12/06/2017 1 Heart Failure Heart Failure (General Medicine) (General Medicine) Cardiovascular continuum Cardiovascular continuum Function of the heart Function of the heart Supply the organs by Supply the organs by O 2 and nutrients sufficient and nutrients sufficient for the metabolic status for the metabolic status Accept blood from organs and push it through Accept blood from organs and push it through pulmonary circulation to the left heart pulmonary circulation to the left heart Requirement equirements Normal structure and function of the heart Normal structure and function of the heart Appropriate blood return from the periphery Appropriate blood return from the periphery Normal structure and function of the tissues Normal structure and function of the tissues surrounding the heart surrounding the heart BLOOD PRESSURE (heart work) Cardiac Output (CO) Peripheral Resistance (PR) Stroke Volume (SV) Heart Rate (HR) Preload Contractility Afterload Vessel length Vessel diameter Viscosity of blood Blood volume Venous compliance Vasoconstriction Vasodilation Compliance of large arteries Vessel wall remodelling Heart failure Heart failure Inability of the heart to supply adequate blood Inability of the heart to supply adequate blood flow and oxygen delivery to peripheral tissues flow and oxygen delivery to peripheral tissues and organs in spite of and organs in spite of normal normal or or increased increased filling pressure ( filling pressure (venous return venous return) Epidemiol Epidemiology of HF ogy of HF Prevalenc Prevalency: 2 : 2 - 3 % 3 % after after 75 75 years years: 10 10 -20 % 20 % In younger individuals is more frequent in men In younger individuals is more frequent in men 50 % 50 % of patients dies within of patients dies within 4 4 years years 40 % 40 % of patients hospitalized with HF dies or is re of patients hospitalized with HF dies or is re- admitted within 1 year admitted within 1 year
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Heart Failure - uniba.sk...Chronic heart failure (CHF) Gradual progressive loss of cardiac function Partly compensated by regulatory mechanisms that become maladaptive Peripheral edemas
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12/06/2017
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Heart FailureHeart Failure
(General Medicine)(General Medicine)
Cardiovascular continuumCardiovascular continuum
Function of the heartFunction of the heart�� Supply the organs by Supply the organs by OO22 and nutrients sufficient and nutrients sufficient
for the metabolic status for the metabolic status
�� Accept blood from organs and push it through Accept blood from organs and push it through
pulmonary circulation to the left heartpulmonary circulation to the left heart
RRequirementequirementss�� Normal structure and function of the heartNormal structure and function of the heart
�� Appropriate blood return from the peripheryAppropriate blood return from the periphery
�� Normal structure and function of the tissues Normal structure and function of the tissues surrounding the heartsurrounding the heart
BLOOD PRESSURE
(heart work)
Cardiac Output (CO) Peripheral Resistance (PR)
Stroke Volume (SV) Heart Rate (HR)
Preload
Contractility
Afterload
Vessel length
Vessel diameter
Viscosity of blood
Blood volume
Venous compliance
Vasoconstriction
Vasodilation
Compliance of large arteries
Vessel wall
remodelling
Heart failureHeart failure
�� Inability of the heart to supply adequate blood Inability of the heart to supply adequate blood
flow and oxygen delivery to peripheral tissues flow and oxygen delivery to peripheral tissues
and organs in spite of and organs in spite of normalnormal or or increasedincreased
↑ i.c. Ca↑ i.c. Ca2+2+Necrosis of cardiomyocytesNecrosis of cardiomyocytes
Forms of Forms of HFHF�� AcuteAcute
�� ChronicChronic
�� RightRight
�� LeftLeft
�� SystolicSystolic
�� DiastolicDiastolic
�� HighHigh--output HFoutput HF
�� LowLow--output HFoutput HF
�� ForwardForward
�� BackwardBackward
ManifestationManifestation of HFof HF
LowLow--output vs. highoutput vs. high--output HFoutput HF
�� LowLow--output HFoutput HF
�� cardiac output lower than before HF, under effort doesn`t cardiac output lower than before HF, under effort doesn`t increase sufficientlyincrease sufficiently
