Pathophysiology of Heart Failure

Definition – Heart Failure Common causes of heart failure

Clinical syndrome characterized by Impaired cardiac function Excess work demands
 Symptoms of breathelessness & fatigue Myocardial disease ↑ Pressure work
 Signs of fluid retention  Cardiomyopathies  Systemic hypertension
 Supported by objective evidence of cardiac dysfunction  Myocarditis  Pulmonary hypertension
(systolic and/or diastolic)  Coronary insufficiency  Coarctation of aorta
Pathological condition – heart unable to pump sufficient blood to  MI ↑ Volume work
meet metabolic demands of body Valvular heart disease  A-V shunt
 Stenotic  Excessive IV infusion
Cardiac output  Regurgitation ↑ Perfusion work
Cardiac output = Heart rate x Stroke volume Congenital heart disease  Thyrotoxicosis
Control of HR Control of SV Constrictive pericarditis  Anemia
Autonomic nervous system Preload
Hormonal control Afterload Causes of HF in Adults
Contractility Most common Slightly common
Coronary heart disease Idiopathic dilated cardiomyopathy
Preload Hypertension Valvular heart disease
Stretching myocardial fibers during diastole Diabetic cardiomyopathy
↑ EDSV (End-diastolic volume)
↑ Force of contraction during systole (Starling’s law) Pathophysiology of Heart Failure
 Venous return to heart determine EDSV ↓ CO
 Stretching of actin-myosin bridges (development of force) ↓ Blood flow to kidneys & organs
 ↑ Force of contraction during systole = ↑ Stroke volume
Disorders Recruitment of compensatory mechanisms (maintain tissue perfusion)
Too ↑ Preload Too ↓ Preload Heart Failure
Length of sarcomere is more than Length of sarcomere is well below ↓ CO
optimal optimal ↓ Organ perfusion
↓ Strength of contraction ↓ Strength of contraction Maintain organ perfusion by (compensatory mechanism)
 Frank-Starling mechanism
Afterload  ↑ Sympathetic activity
Systolic wall tension developed by ventricles to open semilunar valves  RAA mechanism
Eject blood against vascular resistance  Myocardial hypertrophy
Laplace wall

Cardiac contractility
Ability of actin & myosin (of heart muscle) to interact & shorten against load
Contractility ↑ CO independent of preload filing & muscle stretch
Mechanisms involved that ↑ contractility
(↑ [Ca2+]i concentration - ↑ cross-bridges in sarcomere)
↑ Catecholamines
↑ Inotropic drugs
Disorders

↑ Contractility ↓ Contractility
Shift entire ventricular function Shift entire ventricular function
curve upward & left curve downward & right
Ischemia
Hypoxia
Acidosis
Inflammation
Toxins
Metabolic disorders
Types of Heart Failure Right/ Left Heart Failure
Low output vs High output Right Heart Failure Left Heart Failure
Systolic vs Diastolic Impair ability to move deoxygenated Impair pumping of blood from low-
Right vs Left vs Biventricular blood (from systemic circulation to pressure pulmonary circulation into
Acute vs Chronic pulmonary circulation) high-pressure systemic circulation
Accumulate blood in systemic venous ↓ CO
High output/ Low output Failure circulation ↑ LA, LV ED Pressures
↑ Output Failure ↓ Output Failure ↑ RA, RV ED Pressures Congestion in pulmonary circulation
Uncommon Disorders that impair heart pumping ↑ Systemic venous circulation Fluid extravasation from pulmonary
Caused by ↑ CO ability (↓ CO) Results in capillary bed to interstitium & alveoli
Unable to meet perfusion requirem.  IHD  Peripheral edema Results in
Chronic ↑ metabolic rate  Cardiomyopathies  Hepatomegaly  Tachycardia
(eg. thyrotoxicosis)  Splenomegaly  Sweating
↓ O2 carrying capacity of blood  Vascular congestion of GIT  Gallop rhythm
(eg. anaemia)  Jugular vein distention  Left parasternal lift
A-V shunting  Moist crepitations
Caused by (restrict blood to lung)
(eg. A-V fistula) 
 Stenosis/ regurgitation of Pleural effusion
tricuspid & pulmonic valves Caused by
Systolic/ Diastolic Dysfunction 
 RV infarction Acute myocardial infarction
Systolic Diastolic 
 Cardiomyopathy Cardiomyopathy
Defect in ventricular contraction Impaired ability in ventricular filling 
 Persistent left-sided heart Aortic/ aortic valve disorders
Left ventricles lose ability to generate ↓ Filling failure  Rapid infusion of IV fluids in
enough pressure to eject blood ↓ Stroke volume elderly with limited cardiac
Cor pulmonale
forward through ↑ pressure aorta Congestive symptoms tend to reserve
(RV enlargement 2° pulmonary HPT)
(↓ ejection fraction) predominate
Acute Chronic
IHD Mitral stenosis
Massive 2° Obstructive
Cardiomyopathy Myocardial hypertrophy
pulmonary pulmonary
Valvular regurgitation IHD
embolism disease
Anaemia
Primary
Hypertension
pulmonary
Valvular stenosis
hypertension
Most cases are mixed Systolic & Diastolic Dysfunction

