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FAILURE
USA
AO
Aortic
Aortic closure
pressure
Ventricular
pressure
Cross- MO
over Atrial
pressure
M1 A2
Heart S4 T1 P2 S
sounds 3
Cardiologic
systole
a c
v
JVP
Opie (2001)
T P
P
ECG
Q S
0 800 msec
e iso
a b c d
iso
PULMONARY VENOUS
PRESSURE
Input
Filling Emptying
Stroke
ED volume x EFeffective = volume
LV Distensibility Contractility x
Relaxation Afterload Heart
Left atrium Preload
Mitral valve rate
Structure
Pericardium
Diastolic function Systolic function
Output
ED: end diastolic
EF: ejection fraction
CARDIAC OUTPUT
Decreased
Normal diastolic
diastolic chamber
Normal
chamber
Left Ventricular Pressure
A B
Increased Chamber
chamber stiffness dilation
C D
Left ventricular volume
CONTRACTILITY
PRELOAD AFTERLOAD
STROKE
VOLUME
CARDIAC OUTPUT
Frank-Starling Law
Normal
Cardiac O utput Compensated
Normal C.O.
LVEDP: Left
Ventricular
End diastolic
CHF Pressure
CHF:chronic
Heart failure
CO: cardiac
output
LVEDP
Ventricular Function Curve:
Frank-Starlings
Normal
SV
LVEDV Congestion
LVEDV: Left Ventricular End Diastolic Volume
SV: stroke volume
The Pathophysiology of Heart Failure
Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688
Pathophysiological Sequence of
CHF
Heart Failure
Systemic Vasoconstriction
Activation of
RAS and ANS
Hurst. The Heart. Diagnosis and Management of Heart Failure.10th ed. 688
Frank-Starling Effect
Ventricular dilatation
W all stress
Angiotensin II
Growth ALDO
factors
Vasoconstriction
Hypertrophy Fluid
Apoptosis accumulation
Collagen
deposition
SNS: sympathetic nervous system Myofibril
ALDO: aldosterone
necrosis
Sympathetic nervous system up-regulation
Increased
Norepinephrine levels
HR: heart rate; PVR: peripheral Cesario et.al; Reviews in cardiovascular medicine, vol 3, no.1, 2002
vascular resistance
Causes of Heart Failure
Contractility
Pump Performance
( ↑↑) Systolic Work Load ( ↑↑) SAS Drive
Vasoconstriction
RAAS SYSTEM
FLUID RETENTION
MI: myocardial infarction; SAS:
sympathetic autonomic system
Diagnosis of C H F
IDENTIFICATIONS OF HF PATIENTS
CHEST X-RAY
Urinalysis
TSH (thyroid stimulating hormone), C-RP, Uric Acid
ECHOCARDIOGRAPHY
The Preferred Methods
Helpful in Determining the Aetiology
Follow Up of Patients Heart Failure
PULMONARY FUNCTIONS
A Little Value in Diagnosis Heart Failure
Usefull in Excluding Respiratory Diseases
EXERCISE TESTING
NUCLEAR CARDIOLOGY
CMR
( CARDIAC MAGNETIC RESONANCE IMAGING)
Coronary Angiography :
in CAD’s (coronary artery disease) Patients
Haemodynamic Monitoring :
To Assess Diagnostic and Treatment of HF
Endomyocardial Biopsy :
in Patients with Unexplained HF
NATRIURETIC PEPTIDES
Tests Abnormal
Tests Abnormal
Pharmacological therapy
Angiotensin-converting enzyme (ACE) inhibitors
Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
Angiotensin receptor antagonists
Cardiac glycosides
Vasodilator agents (nitrates/hydralazine)
Positive inotropic agents
Anticoagulation
Antiarrhythmic agents
Oxygen
Normal
Asymptomatic
LV dysfunction
EF <40%
Symptomatic CHF
ACEI NYHA II Symptomatic CHF
Diuretics mild NYHA - III
Neurohormonal Symptomatic CHF
inhibitors Loop
NYHA - IV
Digoxin? Diuretics
Inotropes
Specialized therapy
Transplant
Secondary prevention
Modification of physical activity
Pharmacological therapy
Stages in the evolution of HF and recommended therapy by stage