Page 6 - Heart Failure Clinical Guidelines

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3. Echo q3 months
4. CBC, CMP, BNP q 3 months
5. EKG q6 months
6. Holter/Event Monitor q1 year
7. Exercise with Metabolic q 1-2 years

D. Nutrition
A. Malnutrition, Poor Growth
1. weight, head Circumference (age 3yo and less) and length/height will be documented
at each visit
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2. <3 percentile for weight for age and length/height for age, unintended weight loss,
or decrease in z-score of length/height or weight of >1.5 will be referred to dietician for
further evaluation and management
3. treatment of poor growth should concentrate on increased caloric intake and
treatment of GI symptoms that may decrease caloric intake (reflux, delayed gastric
emptying, etc.)

B. Metabolic Syndrome
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1. for patients with BMI >97 percentile for then triglycerides, lipid panel, HbA1C should
be ordered
2. referral to dietician for education/intervention should occur
3. exercise test performed to determine safety of exercise intervention
4. referral to weight loss program

C. Fluid and Salt Restriction
There are multiple studies indicating that fluid and salt restriction improve congestive
symptoms in adult patients. However, the long-term impact on HF outcomes is not yet
studied. There are no studies on fluid restriction in pediatric heart failure. Given that
poor growth and cardiac cachexia are seen often in pediatric heart failure, fluid
restriction may run counter to the need for increased caloric intake. Therefore, a fluid
restriction of approximately 2L or 2gm of salt can be cautiously considered for
adolescent heart failure patients who have congestive symptoms that are not
responsive to aggressive diuretics and will not interfere with delivering proper nutrition.

E. Exercise

1. All patients undergo an exercise test prior to involvement in exercise training and/or competitive
sports to assess blood pressure response, assess risk for adverse events and determine suitability for
exercise training

A. Competitive Sports
The following exercise/activity guidelines are adapted from the AHA/ACC scientific statement on
Competitive Athletes With Cardiovascular Abnormalities
1. Hypertrophic Cardiomyopathy
a. patients with genotype positive HCM without symptoms, LVH on echocardiogram or CMR or
family history of HCM related sudden death may participate in sports
b. patients with probable or unequivocal clinical expression of HCM should not partipate in
competitive sports