Acute/ Chronic Heart Failure

Acute Heart Failure Chronic Heart Failure
Rapid onset of symptoms & signs of Chronic state – stable symptoms
heart failure Acute aggravating factor(s) may cause
Acute deterioration cardiac function acute cardiac decompensation
Clinical Manifestations – Heart Failure Cardiac Cachexia
Congestive Heart Failure – heart failure & congestion of body tissues Malnutrition & tissue wasting
End-stage heart failure
Contributing factors
 Fatigue & depression – interfere with food intake
 Liver & GIT congestion – impair digestion & absorption
 Circulating toxins produce by poorly perfused tissues – impairs appetite

Cyanosis
Bluish discoloration – skin, mucous membranes
↓ Hb in blood
Late sign of heart failure
Cyanosis
Central Peripheral
Impair oxygenation of blood Low-output failure
Due to Due to
 Heart failure  Delivery of poorly oxygenated
 Lung diseases blood to peripheral tissues
 Right-to-left shunts  Peripheral vasoconstriction
Fluid Retention & Edema
Complications of Heart Failure
Cardiac arrhythmias (eg. atrial fibrillation, ventricular arrhythmias)
Pulmonary embolism (due to DVT)
Mural thrombosis (in dilated heart chambers)
Chest infection (due to chronic pulmonary congestion)
Major organ failure (MOF) (eg. renal impairment, cardiac cirrhosis)

Diagnosis of Heart Failure

Signs & Symptoms
Basic investigations
 ECG
 CXR
 Blood Test
Other important investigations
 Echocardiogram
 Natriuretic peptides or their precursors

New York Heart Association (Functional classification) – Heart Disease

Respiratory Manifestations Classification Characteristics
SOB – caused by congestion of pulmonary circulation (left-sided HF) Class I No limitation of physical activity
Dyspnea Class II Slight limitation – Fatigue, Dyspnea, Palpitation
 Perceived shortness of breath (SOB) Class III Marked limitation – Comfortable at rest
Orthopnea Ordinary activities cause symptoms
 SOB occurs when in supine Class IV Inability to carry out any physical activity without
Paroxysmal nocturnal dyspnea symptoms
 Sudden attack of dyspnea during sleep Pain/ discomfort at rest
 Disrupts sleep & awakens with feeling of extreme suffocation
 Resolves when sits up Natriuretic Peptides

Chronic dry, non-productive cough

 Worsen on lying down
Wheezing & difficulty in breathing (cardiac asthma)
 Due to bronchospasm
 Caused by congestion of bronchial mucosa
Cheyne-stokes breathing (periodic breathing)
 Slow waxing & waning of respiration
 Deep breathing when ↑ PaCO2
 Slight or not at all when PaCO2 falls

Cardiac Fatigue
Diminished CO
Usually does not present in the morning
Appears usually as activity increases during the day
Acute/ severe heart failure (or in elderly with advanced HF)
 ↓ CO (insufficient for brain perfusion)
 Mental confusion
 Memory impairment
 Anxiety
 Restlessness
 Insomnia