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Pathophysiology of Heart Failure

Definition Heart Failure


Clinical syndrome characterized by

Symptoms of breathelessness & fatigue

Signs of fluid retention

Supported by objective evidence of cardiac dysfunction


(systolic and/or diastolic)
Pathological condition heart unable to pump sufficient blood
to
meet metabolic demands of body
Cardiac output
Cardiac output = Heart rate x Stroke volume
Control of HR
Control of SV
Autonomic nervous system
Preload
Hormonal control
Afterload
Contractility
Preload
Stretching myocardial fibers during diastole
EDSV (End-diastolic volume)
Force of contraction during systole (Starlings law)

Venous return to heart determine EDSV

Stretching of actin-myosin bridges (development of force)

Force of contraction during systole = Stroke volume


Disorders
Too Preload
Too Preload
Length of sarcomere is more
Length of sarcomere is well
than optimal
below optimal
Strength of contraction
Strength of contraction
Afterload
Systolic wall tension developed by ventricles to open semilunar
valves
Eject blood against vascular resistance
Laplace wall
Cardiac contractility
Ability of actin & myosin (of heart muscle) to interact & shorten
against load
Contractility CO independent of preload filing & muscle
stretch
Mechanisms involved that contractility
( [Ca2+]i concentration - cross-bridges in sarcomere)
Catecholamines
Inotropic drugs
Disorders

Contractility
Shift entire ventricular
function curve upward & left

Contractility
Shift entire ventricular
function curve downward &
right
Ischemia
Hypoxia
Acidosis
Inflammation
Toxins
Metabolic disorders

Common causes of heart failure


Impaired cardiac function
Excess work demands
Myocardial disease
Pressure work

Cardiomyopathies

Systemic hypertension

Myocarditis

Pulmonary hypertension

Coronary insufficiency

Coarctation of aorta

MI
Volume work
Valvular heart disease

A-V shunt

Stenotic

Excessive IV infusion

Regurgitation
Perfusion work
Congenital heart disease

Thyrotoxicosis
Constrictive pericarditis

Anemia
Causes of HF in Adults
Most common
Coronary heart disease
Hypertension

Slightly common
Idiopathic dilated
cardiomyopathy
Valvular heart disease
Diabetic cardiomyopathy

Pathophysiology of Heart Failure


CO
Blood flow to kidneys & organs
Recruitment of compensatory mechanisms (maintain
tissue perfusion)
Heart Failure
CO
Organ perfusion
Maintain organ perfusion by (compensatory mechanism)

Frank-Starling mechanism

Sympathetic activity

RAA mechanism

Myocardial hypertrophy

Types of Heart Failure


Low output vs High output
Systolic vs Diastolic
Right vs Left vs Biventricular
Acute vs Chronic
High output/ Low output Failure
Output Failure
Output Failure
Uncommon
Disorders that impair heart
Caused by CO
pumping ability ( CO)
Unable to meet perfusion

IHD
requirem.

Cardiomyopathies
Chronic metabolic rate
(eg. thyrotoxicosis)
O2 carrying capacity of
blood
(eg. anaemia)
A-V shunting
(eg. A-V fistula)
Systolic/ Diastolic Dysfunction
Systolic
Diastolic
Defect in ventricular
Impaired ability in ventricular
contraction
filling
Left ventricles lose ability to
Filling
generate enough pressure to
Stroke volume
eject blood forward through
Congestive symptoms tend to
pressure aorta
predominate
( ejection fraction)
IHD
Mitral stenosis
Cardiomyopathy
Myocardial hypertrophy
Valvular regurgitation
IHD
Anaemia
Hypertension
Valvular stenosis
Most cases are mixed Systolic & Diastolic Dysfunction

Right/ Left Heart Failure


Right Heart Failure
Impair ability to move
deoxygenated blood (from
systemic circulation to
pulmonary circulation)
Accumulate blood in systemic
venous circulation
RA, RV ED Pressures
Systemic venous circulation
Results in

Peripheral edema

Hepatomegaly

Splenomegaly

Vascular congestion of
GIT

Jugular vein distention


Caused by (restrict blood to
lung)

