Pediatric Dilated Cardiomyopathy Medication

Updated: Jan 25, 2019
  • Author: Poothirikovil Venugopalan, MBBS, MD, FRCPCH; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Medication

Medication Summary

Medical therapy in dilated cardiomyopathy (DCM) includes diuretics, angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers. Antibiotics for endocarditis prophylaxis are administered to patients with certain cardiac conditions, such as DCM, before performing procedures that may cause bacteremia. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.

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Diuretics

Class Summary

These agents are used to eliminate retained fluid and preload reduction.

Furosemide (Lasix)

Furosemide is the drug of choice for diuresis in acute heart failure and in exacerbations of chronic heart failure. It is also used for long-term management of chronic heart failure.

Furosemide inhibits reabsorption of fluid from the ascending loop of Henle in the renal tubule. When administered intravenously, it produces venodilation and lowers preload even before diuresis sets in.

Spironolactone (Aldactone)

Spironolactone is a potassium-sparing diuretic that acts on the distal convoluted tubule of the kidney as an aldosterone antagonist. It exhibits synergistic action with furosemide.

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Angiotensin-Converting Enzyme Inhibitors

Class Summary

These drugs reduce afterload and decrease myocardial remodeling that worsens chronic heart failure.

Captopril

Captopril is accepted as an essential part of any therapy against heart failure, providing symptomatic improvement and prolonged survival. Captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Enalapril (Vasotec)

This agent is an ACE inhibitor with prolonged duration of action with oral administration. A competitive inhibitor of ACE, it reduces angiotensin II levels, decreasing aldosterone secretion.

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Cardiac Glycosides

Class Summary

These drugs provide improvement of symptoms with chronic administration. The role of cardiac glycosides is less clear than in the past.

Digoxin (Lanoxin)

Digoxin improves myocardial contractility, reduces heart rate, and lowers sympathetic stimulation in chronic heart failure. It inhibits the Na+-K+ ATPase pump. Sodium preferentially exchanges with calcium, increasing the intracellular calcium and resulting in an increase in contractility.

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Anticoagulants

Class Summary

These agents are administered to prevent recurrence of thromboembolic episodes of cardiac origin.

Warfarin (Coumadin, Jantoven)

Warfarin interferes with hepatic synthesis of vitamin K–dependent coagulation factors. It prevents thrombus formation within cardiac chambers and the venous circulation. Tailor the dose to maintain an International Normalized Ratio (INR) of 2-3.

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Beta-Adrenergic Blocking Agents

Class Summary

These agents block the beta-adrenergic receptor and are modulators of the autonomic system.

Propranolol (Inderal LA, Inderal XL)

Propranolol is a nonselective beta-adrenergic antagonist (ie, it inhibits both beta1- and beta2-adrenergic receptors).

Carvedilol (Coreg)

Carvedilol is a nonselective beta-blocker with additional direct vasodilator action.

Metoprolol (Lopressor, Toprol XL)

Metoprolol is a selective beta-1 adrenergic receptor blocker that decreases automaticity of contractions.

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Adrenergic Agonist Agents

Class Summary

These agents are used in resistant cases as intravenous infusions and stimulate beta1-adrenergic receptors in the myocardium. They are also useful for periodic home inotropic therapy in end-stage disease, in which cardiac transplant is not feasible, to improve the quality of life. However, studies have shown increased mortality related to arrhythmogenic potential.

Dobutamine

Dobutamine is a synthetic catecholamine with potent cardiac-stimulating properties; in addition, it has direct vasodilating action on peripheral blood vessels. Infusion with or without additional dopamine in renal dose would be appropriate therapy for cardiogenic shock secondary to dilated cardiomyopathy.

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Phosphodiesterase Enzyme Inhibitors

Class Summary

These agents elicit positive inotropic and vasodilatory effects.

Milrinone

Milrinone is a bipyridine with positive inotrope and vasodilator activity. Little chronotropic activity is observed. This agent differs in its mode of action from both digitalis glycosides and catecholamines. It selectively inhibits phosphodiesterase type III (PDE III) in cardiac and smooth vascular muscle, resulting in reduced afterload, reduced preload, and increased inotropy.

Milrinone is not approved by the US Food and Drug Administration (FDA) for use in pediatric patients. Nevertheless, it is often considered the drug of choice in pediatric patients in the intensive care unit setting.

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