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CHRONIC HEART FAILURE
Pathophysiology
Toni M. Aprami
Department of Cardiology and Vascular MedicineCardiovascular Subdivision, Department of Internal Medicine
Hasan Sadikin Hospital/Medical School, Padjadjaran University
Pulmonaryveins
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 FAILUREMyocardial disease Viral or other infectious agentsCoronary artery disease Toxic or drug-induced damage Myocardial infarction* Disorders of rate and rhythm Myocardial ischemia* Chronic bradiarrhythmiasChronic pressure overload Chronic tachyarrhythmias Hypertension* Pulmonary heart disease Obstructive valvular disease* Cor pulmonaleChronic volume overload Pulmonary vascular disorders Regurgitant valvular disease High-output state Intracardiac (left-to-right) shunting Metabolic disorders Extracardiac shunting ThyrotoxicosisNonischemic dilated cardiomyopathy Nutritional disorders (beriberi) Familial/genetic disorders Excessive blood flow requirements Infiltrative disorders* Systemic arteriovenosus shunting Metabolic disorders* Chronic anemia
*Indicates conditions that can also lead to HF with a preserved ejection fraction
Input
Block diagram of left ventricular pump performance
(Little, 2001)
Output
PULMONARY VENOUSPRESSURE
CARDIAC OUTPUT
Filling EmptyingED volume x EFeffective = Stroke
volume
Heartrate
x
Diastolic function Systolic function
LV DistensibilityRelaxationLeft atriumMitral valvePericardium
ContractilityAfterloadPreloadStructure
Right Atrium
Right ventricle
Pulm
onal
art
ery
Left ventricle
Pulmonal vein
Lung
Left atrium
Aorta
organ
Systemic Vascular
Resistance(SVR)
Pump
Container
Volume (blood within circulatory system)
SVC
IVC
DETERMINANTS OF VENTRICULAR FUNCTION
STROKE VOLUME
PRELOAD
CONTRACTILITY
CARDIAC OUTPUT
HEART RATE - Synergistic LV contraction - LV wall integrity - Valvular competence
AFTERLOAD
Determinants of heart rate:
-balance of parasympathetic and sympathetic tone-sinus node function
-presence of an ectopic focus-conduction system
COMPENSATORY MECHANISM
• Frank - Starling mechanism
• Neurohormonal stimulation
• Myocardial hypertrophy with or without chamber
dilatation
Myocardial Failure or Valvular Insufficiency
Reduced cardiac output
Decreased tissue perfusion
Activation of compensatory mechanisms:-Sympathetic Nervous System (SNS)-Frank-Starling Mechanism-Renin-Angiotensin-System (RAS)-Aldosterone-Ventricular hypertrophy-others… (anti-diuretic hormone, atrial natriuretic factor)
An effort to normalize tissue perfusion and blood pressure
Reduced blood pressure
Myocardial Failure or Valvular Insufficiency
SNS
F-S Mech.
