Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association

Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association Focused Guidelines on Acute Heart Failure in Children

2026Version 2026 Focused UpdateCanada

This guideline holds 10 recommendations and 128 references.

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Summary

The 2026 Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association focused guidelines outline 10 key recommendations for pediatric acute heart failure. Key domains address diagnostics (recommending CMR for myocarditis, using natriuretic peptides for prognosis, and prioritizing whole exome sequencing over targeted panels) and therapeutic care (encouraging early diuretics, alternating GDMT, choosing milrinone as the preferred inotrope, avoiding routine pulmonary artery catheters, promoting timely VAD implantation, prioritizing temporary MCS over VA-ECMO, and advocating for early left heart decompression under VA-ECMO support).

Acute heart failure in children is a complex clinical syndrome with high morbidity and mortality. Because historical pediatric-specific data is limited and clinical presentation is highly heterogeneous, pediatric heart failure care has suffered from wide variations. These guidelines aim to provide updated, standardized, and evidence-informed recommendations to streamline and improve diagnostic and therapeutic workflows.

Key takeaways

Confirm pediatric myocarditis using Cardiac Magnetic Resonance (CMR) focusing on tissue characteristics like edema and myocardial injury.
Utilize tissue-based BNP/NT-proBNP within 12-24 hours of admission for baseline prognosis and risk stratification.
Prefer Whole Exome Sequencing (WES) over targeted cardiomyopathy panels as a first-tier genetic test, especially in infants.
Initiate early diuretic therapy (within 6 hours) rather than delayed treatment for congestion.
Implement alternating, simultaneous low-dose initiation of GDMT instead of sequential drug up-titration.
Select milrinone as the first-line inotrope over dobutamine or levosimendan.

Recommendations

Diagnostics

We suggest a cardiac magnetic resonance study be performed in children with suspected myocarditis in whom it is feasible and can be performed with acceptable risk to confirm the diagnosis, define the degree of myocardial injury and edema, aid in risk stratification, and inform management.
Population: Children with suspected myocarditisWhen: Suspected myocarditis
Conditional recommendationEvidence: very low certainty evidenceDiagnostic
We suggest the use of tissue-based natriuretic peptides (BNP or NT-proBNP) as a prognostic factor in the management of children with AHF.
Population: Children with AHFWhen: Acute Heart Failure (AHF)
Conditional recommendationEvidence: very low certainty evidenceDiagnostic
We suggest performing WES rather than a targeted cardiomyopathy panel in children with acute HF.
Population: Children with acute HFWhen: Acute Heart Failure (AHF)
Conditional recommendationEvidence: very low certainty evidenceDiagnostic

Therapeutics

We suggest the use of early (ie, within 6 hours of presentation) rather than late diuretic therapy (> 6 hours) for children with new-onset symptomatic HF.
Population: Children with new-onset symptomatic HFWhen: New-onset symptomatic heart failure
Conditional recommendationEvidence: low certainty evidenceTherapeutic
We suggest that alternating (ie, starting multiple HF medications relatively simultaneously at low doses), rather than sequential initiation (ie, starting one medication and completing the up-titration to target dosing before starting the next) of GDMT can be used in children with new onset HF.
Population: Children with new onset HFWhen: New onset heart failure
Conditional recommendationEvidence: low certainty evidenceTherapeutic
We suggest milrinone as the preferred inotrope over dobutamine or levosimendan for children with AHF.
Population: Children with AHFWhen: Acute Heart Failure (AHF)
Conditional recommendationEvidence: very low certainty evidenceTherapeutic

Monitoring

We suggest against the use of routine invasive monitoring with a PAC in children with AHF.
Population: Children with AHFWhen: Acute Heart Failure (AHF)
Conditional recommendation against the interventionEvidence: very low certainty evidenceMonitoring

Mechanical Circulatory Support

We recommend VAD implantation before the development of cardiogenic shock or in children with medically unresponsive acute HF (ie, INTERMACS/ PEDIMACS profile >= 2) rather than/over waiting until cardiogenic shock is established (ie, INTERMACS/ PEDIMACS profile 1).
Population: Children with medically unresponsive acute HFWhen: Acute Heart Failure (AHF)
Strong recommendationEvidence: very low certainty evidenceTherapeutic

Canadian Cardiovascular Society/Canadian Pediatric Cardiology Association Focused Guidelines on Acute Heart Failure in Children

Summary

Key takeaways

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What is new in this version

Recommendations

Diagnostics

Therapeutics

Monitoring

Mechanical Circulatory Support

Scope and population

How the evidence was graded

Safety

Definitions

For learning

Study materials

At a glance

Keywords

Summary

Key takeaways

Ask a question about this guideline.

What is new in this version

Recommendations

Diagnostics

Therapeutics

Monitoring

Mechanical Circulatory Support

Scope and population

How the evidence was graded

Safety

Definitions

For learning

Related guidelines

Study materials

At a glance

Keywords