C hronic h eart f ailure
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C HRONIC H EART F AILURE. Pathophysiology. Toni M. Aprami Department of Cardiology and Vascular Medicine Cardiovascular Subdivision, Department of Internal Medicine Hasan Sadikin Hospital/Medical School, Padjadjaran University. Pulmonary veins. Definition : Heart Failure .

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C hronic h eart f ailure

CHRONIC HEART FAILURE

Pathophysiology

Toni M. Aprami

Department of Cardiology and Vascular Medicine

Cardiovascular Subdivision, Department of Internal Medicine

HasanSadikin Hospital/Medical School, Padjadjaran University


C hronic h eart f ailure

Pulmonary

veins


Definition heart failure

Definition : Heart Failure

“The situation when the heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and the venous return.“ Braunwald’s Heart Disease, 8th Ed, 2008

“Pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues.”

Euro Heart J; 2001. 22: 1527-1560


Causes of heart failure

CAUSES OF HEART FAILURE

*Indicates conditions that can also lead to HF with a preserved ejection fraction


C hronic h eart f ailure

Block diagram of left ventricular pump performance

PULMONARY VENOUS

PRESSURE

Input

Filling

Emptying

ED volume

x

EFeffective

=

Stroke

volume

LV Distensibility

Relaxation

Left atrium

Mitral valve

Pericardium

Contractility

Afterload

Preload

Structure

x

Heart

rate

Diastolic function Systolic function

Output

(Little, 2001)

CARDIAC OUTPUT


C hronic h eart f ailure

Aorta

Lung

Left atrium

Pulmonal vein

SVC

Pump

Container

Pulmonal artery

Right Atrium

Systemic Vascular Resistance

(SVR)

Left ventricle

Right ventricle

IVC

organ

Volume (blood within

circulatory system)


C hronic h eart f ailure

- Synergistic LV contraction - LV wall integrity - Valvular competence

DETERMINANTS OF VENTRICULAR FUNCTION

CONTRACTILITY

PRELOAD

AFTERLOAD

STROKEVOLUME

HEART RATE

Determinants of heart rate:

-balance of parasympathetic and sympathetic tone

-sinus node function

-presence of an ectopic focus

-conduction system

CARDIAC OUTPUT


Compensatory mechanism

COMPENSATORY MECHANISM

Frank - Starling mechanism

Neurohormonal stimulation

Myocardial hypertrophy with or without chamber dilatation


C hronic h eart f ailure

Myocardial Failure or Valvular Insufficiency

Reduced cardiac output

Decreased tissue perfusion

Reduced blood pressure

Activation of compensatory mechanisms:

-Sympathetic Nervous System (SNS)

-Frank-Starling Mechanism

-Renin-Angiotensin-System (RAS)

-Aldosterone

-Ventricular hypertrophy

-others… (anti-diuretic hormone, atrialnatriuretic factor)

An effort to normalize tissue perfusion and blood pressure


C hronic h eart f ailure

Myocardial Failure or Valvular Insufficiency

Activates Compensatory Mechanisms

SNS

Anti-diuretic Hormone

RAS

Aldosterone

Angiotensin II

Vasoconstriction

Sodium and water retention

Increased Venous Return

and Increased Blood Pressure

Heart Rate

F-S Mech.

