Burden, clinical characteristics, management, and outcomes of pediatric acute heart failure in emergency and acute-care settings in low- and middle-income countries: a scoping review

Abstract

Pediatric acute heart failure (AHF) is associated with substantial morbidity and mortality, but its clinical presentation, management, and outcomes in low- and middle-income countries (LMICs) remain poorly characterized. This scoping review mapped the available evidence on pediatric AHF in emergency and acute-care settings in LMICs. Following Joanna Briggs Institute guidance and the PRISMA extension for scoping reviews, PubMed/MEDLINE, Global Index Medicus, and the Cochrane Library were searched from inception through June 2026. AHF was defined as new or worsening heart failure requiring unplanned acute hospital care, including acute decompensation of chronic heart failure. Primary studies reporting AHF or acute decompensated heart failure among neonates, infants, children, and adolescents receiving unplanned acute hospital care in LMICs were eligible. Data were charted across burden, clinical characteristics, etiology, diagnosis and triage, acute management, outcomes, and health-system and equity domains and results were synthesized narratively. Of 1,124 records identified, 33 studies from 16 LMICs were included​. Most were single-center observational studies; the median sample size was 42 children, and 18 studies enrolled fewer than 50 participants. Infants and preschool-aged children predominated, except in rheumatic disease cohorts. Presentations were typically severe and congestion-dominated, with respiratory distress and hepatomegaly frequently reported; 71%–94% of children were in modified Ross or New York Heart Association class III–IV where severity was graded. In unselected emergency and general pediatric populations, infection and severe anemia commonly precipitated AHF, whereas congenital heart disease, cardiomyopathy, myocarditis, and rheumatic disease predominated in cardiology and intensive-care cohorts. Region-specific, potentially reversible causes included cardiac beriberi and epidemic dropsy. Where AHF was ascertained in unselected p​ediatric admissions, it accounted for 4.0%–10.8% of admissions; PICU and disease-specific estimates are reported separately. All-cause in-hospital mortality ranged from 3.2% to 39.7%, with disease-specific cohorts reporting lower case fatality. Late presentation independently predicted mortality in one two-center study. Diagnosis frequently depended on clinical criteria and basic investigations, while access to echocardiography, specialist care, cardiac surgery, and mechanical circulatory support varied markedly. Health-system exposures were formally evaluated in only three studies. Available evidence depicts pediatric AHF in LMIC acute-care settings as a severe condition that presents late, predominantly affecting​ young children, and is often precipitated by conditions that are preventable or treatable. There is an urgent need for prospective multicenter studies at the initial point of contact, utilizing standardized definitions, minimum datasets, and within specified outcome periods.