Stenosis/ regurgitation of
tricuspid & pulmonic
valves

RV infarction

Cardiomyopathy

Persistent left-sided heart


failure
Cor pulmonale
(RV enlargement 2
pulmonary HPT)
Acute
Chronic
Massive
2
pulmonary
Obstructive
embolism
pulmonary
disease
Primary
pulmonary
hypertensio
n

Acute/ Chronic Heart Failure


Acute Heart Failure
Rapid onset of symptoms &
signs of heart failure
Acute deterioration cardiac
function

Left Heart Failure


Impair pumping of blood from
low-pressure pulmonary
circulation into high-pressure
systemic circulation
CO
LA, LV ED Pressures
Congestion in pulmonary
circulation
Fluid extravasation from
pulmonary capillary bed to
interstitium & alveoli
Results in

Tachycardia

Sweating

Gallop rhythm

Left parasternal lift

Moist crepitations

Pleural effusion
Caused by

Acute myocardial
infarction

Cardiomyopathy

Aortic/ aortic valve


disorders

Rapid infusion of IV fluids


in elderly with limited
cardiac reserve

Chronic Heart Failure


Chronic state stable
symptoms
Acute aggravating factor(s)
may cause acute cardiac
decompensation

Clinical Manifestations Heart Failure


Congestive Heart Failure heart failure & congestion of body
tissues

Fluid Retention & Edema

Respiratory Manifestations
SOB caused by congestion of pulmonary circulation (left-sided
HF)
Dyspnea

Perceived shortness of breath (SOB)


Orthopnea

SOB occurs when in supine


Paroxysmal nocturnal dyspnea

Sudden attack of dyspnea during sleep

Disrupts sleep & awakens with feeling of extreme


suffocation

Resolves when sits up

Chronic dry, non-productive cough

Worsen on lying down


Wheezing & difficulty in breathing (cardiac asthma)

Due to bronchospasm

Caused by congestion of bronchial mucosa


Cheyne-stokes breathing (periodic breathing)

Slow waxing & waning of respiration

Deep breathing when PaCO2

Slight or not at all when PaCO2 falls


Cardiac Fatigue
Diminished CO
Usually does not present in the morning
Appears usually as activity increases during the day
Acute/ severe heart failure (or in elderly with advanced HF)

CO (insufficient for brain perfusion)

Mental confusion

Memory impairment

Anxiety
Restlessness
Insomnia

Cardiac Cachexia
Malnutrition & tissue wasting
End-stage heart failure
Contributing factors

Fatigue & depression interfere with food intake

Liver & GIT congestion impair digestion & absorption

Circulating toxins produce by poorly perfused tissues


impairs appetite
Cyanosis
Bluish discoloration skin, mucous membranes
Hb in blood
Late sign of heart failure
Cyanosis
Central
Peripheral
Impair oxygenation of blood
Low-output failure
Due to
Due to

Heart failure

Delivery of poorly

Lung diseases
oxygenated blood to

Right-to-left shunts
peripheral tissues

Peripheral
vasoconstriction
Complications of Heart Failure
Cardiac arrhythmias (eg. atrial fibrillation, ventricular
arrhythmias)
Pulmonary embolism (due to DVT)
Mural thrombosis (in dilated heart chambers)
Chest infection (due to chronic pulmonary congestion)
Major organ failure (MOF) (eg. renal impairment, cardiac
cirrhosis)
Diagnosis of Heart Failure
Signs & Symptoms
Basic investigations

ECG

CXR

Blood Test
Other important investigations

Echocardiogram

Natriuretic peptides or their precursors


New York Heart Association (Functional classification)
Heart Disease
Classification
Characteristics
Class I
No limitation of physical activity
Class II
Slight limitation Fatigue, Dyspnea,
Palpitation
Class III
Marked limitation Comfortable at rest
Ordinary activities cause symptoms
Class IV
Inability to carry out any physical activity
without symptoms
Pain/ discomfort at rest
Natriuretic Peptides

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