Contractility

Augmentation of cardiac performance


C hronic h eart f ailure

CONCENTRIC HYPERTROPHY

PRESSURE

OVERLOAD

Thickened Ventricular Walls

Altered ventricular geometry

Myocardial

Failure

Valvular Insufficiency

Ischemia and Fibrosis

Elevated

Cardiac Filling Pressures

Diastolic Dysfunction

CONGESTIVE HEART FAILURE


C hronic h eart f ailure

  • - Thick and Stiff Ventricular Walls

  • - Abnormal Ventricular Relaxation

  • - Ventricular Fibrosis

  • Pericardial Disease

- Myocardial Failure

- Valvular Insufficiency

  • Moderate to large

  • L -> R shunt

VOLUME OVERLOAD

DIASTOLIC DYSFUNCTION

Elevated Cardiac Filling Pressures

CONGESTIVE HEART FAILURE


C hronic h eart f ailure

MECHANISM OF HEART FAILURE

Pressure

overload

Normal pumping function

adequate

Compensatory

mechanism

Volume

overload

failed

Heart failure

  • Myocardial

  • contractility


Classical pathophysiology of hf

Classical Pathophysiology of HF

Primary disease state

Release of Renin / angiotensin aldosteron

Decreased aortic pressure

SNS stimulation

Decreased cardiac output

Vasoconstriction

Increased vascular volume

Ventricular dilatation

Increased afterload

Heart Failure symptoms

Increased Preload


Mi i nduced h eart f ailure

MI-INDUCED HEART FAILURE

Myocardial Damage

Contractility

Pump Performance

 Systolic Work Load

 SAS Drive

Vasoconstriction

RAAS SYSTEM

FLUID RETENTION


C hronic h eart f ailure

EVOLUTION OF CLINICAL STAGES

Normal

Asymptomatic

LV Dysfunction

No symptoms

Normal exercise

Normal LV fxn

No symptoms

Normal exercise

Abnormal LV fxn

Compensated

CHF

Decompensated

CHF

No symptoms

 Exercise

Abnormal LV fxn

Refractory

CHF

Symptoms

 Exercise

Abnormal LV fxn

Symptoms not controlled

with treatment


C hronic h eart f ailure

Stages in the evolution of HF and recommended therapy by stage

Stage A

Stage B

Stage C

Stage D

  • Pts with :

  • Struct. HD

  • Shortness of breath and fatigue, reduce exercise tolerance

  • Pts with :

  • Hypertension

  • CAD

  • DM

  • Cardiotoxins

  • FHx CM

  • Pts with :

  • Previous MI

  • LV systolic

  • dysfunction

  • Asymptomatic

  • Valvular disease

Pts who have marked symptoms at rest despite maximal medical therapy.

Refract.

Symp.of

HF at rest

Struct.

Heart Disease

Develop

Symp.of

HF

  • THERAPY

  • All measures under stage A

  • ACE inhibitor

  • Beta-blockers

  • THERAPY

  • Treat Hypertension

  • Stop smoking

  • Treat lipid disorders

  • Encourage regular exercise

  • Stop alcohol & drug use

  • ACE inhibition

  • THERAPY

  • All measures under stage A

  • Drugs for routine use:

    • diuretic

    • ACE inhibitor

    • Beta-blockers

    • digitalis

  • THERAPY

  • All measures under stage A,B and C

  • Mechanical assist device

  • Heart transplantation

  • Continuous IV inotrphic infusions for palliation

ACC/AHA Guidelines for the

Evaluation and Management of Chronic Heart Failure in the Adult 2005


C hronic h eart f ailure

Pregnancy

Arrhythmias (AF)

Infections

Hyperthyroidism

Thromboembolism

Endocarditis

Obesity

Hypertension

Physical activity

Dietary excess


Diagnosis of c h f

Diagnosis of C H F


C hronic h eart f ailure

  • IDENTIFICATIONS OF HEART FAILURE PATIENTS

  • Criteria 1 and 2 should be fulfilled in all cases

1. Symptoms of heart failure

(at rest or during exercise)

And

2. Objective evidence of cardiac dysfunction

(at rest)

And

(in cases where the diagnosis is in doubt)

3. Response to treatment directed towards heart failure

Task Force Report. Guidelines for the diagnosis and treatment of chronic heart failure.