�� cardiac output during HF is HIGHER than before HF, cardiac output during HF is HIGHER than before HF, cannot supply inadequately high requestscannot supply inadequately high requests
↓↓ aortic pressure (BP)aortic pressure (BP) ↑↑ LV, LA, pulmonary bed pressureLV, LA, pulmonary bed pressure
Stim. of baroreceptors, chemoreceptors in Stim. of baroreceptors, chemoreceptors in aorta, ventricles, atrii, aorta, ventricles, atrii, pulmonary bedpulmonary bed
G Jackson, C R Gibbs, M K Davies and G Y H Lip: ABC of heart failure: Pathophysiology, BMJ 2000;320;167-170
�� Structural adaptation of the heart to a longStructural adaptation of the heart to a long--term term hemodynamic overload hemodynamic overload
�� Stimulated by inadequate Stimulated by inadequate ↑↑ in ventricular wall stress in ventricular wall stress -- pressure pressure load and neurohumoral agents (angiotensin II, aldosterone)load and neurohumoral agents (angiotensin II, aldosterone)
�� Leads to remodeling of the myocardial architectureLeads to remodeling of the myocardial architecture
�� function of each mass unit is normal or even increased: function of each mass unit is normal or even increased: �� enlargement of the muscle massenlargement of the muscle mass�� improvement of contractility of each mass unit … improvement of contractility of each mass unit … ↑ systolic ↑ systolic
functionfunction
�� the content of connective tissue does not increase … elasticity … the content of connective tissue does not increase … elasticity … diastolic functiondiastolic function
�� OrthopneaOrthopnea�� Dyspnea in horizontal positionDyspnea in horizontal position�� blood redistribution from distal parts into the heartblood redistribution from distal parts into the heart
�� Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea�� horisontal positionhorisontal position ++�� PSp. PSp. during sleepingduring sleeping→ → �� contractility andcontractility and�� activityactivity of centre of breathingof centre of breathing
EdemaEdema
�� RV HF!RV HF!
�� Swelling of ankles, feetSwelling of ankles, feet
�� Right hypochondrial pain: liver distensionRight hypochondrial pain: liver distension
�� Vasoconstriction: blood stagnating in tissues: cold, shock, HFVasoconstriction: blood stagnating in tissues: cold, shock, HF
�� Cold, pale auricles, nose, cheeks, external lips, tips of fingers and Cold, pale auricles, nose, cheeks, external lips, tips of fingers and toestoes
�� Central cyanosisCentral cyanosis
�� ↓ saturation↓ saturation
�� ↑ physical exercise, (inborn) heart defects with right↑ physical exercise, (inborn) heart defects with right--left shunts, left shunts, pulmonary diseases, HFpulmonary diseases, HF
�� TachycardiaTachycardia�� Distension of atrial / ventricular wallsDistension of atrial / ventricular walls
�� ↑ Sp. ↑ Sp. sstimulationtimulation
Changes of heart rhythmChanges of heart rhythm Third heart sound (S3)Third heart sound (S3)
�� S1:S1: closing of mitral and tricuspid valves during systoleclosing of mitral and tricuspid valves during systole
�� S2:S2: closing of aortic and pulmonary valves during closing of aortic and pulmonary valves during diastolediastole
�� S3: S3: �� at the end of diastole, the ventricle is forced to dilate beyond at the end of diastole, the ventricle is forced to dilate beyond its normal range because the atrium has overloaded volumeits normal range because the atrium has overloaded volume
�� normal in children, young adults and pregnant women in 3rd normal in children, young adults and pregnant women in 3rd trimestertrimester
�� pathologic in dilated heart overloaded with blood (HF, mitral pathologic in dilated heart overloaded with blood (HF, mitral regurgitation)regurgitation)
�� heard best with the bell of the stethoscope placed at the apex heard best with the bell of the stethoscope placed at the apex while the patient is in the left lateral decubitus positionwhile the patient is in the left lateral decubitus position
S1S1 S2 S3S2 S3
Cardiovascular continuumCardiovascular continuumFramingham criteria for diagnosis of HFFramingham criteria for diagnosis of HF**
•• Decrease in vital capacity by Decrease in vital capacity by
one third.one third.