RAS
Activates Compensatory Mechanisms
Aldosterone
Heart Rate
Vasoconstriction
Increased Venous Return and Increased Blood Pressure
Augmentation of cardiac performance
Angiotensin II
Contractility
Anti-diuretic Hormone
Sodium and water retention
PRESSURE OVERLOAD
Valvular InsufficiencyMyocardial Failure
Diastolic Dysfunction
CONCENTRIC HYPERTROPHY
Altered ventricular geometry
Thickened Ventricular Walls
Ischemia and Fibrosis
ElevatedCardiac Filling Pressures
CONGESTIVE HEART FAILURE
CONGESTIVE HEART FAILURE
Elevated Cardiac Filling Pressures
- Valvular Insufficiency
VOLUME OVERLOAD DIASTOLIC DYSFUNCTION
- Thick and Stiff Ventricular Walls
- Abnormal Ventricular Relaxation
- Ventricular Fibrosis
-Pericardial Disease
- Myocardial Failure
-Moderate to large L -> R shunt
Pressureoverload
Volumeoverload
¯ Myocardialcontractility
MECHANISM OF HEART FAILURE
Compensatory
mechanism
Normal pumping function
adequate
Heart failure
failed
Classical Pathophysiology of HF
Heart Failure
symptoms
Release of Renin /
angiotensin aldosteron
Vasoconstriction Increased vascular volume
Increased Preload
Increased afterload
Decreased aortic pressure
SNS stimulati
on
Decreased cardiac output
Ventricular dilatation
Primary disease state
MI-INDUCED HEART FAILURE
Myocardial Damage
Contractility
Pump Performance
SAS DriveVasoconstriction
Systolic Work Load
RAAS SYSTEMFLUID RETENTION
Normal
EVOLUTION OF CLINICAL STAGES
Asymptomatic LV Dysfunction
CompensatedCHF
DecompensatedCHF
No symptomsNormal exerciseNormal LV fxn
No symptomsNormal exerciseAbnormal LV fxn
No symptoms ¯ ExerciseAbnormal LV fxn
Symptoms ¯ ExerciseAbnormal LV fxn
RefractoryCHF
Symptoms not controlled with treatment
Stage A Stage B Stage C Stage D
Pts with :• Hypertension• CAD• DM• Cardiotoxins• FHx CM
THERAPY• Treat Hypertension• Stop smoking • Treat lipid
disorders• Encourage regular
exercise• Stop alcohol
& drug use• ACE inhibition
Pts with :• Previous MI• LV systolic
dysfunction• Asymptomatic
Valvular disease
THERAPY• All measures under
stage A• ACE inhibitor • Beta-blockers
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
Pts who have marked symptoms at rest despite maximal medical therapy.
Pts with :• Struct. HD• Shortness of
breath and fatigue, reduce exercise tolerance
Struct.Heart Disease
DevelopSymp.of
HF
Refract. Symp.of HF at rest
Stages in the evolution of HF and recommended therapy by stage
ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult 2005
EndocarditisObesityHypertensionPhysical activityDietary excess
PregnancyArrhythmias (AF)InfectionsHyperthyroidismThromboembolism
Diagnosis of C H F
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)
And2. 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
SYMPTOMS AND SIGN
Breathlessness, Ankle Swelling, Fatique→ Characteristic Symptoms
Peripheral Oedema, JVP ↑, Hepatomegaly→ Signs of Congestion of Systemic Veins
S3 , Pulmonary Rales , Cardiac Murmur
Physical Examinations of Heart Failure patientVital Signs• Positional blood pressure• Pulse rate, rhythm, pulse pressure• Respiratory rate and pattern• Temperature
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
Pulmonary• Rales• Rhonchi• Prolonged expiration• wheezes• dullness to chest percussion• Friction rubs
Abdominal• Ascites • Hepatosplenomegaly• Pulsatile liver• Decreased bowel sounds• Obesity
Neurologic• Mental status abnormalities
Systemic• Acrocyanosis• Edema• Temporal muscle wasting• Cachexia
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 GA normal ECG suggests that the diagnosis of CHF
should be carefully reviewedLAH and LVH May Be Associated wit LV DysfunctionAnterior Q-wave and LBBB a good predictors of EF ↓↓Detecting Arrhytmias as Causative of HF
Value of electrocardiography* in identifying heart failureResulting from left ventricular systolic dysfunction
Sensitivity 94%Specificity 61%Positive predictive value 35%Negative predictive value 98%
*Electrocardiographic abnormalities are defined as atrial fibrillation, evidence ofPrevious myocardial infarction, left ventricular hypertrophy, bundle branch block, and left axis deviation.
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• Cardiac Function ↓↓ (LV Function ↓↓) →
↑↑ Plasma Natriuretic Peptide Concentration
(Diagnostic Blood Use for HF)• Natriuretic Peptide ↑↑ :
Greatest Risk of CV EventsNatriuretic Peptide ↓↓ : Improve Outcome in Patients with
Treatment• Identify Pts. With Asymptomatic LV
Dysfunction (MI, CAD)
PULMONARY FUNCTIONS
A Little Value in Diagnosis Heart Failure Usefull in Excluding Respiratory
Diseases
EXERCISE TESTING
Focused on Functional, Treatment Assessment and Prognostic
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
INVASIVE INVESTIGATION
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
Terima Kasih