HF	Recommendation
Renin-angiotensin-aldosterone system	PANORAMA study[50] did not show advantage of sacubitril/valsartan over ACEI	Angiotensin converting enzyme inhibitors are used routinely
Inhibitors: Captopril, enalapril, lisinopril and sacubitril/valsartan	A study involving 23 patients showed improvement of EF and LV dimensions with a low dose[51]	The United States Food and Drug Administration has approved sacubitril/valsartan pediatric HF > 1 year of age
β-blockers	There is not enough evidence to support or discourage the use[52]	May be used with close observation
Carvedilol
Mineralocorticoid receptor antagonists (spironolactone)	Evidence mainly derived from adult studies[53]	Used in HF
Digoxin	Evidence mainly derived from adult studies	Used as 3rd or 4th line in CHF
		Used in tachyarrhythmias
Diuretics	Evidence mainly derived from adult studies[54]	Loop diuretics are used for fluid overload
Furosemide		Addition of other diuretics enhances loop diuretic effect
Spironolactone
Thiazides
Metolazone
Sodium-glucose cotransporter-2 inhibitors	Use in children was found to be safe and well tolerated in a meta-analysis[55]	Awaiting more studies to be approved
Ivabradine	Evidence of improvement in HF[56]	Can be used in children

HF: Heart failure; ACEI: Angiotensin converting enzyme inhibitors; EF: Ejection fraction; LV: Left ventricle; CHF: Congestive heart failure.