The diagnosis of heart failure required 2 major or one major and 2 minor criteria. Minor criteria The diagnosis of heart failure required 2 major or one major and 2 minor criteria. Minor criteria
were only acceptable if they could not be attributed to another medical disorder. were only acceptable if they could not be attributed to another medical disorder.
* From Ho, KL * From Ho, KL et alet al The epidemiology of heart failure: The Framingham Study. The epidemiology of heart failure: The Framingham Study. J Am Coll Cardiol 22J Am Coll Cardiol 22(Suppl A): 6A, (1993). (Suppl A): 6A, (1993).
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NYHA classification of heart failureNYHA classification of heart failure
�� Class IClass I No limitation of physical activity.No limitation of physical activity.
�� Class IIClass II Slight limitation of physical activitySlight limitation of physical activity——
symptoms with ordinary levels of exertion (e.g. symptoms with ordinary levels of exertion (e.g.
walking up stairs).walking up stairs).
�� Class IIIClass III Marked limitation of physical activityMarked limitation of physical activity——
symptoms with minimal levels of exertion (e.g. symptoms with minimal levels of exertion (e.g.
dressing).dressing).
�� Class IVClass IV Symptoms at rest.Symptoms at rest.
Pathophysiological principles of HF Pathophysiological principles of HF
therapytherapy
�� ↓↓ requirements on the work of the heartrequirements on the work of the heart
�� Improvement of the output of the heartImprovement of the output of the heart
�� Improvement of the function of peripheral Improvement of the function of peripheral
organs: kidneys!organs: kidneys!
�� ↑ i.c. Ca2+↑ i.c. Ca2+
�� Inh. of Na+Inh. of Na+--K+ ATPase:K+ ATPase:
�� Accumulation of i.c. Na+ … stim. of Na+Accumulation of i.c. Na+ … stim. of Na+--Ca2+ exchanger … ↑ Ca2+ exchanger … ↑
�� At higher dosages may cause At higher dosages may cause ↑↑ heart rate, exacerbating myocardial heart rate, exacerbating myocardial ischemia.ischemia.
�� DopamineDopamine
�� Catecholamine, precursor to NECatecholamine, precursor to NE
�� Stimulates adrenergic and dopaminergic receptorsStimulates adrenergic and dopaminergic receptors
�� LowLow--dose: dilation within renal and splanchnic vasculature … dose: dilation within renal and splanchnic vasculature … ↑↑ diuresisdiuresis
�� Moderate doses: Moderate doses: ↑↑ cardiac contractility and heart ratecardiac contractility and heart rate
�� Higher doses: Higher doses: ↑↑ afterload through peripheral vasoconstriction.afterload through peripheral vasoconstriction.
