Objective: Perturbed hemodynamic function complicates severe malaria. The FEAST trial demonstrated that fluid resuscitation, involving children with severe malaria, was associated with increased mortality, primarily due to cardiovascular collapse, suggesting that myocardial dysfunction may have a role. The aim of this study was to characterize cardiac function in children with severe malaria.
Design: A prospective observational study with clinical, laboratory and echocardiographic data collected at presentation (T0) and 24 hours (T1) in children with severe malaria. Cardiac Index (CI) and Ejection Fraction (EF) were calculated at T0 and T1. Cardiac Troponin I (cTnI) and Brain-Naturetic-Peptide (BNP) were measured at T0. We compared clinical and echocardiographic parameters in children with and without severe anemia [Hb < 5mg/dl] (SMA) at T0 and T1.
Setting: Mbale Regional Referral Hospital.
Patients: Children aged 3 months–12 years with severe falciparum malaria.
Interventions: usual care
Measurements and Main Results: We enrolled 104 children, median age 23.3 months, including 61 children with SMA. cTnI levels were elevated (>0.1ng/ml) in n=50, (48%); and median BNP was within normal range (69.1pg/ml, IQR 48.4-90.8). At T0, median CI was significantly higher in the SMA vs. non-SMA group (6.89 vs. 5.28 L/min/m2) (p=0.001), which normalized in both groups at T1 (5.60 vs 5.13 L/min/m2) (p=0.452). CI negatively correlated with hemoglobin, r = -0.380 (p<0.001). Four patients (3.8%) had evidence of depressed cardiac systolic function (EF <45%). Overall, 6 children died, none developed pulmonary oedema, biventricular failure or required diuretic treatment.
Conclusions: Elevation of CI, due to increased stroke volume, in severe malaria is a physiological response to circulatory compromise and correlates with anemia. Following whole blood transfusion and antimalarial therapy, CI in SMA returns to normal. The majority (>96%) of children with severe malaria have preserved myocardial systolic function. While there is evidence for myocardial injury (elevated cTnI), this does not correlate with cardiac dysfunction.