Current management of acute HF are focus in improvement of hemodynamics and prevent deterioration and includes stabilization with intravenous inotropes/vasopressors, mechanical ventilation, treatment of arrhythmia, and progression to mechanical support, if needed. The goal in chronic HF is prevent progression, and provide a reasonable clinical status of the children to allow somatic growth and optimal development. Treatment in HF is based in avoiding the mechanisms neurohormonals.

Drug trials in pediatric cardiomyopathy are challenging because of limitations in power because of small sample size, lack of validated end points, and incomplete pharmacokinetic /pharmacodynamic data. Despite the lack of sufficient randomized prospective studies, angiotensin-converting enzyme antagonists inhibitors (ACEi) are the first-line therapy and beta-blockers are second-line in children. Beta-blockers have to start when patient has been stabilized, never in acute HF episode, carvedilol is the first choice, starting with a low dose and titrating every 2 weeks to check tolerance, in case of arrhythmias, metoprolol is better option. Mineralocorticoids are accepted at the beginning of the episodes while diuretics should be used to achieve a euvolemic status.

Digoxin has been studied extensively in adults with congestive HF, in whom there is some evidence of acute hemodynamic benefit in chronic congestive, decreasing the rate of hospitalization and improved quality of life, but not survival. Despite the lack of data regarding its use in children, digoxin continues to be used by most clinicians in the management of pediatric heart failure due to low cost, and continued confidence in the usefulness of the drug based on long years of experience.

The common drugs used in pediatric HF (except anti-arrhythmics treatment) and mechanism of actions are summarized in this Table: