NORMAL HEART HEART FAILURE

06/15/17 1
 Introduction
Heart failure is the pathological
process in which the systolic
or/and diastolic function of the
heart is impaired, and as a result,
cardiac output decreases and is
unable to meet the metabolic
demands of the body.

06/15/17 2
 Cardiac Physiology

CO = SV x HR Preload Contractility Afterload

HR: parasympathetic
and sympathetic
Stroke Volume Heart Rate
tone

SV: preload,
afterload, Cardiac Output
contractility

06/15/17 3
 Stroke Volume
PRELOAD : Passive stretch of muscle prior
to contraction function of LVEDP
AFTERLOAD : Force opposing/stretching
muscle after contraction begins
measured by SVR (Systemic Vascular
Resistance)
CONTRACTILITY : ability of the muscle to
contract at a given force for a given
stretch, independent of preload or
afterload forces
06/15/17 4
 Frank Starling Mechanism

06/15/17 5
 Pathophysiology
Systolic dyfunctions :
The contractile state of the
myocardium
The preload of the ventricle
The afterload applied to the
ventricle
The heart rate
Dysfunction of myocardium :
Myocardial damage :
myocardial infarction;
Cardiomyopathy;
Myocarditis
Metabolic disturbance :
ischemia and hypoxia;
diabetes

Overload for myocardium :

Pressure overload (afterload) : Hypertension, aortic stenosis;
Pulmonary hypertension
Volume overload (preload) : Mitral regurgitation
Restriction of cardiac dilation : Pericardial effusion
06/15/17 7
 Ventricular Remodeling

Ventricular remodeling is the process by which mechanical,

neurohormonal, and possibly genetic factors alter
ventricular size, shape, and function.
Its hallmarks include hypertrophy, loss of myocytes, and
increased interstitial fibrosis.

Ventricular remodeling in diastolic and systolic heart

failure

Normal heart Hypertrophied heart Dilated heart

(diastolic heart (systolic heart
 Etiology of HF

Hypertensive heart disease

Coronary artery disease
Valvular disease
Heart inflammation : pericarditis, myocarditis.
Cardiomyopathy
Venous disease (deep vein thrombosis) right
heart failure

March 2013 ghennersdorf DGK ESC SES

 The precipitating causes
Ischemia
Arrhythmia : Tachycardia atrial fibrillation
Bradycardia
Infection : especially lung infection
Excessive physical activity
Pregnancy and delivery
Anemia
Administration of inappropriate drug
Medication noncompliance
Excess fluid intake
Thyrotoxicosis
 Functional class of Heart
Failure
New York Heart Association

Clas % of Symptoms
s patient

s
I 35% No symptoms or limitations in
ordinary physical activity

II 35% Mild symptoms and slight
limitation during ordinary
activity
III 25% Marked limitation in activity
even during minimal activity.
Comfortable only at rest
IV
06/15/17 5% Severe limitation. Experiences11
 Stages of heart failure

Stage A: Asymptomatic with no heart damage but

have risk factors for heart failure
Stage B: Asymptomatic but have signs of structural
heart damage
Stage C: Have symptoms and heart damage
Stage D: End stage disease

ACC/AHA guidelines, 2001

 Clinical classification
According to the course of disease
Acute HF
Chronic HF
According to the cardiac output (CO)
Low-output HF
High-output HF
According to the location of heart failure
Left -side heart failure (LHF)
Right-side heart failure (RHF)
Biventricular failure (whole heart failure)
According to the function impaired
Systolic failure
Diastolic failure
 Acute versus
Chronic
Acute heart failure
develops rapidly
can be immediately life
threatening due to lack of
time to undergo
compensatory adaptations.
may result from CABG, acute
infection (sepsis), acute
myocardial infarction, valve
dysfunction, severe
arrhythmias, etc.
can often be managed
successfully by
pharmacological or surgical
interventions.
06/15/17
Chronic heart failure
a long-term condition
(months/years) that is
associated with the
heart undergoing
adaptive responses
(e.g., dilation,
hypertrophy) to a
precipitating cause.
These adaptive
responses, however,
can be deleterious in
the long-term and lead
to a worsening
condition. 14
 Systolic versus
Diastolic
SYSTOLIC DIASTOLIC
HEART FAILURE HEART FAILURE

Systolic cant Diastolic- cant fill

pump Mitral Stenosis
Aortic Stenosis Tamponade
HTN
Hypertrophy
Aortic Insufficiency
Infiltration
Mitral Regurgitation
Fibrosis
Muscle Loss
Ischemia
Fibrosis
Infiltration
06/15/17 15
06/15/17 15
Diastolic HF vs Systolic HF
What Are The Symptoms
of Heart Failure?

