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