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Cardiac Pathophysiology Part B. Heart Failure. The heart as a pump is insufficient to meet the metabolic requirements of tissues. Can be due to: dysfunction of the left ventricle dysfunction of the right ventricle or due to inadequate perfusion despite normal or elevated cardiac output.

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heart failure
Heart Failure
  • The heart as a pump is insufficient to meet the metabolic requirements of tissues.
  • Can be due to:
    • dysfunction of the left ventricle
    • dysfunction of the right ventricle
    • or due to inadequate perfusion despite normal or elevated cardiac output
classification of heart failure
Classification of Heart Failure
  • Acute –develops quickly
  • Chronic – conditions gradually increase demands on the heart; when the heart and circulatory system can no longer adapt the result is heart failure
    • Can lead to acute failure with excessive cardiac demand
four broad consequences of heart failure
Four broad consequences of heart failure
  • Congestion – blood backs up
  • Activation of circulatory compensations
  • Cardiac output declines
  • Death
types of heart failure
Types of Heart Failure
  • High output vs. Low output
  • High output
    • Anemia
    • Septicemia
    • Hyperthroidism (thyrotoxicosis)
    • Beriberi
  • Low output
    • Decreased pumping ability and cardiac output
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Right-sided vs. Left sided Heart Failure

  • Right-sided HF
    • Most common cause is left heart failure
    • Can occur independently in primary lung disease conditions
      • COPD, ARDS, cystic fibrosis
      • Cor pulmonale
  • Left-sided HF
    • Decreased output to body
    • Blood backs up
systolic vs diastolic hf
Systolic vs. Diastolic HF
  • Systolic – decreased contraction leads to decreased output and poor perfusion of tissues
contractility is reduced by diseases that disrupt myocyte activity
Contractility is reduced by diseases that disrupt myocyte activity
    • Most common cause is myocardial infarction
    • Myocarditis
    • Myocardopathies
  • When contractility decreases, stroke volume decreases, and left ventricular end-diastolic volume (LVEDV) increases.
  • This causes dilation of the heart and increased preload
preload can also increase with excess plasma volume
Preload can also increase with excess plasma volume
    • I.V. Fluid administration
    • Renal failure
    • Mitral valve disease
  • Increased LVEDV at first increases C.O., but over time can cause dysfunction of sarcomeres (stretched too far) and decreased contractility
increased afterload is usually due to increased peripheral resistance
Increased afterload is usually due to increased peripheral resistance
    • Hypertension
  • Left ventricle works harder to overcome resistance, and hypertrophies.
  • Hypertrophy causes changes in the myocytes.
  • Also see deposition of collagen between myocyctes which can disrupt contractility and make ventricle more likely to dilate and fail.
leads to increased blood pressure and pulmonary congestion
Leads to increased blood pressure and pulmonary congestion
  • Dyspnea
  • Orthopnea – difficulty breathing in any position other than upright
  • Coughing up frothy sputum
  • Chest pain –due to hypoxia at heart
  • Fatigue/confusion
  • Skin is pale, cold, sweaty
  • Pulse and lung sounds abnormal
  • Decreased urine output
  • Edema
slide12
Treatment is aimed at breaking the cycle of decreasing contractility and increasing preload and afterload.
  • Oxygen, nitrates and morphine – improve myocardial oxygenation, help relieve coronary spasm while lowering preload through systemic vasodilation.
  • I.V. inotropic drugs such as dopamine or dobutamine – increase contractility of the heart and can raise B.P. in hypotensive individuals.
slide13
Diuretics – reduce preload
  • ACE inhibitors – reduce preload and afterload by decreasing aldosterone levels and reducing peripheral venous resistance
  • Beta-blockers have been helpful in some people
  • Coronary by-pass
  • Salt restriction
  • Heart transplant
diastolic heart failure
Diastolic Heart Failure
  • See symptoms and signs of heart failure, a preserved ejection fraction, and abnormal diastolic function
  • Accounts for 25 -40% of all cases of heart failure
diastolic h f results from
Diastolic H.F. Results from:
  • Decreased compliance of left ventricle and abnormal diastolic relaxation- results in increased pressure in ventricle at the end of diastole
  • Pressure is reflected back into the atrium and pulmonary circulation
major causes
Major causes:
  • Hypertension – induced myocardial hypertrophy and myocardial ischemia with ventricular remodeling
  • Aortic valvular disease
  • Mitral valvular disease
  • Cardiomyopathies
signs and symptoms are similar to systolic heart failure
Signs and symptoms are similar to systolic heart failure
  • Diagnosis made by echocardiography and heart cateterization
management
Management
  • Improve ventricular relaxation and prolong diastolic filling times to reduce diastolic pressure
  • Calcium channel blockers, beta-blockers, and ACE inhibitors have been used with success