Pathophysiology of CHF

CHF What is CHF? Fix the underlying problem Heart is a 2 sided pump Both sides can fail independent of each other.

CHF What different types of pathophysiology cause it? Systolic Dysfunction Diastolic Dysfunction High Output States

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

CHF Diastolic Dysfunction – What is it? –1. Impaired Relaxation –2. Obstruction to filling Can systolic and diastolic functions coexist?

CHF Pressure volume loops are used to distinguish between systolic vs. diastolic dysfunction

CHF High Output States – What is it? –Paget’s Disease –Anemia –Thiamine Deficiency –Hyperthyroidism

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

CHF What is looks like:

CHF Compensations Frank Starling –Length Tension Mechanism

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?

CHF Compensations Hoarseness:

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?

CHF Compensation L sided failure and the lungs continued… –Pulmonary congestion

CHF Compensation L sided failure and lungs continued… –Pulmonary Hypertension –Does pulmonary hypertension happen immediately?

L sided Compensation L sided failure and CXR –Cephalization –Indistinct vessels, Kerly B-Lines –Whited Out lungs fields

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

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

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.

CHF Compensations What happens when this blood backs up? –Liver Congestion  –Gastrointestinal Tract Nutmeg Liver

CHF Compensations What happens when this blood backs up continued… –Pitting Edema Frank Starling Forces Stasis Dermatitis P02?

CHF Compensations JVD – jugular venous pressure chart

CHF Compensations Acute R sided failure –Causes? –Would you expect to see any change to the R ventricle?

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

CHF complications Would you expect someone with R sided failure only, that is, no L sided failure, to have pulmonary hypertension or pulmonary edema?

CHF Compensations Neurohormonal changes: –Renin-Angiotensin System –Adrenergic System –ADH

CHF Compensations Renin-Angiotensin System – raise EABV, and lower plasma oncotic p.

CHF Compensations Does the Renin-Angiotensin System restore EABV back to normal? Why is this harmful in the end?

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?

CHF Compensations Does the adrenergic system restore the EABV? Why is this harmful in the end?

CHF Compensations ADH secretion –Why do its effects become blunted in long run?

CHF Compensations Ventricular Remodeling