�� in severe heart failurein severe heart failure
�� NorepinephrineNorepinephrine
�� catecholamine catecholamine
�� Stimulates beta1Stimulates beta1-- and alphaand alpha--adrenergic receptorsadrenergic receptors
�� ↑↑ cardiac muscle contractility, heart rate, and vasoconstrictioncardiac muscle contractility, heart rate, and vasoconstriction
�� ↑↑ blood pressure and afterloadblood pressure and afterload
�� ↑↑ afterload may result in afterload may result in ↓↓ cardiac output, cardiac output, ↑↑ myocardial oxygen demand, and myocardial oxygen demand, and cardiac ischemiacardiac ischemia
Inotropic agentsInotropic agents
�� Optimal ventricular filling for ideal utilization of Optimal ventricular filling for ideal utilization of
FrankFrank--Starling mechanismStarling mechanism
�� ↓ venous return to optimal level↓ venous return to optimal level
�� restriction of physical activityrestriction of physical activity
�� ↓ salt intake↓ salt intake
�� venodilatorsvenodilators
�� �� dyspnoedyspnoe
Modification of preloadModification of preload
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DiureticsDiuretics
�� Symptomatic relief, in the presence of edemaSymptomatic relief, in the presence of edema�� elimination of retained fluid and preload reductionelimination of retained fluid and preload reduction
�� hhelp counteract the sodium and water retention caused by activation elp counteract the sodium and water retention caused by activation of the RAASof the RAAS
�� Isosorbide dinitrate (nitroglycerin)Isosorbide dinitrate (nitroglycerin)�� firstfirst--line therapy for not hypotensive patients. line therapy for not hypotensive patients.
�� ↓↓ preload preload
�� mild mild ↓↓ afterloadafterload
�� rapid onset and offsetrapid onset and offset
�� Combine with Combine with hydralazinehydralazine�� ↓↓ systemic resistance (direct vasodilation of arterioles)systemic resistance (direct vasodilation of arterioles)
�� Nitroprusside (Nitropress)Nitroprusside (Nitropress)�� vasodilation and vasodilation and ↑↑ inotropic activity of the heart. At higher dosages, may inotropic activity of the heart. At higher dosages, may
exacerbate myocardial ischemia by increasing heart rate.exacerbate myocardial ischemia by increasing heart rate.
�� Nesiritide:Nesiritide: human BNPhuman BNP
Modification of afterloadModification of afterload
�� Inhibit production of Ang II (vasoconstrictor, growth factor) Inhibit production of Ang II (vasoconstrictor, growth factor) … … vasodilationvasodilation
�� Increase production of bradykinin (Increase production of bradykinin (vasodilationvasodilation, release of , release of NO, PGI2, cough, hypotension, angioedema)NO, PGI2, cough, hypotension, angioedema)
�� Reduce activity of Sp. Reduce activity of Sp.
�� UpUp--regulate regulate ββ--receptorsreceptors
�� Improve variation in heart rateImprove variation in heart rate
�� Improve baroreceptor functionImprove baroreceptor function
�� Improve autonomic functionImprove autonomic function
Aldosterone receptor antagonistsAldosterone receptor antagonists�� Management of edema from excessive aldosterone excretionManagement of edema from excessive aldosterone excretion
�� Competes with aldosterone for receptor sites in distal renal Competes with aldosterone for receptor sites in distal renal
tubules, tubules, ↑↑ water excretion while retaining potassium and water excretion while retaining potassium and
hydrogen ions hydrogen ions
�� spironolactonespironolactone
BetaBeta--adrenergic blockersadrenergic blockers�� ↓ sympathetic tone↓ sympathetic tone
�� DietDiet -- adequate general nutrition and, in obese patients, weight adequate general nutrition and, in obese patients, weight
reductionreduction
�� SaltSalt -- avoid high salt content foods (in severe cases of congestive heart avoid high salt content foods (in severe cases of congestive heart
failurefailure!)!)
�� FluidFluid -- urge overloaded patients and those with severe congestive heart urge overloaded patients and those with severe congestive heart
failure to restrict fluid intakefailure to restrict fluid intake
�� AlcoholAlcohol -- advise moderate alcohol consumption (abstinence in alcohol advise moderate alcohol consumption (abstinence in alcohol
related cardiomyopathy)related cardiomyopathy)
�� SmokingSmoking -- avoid smoking (adverse effects on coronary disease, adverse avoid smoking (adverse effects on coronary disease, adverse
haemodynamic effects)haemodynamic effects)
�� ExerciseExercise -- regular exercise should be encouragedregular exercise should be encouraged
�� VaccinationVaccination -- patients should consider influenza and pneumococcal patients should consider influenza and pneumococcal vaccinationsvaccinations