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Pathophysiology of CHF
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CHF
• What is CHF?
• Fix the underlying problem
• Heart is a 2 sided pump
• Both sides can fail independent of each other.
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CHF
• What different types of pathophysiology cause it?
• Systolic Dysfunction
• Diastolic Dysfunction
• High Output States
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CHF• Systolic Dysfunction – What is it? Is it only related to
events that occur in Systole?-1. Decreased Contractility
- a. Loss of Myocytes
- b. Over-stretched Heart
-2. Increased Afterload- a. Increased BP
- b. Stenotic Valve- Pulmonic Valve and carcinoid syndrome – 5HIAA
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CHF
• Diastolic Dysfunction – What is it? – 1. Impaired Relaxation
– 2. Obstruction to filling
• Can systolic and diastolic functions coexist?
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CHF
• Pressure volume loops are used to distinguish between systolic vs. diastolic dysfunction
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CHF
• High Output States – What is it?– Paget’s Disease
– Anemia
– Thiamine Deficiency
– Hyperthyroidism
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CHF
• The failing heart and how it compensates– What does a failing heart mean, and what is
decompensation? What does a failing heart look like?
– Compensations made by a failing heart• Frank Starling Forces• Neuro-Hormonal Changes• Ventricular Remodeling
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CHFWhat is looks like:
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CHF Compensations
• Frank Starling– Length Tension Mechanism
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CHF Compensations
• L sided failure and Frank– Blood is not going to go forward
– Blood is going to back up into L atrium and pulmonary venous circulation
• L Atrium, what happens when it distends?
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CHF Compensations
• Hoarseness:
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CHF Compensations
• L sided Failure and Frank– Blood eventually backs up into the pulmonary
circulation• What happens there?
• What’s the deal with Frank Starling Forces?
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CHF Compensation
• L sided failure and the lungs continued…– Pulmonary congestion
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CHF Compensation
• L sided failure and lungs continued…– Pulmonary Hypertension– Does pulmonary hypertension happen
immediately?
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L sided Compensation
• L sided failure and CXR– Cephalization
– Indistinct vessels, Kerly B-Lines
– Whited Out lungs fields
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CHF Compensations
• L sided failure symptoms related to congestion– Blood not going forward:
• Muscle fatigue• Confusion
– Blood going backwards:• Atrial Distension
– Arrhythmias
– Thrombus formation
– Hoarseness
– Mitral Regurgitation
– S3
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CHF Compensations
• L sided failure symptoms continued…– Blood going backwards continued…
• Pulmonary congestion– Pulmonary edema– Pulmonary hypertension – R sided failure– Dyspnea, Dyspnea at night– Nocturnal enuresis– Orthopnea– Cardiac Asthma– Hypoxia, cyanosis
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CHF Compensations
• R sided failure and Frank:– Most Common Cause is?– Cor pulmonale?– Blood is going to eventually back up into the R atrium and systemic and portal venous
circulation.
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CHF Compensations
• What happens when this blood backs up?– Liver Congestion
– Gastrointestinal Tract Nutmeg Liver
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CHF Compensations
• What happens when this blood backs up continued…– Pitting Edema
• Frank Starling Forces
• Stasis Dermatitis
• P02?
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CHF Compensations
• JVD – jugular venous pressure chart
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CHF Compensations
• Acute R sided failure– Causes?– Would you expect to see any change to the R
ventricle?
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CHF Compensations
• R sided failure symptoms from the backing up of blood:– Pitting Edema– JVD– GI discomfort– Liver congestion
• RUQ pain• Hepatojugular Reflex• Ascites – Puddle sign
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CHF complications
• Would you expect someone with R sided failure only, that is, no L sided failure, to have pulmonary hypertension or pulmonary edema?
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CHF Compensations
• Neurohormonal changes:– Renin-Angiotensin System
– Adrenergic System
– ADH
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CHF Compensations
• Renin-Angiotensin System – raise EABV, and lower plasma oncotic p.
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CHF Compensations
• Does the Renin-Angiotensin System restore EABV back to normal?
• Why is this harmful in the end?
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CHF Compensations
• Adrenergic System:– Increased Sympathetic
outflow– Increased effects of
epinephrine on adrenergic receptors throughout your body
– What pathological process could keep the adrenergic system on even if the EABV is restored?
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CHF Compensations
• Does the adrenergic system restore the EABV?
• Why is this harmful in the end?
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CHF Compensations
• ADH secretion
– Why do its effects become blunted in long run?
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CHF Compensations
• Ventricular Remodeling