Think FACES...
Fatigue
Activities limited
Chest congestion
Edema or ankle swelling
Shortness of breath
 Modified Framingham
Criteria Diagnosis for Heart
Failure

Major criteria Minor criteria

Neck vein distension Bilateral ankle
Orthopnea edema
Cardiomegaly on CXR Night cough
CVP > 12 mm Hg Dyspnea on exertion
Left Ventricular Hepatomegaly
dysfunction on EKG Pleural effusion
Weight loss Tachycardia (> 120
Acute pulmonary beats/min)
edema
06/15/17 19
 Clinical Data
HEART SOUNDS!!!
Systolic Murmurs
Mitral Regurgitation
Aortic Stenosis
Diastolic Murmurs
Mitral Stenosis Mitral Stenosis
Aortic Insufficiency
S3: Rapid filling of a diseased ventricle
06/15/17 21
 Clinical Data
CXR(Chest X-Ray)
Kerleys lines : A and B
Pulmonary Edema
Cephalization
Pleural Effusions (bilateral)
EKG(Electrocardiogram)
Left atrial enlargement
Arrhythmias
Hypertrophy (left or right)
06/15/17 22
 Clinical Data
Laboratory Data

Chemistry
Renal Function: Be Wary

BNP(Brain Natriuretic Peptide) Test

Used in ER departments the world over
Pulmonary versus cardiac dyspnea

06/15/17 23
 Treatment Strategies of HF

Etiology therapy
Treatment of etiology causes
Treatment of precipitating causes
Improve life-style
Lessen cardiac load
Rest
Limitation of salt intake
Water intake
Diuretics
Drug treatment for CHF
Diuretics, ACE inhibitors

Reduce the number of sacks on

the wagon
 Diuretics
Indicated in patients with symptoms of fluid retention

Initiated with low doses followed by increments in

dosage until urine output increases and weight decreases
by 0.5-1kg daily

Benefits :
Improves symptoms of congestion
Can improve cardiac output

Limitations :
Excessive volume depletion
Electrolyte disturbance
Ototoxicity
 ACE Inhibitor
All patients with symptomatic heart failure and functional
class I with reduced LV function, unless contraindicated or
not tolerated
Should be continued indefinitely and titrate to optimal
dosage in the absence of symptoms or adverse effects on
end-organ perfusion
Increases exercise capacity and improves functional class
Attenuation of LV remodeling post MI
 Beta-blockers
Limit donkeys speed, thus saving
energy

Initiate with low dosage

Titration to target dosage
 Digitalis

Like the carrot placed in front of the

donkey
 Digitalis
Enhances LV function, normalizes baroreceptor-mediated
reflexes and increases cardiac output at rest and during
exercise
Should be used in conjunction with diuretics, ACE inhibitors
and beta-blockers
Also recommended in patients with heart failure who have
atrial fibrillation
Adverse effects include cardiac arrhythmias, GI symptoms
and neurological complaints (eg. visual disturbances,
confusion)
 CRT/CRT-D
Increase the donkeys (heart) efficiency
CRT device:
Pts with NYHA Class /

Symptomatic despite
optimal medical therapy
QRS 130 msec

LVEF 35%
 Treatment Strategies of HF

Aldosterone antagonist:
RALES, serious HF
Angiotensin receptor blocker:
substitute, not replace
TripleTherapy
TripleThe rapyfor
for
most patients ACE,
B-Blocker and MRA
Heart failure:
More than just drugs.

Dietary counseling
Patient education
Physical activity
Medication compliance
Aggressive follow-up
Sudden death assessment
 Questions to determine therapeutic
strategy in CHF patients

Is heart failure present?

What caused the problem?

What precipitated deterioration?

How severe is the heart failure?

What is the best chronic therapeutic strategy?

Can the initiating/precipitating problem be cured, and can

the state of HF be attenuated?
What is the prognosis?
 ventricular filling occurs during this phase.

Intra atrial pressure recordings reveal two peaks and two descents. The a waveis the
atrial pressure generated during atrial systole immediately preceding ventricular systole.
The peak atrial pressure recorded during ventricular systole before the tricuspid and
mitral valves open is the v wave.

120 mmHg

Aortic Valve Opens Aortic Valve Closes

80 mmHg
Aortic Pressure

Mitral Valve Opens

Mitral Valve Closes

v
LA Pressure
a wave
wave
10 mmHg
LV Pressure
Diastole Systole Diastole
06/15/17 40