European Society of Cardiology.2005


S ymptoms a nd s ign

SYMPTOMS AND SIGN

  • Breathlessness, Ankle Swelling, Fatique

    → Characteristic Symptoms

  • Peripheral Oedema, JVP ↑, Hepatomegaly

    → Signs of Congestion of Systemic Veins

  • S3 , Pulmonary Rales , Cardiac Murmur 


C hronic h eart f ailure

  • Vital Signs

  • Positional blood pressure

  • Pulse rate, rhythm, pulse pressure

  • Respiratory rate and pattern

  • Temperature

  • Abdominal

  • Ascites

  • Hepatosplenomegaly

  • Pulsatile liver

  • Decreased bowel sounds

  • Obesity

  • Neurologic

  • Mental status abnormalities

  • Pulmonary

  • Rales

  • Rhonchi

  • Prolonged expiration

  • wheezes

  • dullness to chest percussion

  • Friction rubs

  • Cardiovascular

  • Neck vein distention

  • Abdominal-jugular neck vein reflux

  • Cardiomegaly

  • Displaced, sustained, or hyperkinetic apical impulse

  • Chest wall pulsatile activity (Right ventricular lift)

  • Gallop rhythms

  • Heart murmurs (especially aortic, mitral, tricuspid,

  • and pulmonic insufficiency or stenosis murmurs)

  • Diminished S1 or S2

  • Friction rub

  • Peripheral venous insufficiency

  • Systemic

  • Acrocyanosis

  • Edema

  • Temporal muscle wasting

  • Cachexia

Physical Examinations of Heart Failure patient


C hronic h eart f ailure

CHEST X-RAY

  • A Part of Initial Diagnosis of HF

    → Cardiomegaly, Pulmonary Congestion,

    pulmonary disease

  • In pts CHF, CTR > 0.50 and pulmonary congestion → indicators of abnormal cardiac func. with ↓ EF

  • Relationship Between Radiological Signs and Haemodynamic Findings may Depend on the Duration and Severity HF


E c g

E C G

  • A normal ECG suggests that the diagnosis of CHF should be carefully reviewed

  • LAH and LVH May Be Associated wit LV Dysfunction

  • Anterior Q-wave and LBBB a good predictors of EF ↓↓

  • Detecting Arrhytmias as Causative of HF

Value of electrocardiography* in identifying heart failure

Resulting from left ventricular systolic dysfunction

Sensitivity94%

Specificity61%

Positive predictive value35%

Negative predictive value98%

*Electrocardiographic abnormalities are defined as atrial fibrillation, evidence of

Previous myocardial infarction, left ventricular hypertrophy, bundle branch block, and left axis deviation.


H aematology b iochemistry

HAEMATOLOGY & BIOCHEMISTRY

A Part of Routine Diagnostic

  • Hb, Leucocyte, Platelets

  • Electrolytes, Creatinine, Glucose, Hepatic Enzyme, Urinalysis

  • TSH, hs-CRP, Uric Acid

ECHOCARDIOGRAPHY

  • The Preferred Methods

  • Helpful in Determining the Aetiology

  • Follow Up of Patients Heart Failure


Natriuretic peptides

NATRIURETIC PEPTIDES

  • Cardiac Function ↓↓ (LV Function ↓↓) →

    ↑↑ Plasma Natriuretic Peptide Concentration

    (Diagnostic Blood Use for HF)

  • Natriuretic Peptide ↑↑ :

    Greatest Risk of CV Events

    Natriuretic Peptide ↓↓ :

    Improve Outcome in Patients with Treatment

  • Identify Pts. With Asymptomatic LV Dysfunction (MI, CAD)


P ulmonary f unctions

PULMONARY FUNCTIONS

  • A Little Value in Diagnosis Heart Failure

  • Usefull in Excluding Respiratory Diseases

EXERCISE TESTING

  • Focused on Functional, Treatment Assessment and Prognostic


S tress e chocardiography

STRESS ECHOCARDIOGRAPHY

  • For Detecting Ischaemia

  • Viability Study

NUCLEAR CARDIOLOGY

  • Not Recommended as a Routine Use

CMR ( CARDIAC MAGNETIC RESONANCE IMAGING)

  • Recommended if Other Imaging Techniques not

    Provided Diagnostic Answer


I nvasive i nvestigation

INVASIVEINVESTIGATION

Elucidating the Cause and Prognostic Informations

  • Coronary Angiography :

    in CAD’s Patients

  • Haemodynamic Monitoring :

    To Assess Diagnostic and Treatment of HF

  • Endomyocardial Biopsy :

    in Patients with Unexplained HF


C hronic h eart f ailure

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