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Heart failure 2013 Pathophysiology

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Heart failure 2013 Pathophysiology

  1. 1. Congestive Heart Failure CHF 1. PathophysiologyMarch 2013 ghennersdorf DGK ESC SES
  2. 2. Epidemiology 2000 (US Database) 4.78 Mio. victims in USA 16 Mio. victims world wide 400.000 pts. incidence/year US 1.5 Mio. pts. incidence/year world wide 41810 deaths / year (USA) 17.5 Bill. $ direct costs (USA): mainly by hospitalization Fourfold hospitalization within the last 15 years No valid data for Tanzania so far!March 2013 ghennersdorf DGK ESC SES
  3. 3. Survival rates after CHF (effect of medical therapy) x x Braunwald x 1988* xMarch 2013 ghennersdorf DGK ESC SES
  4. 4. Definition of Heart Failure CHF (1)• Inability of the heart to meet the peripheral demands under rest or exercise conditions caused by – muscular dysfunction (systolic/diastolic) – mechanical disorder (valve disease) – combinationMarch 2013 ghennersdorf DGK ESC SES
  5. 5. Definition of Heart Failure CHF (2)• Definition by activity – resting HF – exercise HF• Definition by time course – Acute – ChronicMarch 2013 ghennersdorf DGK ESC SES
  6. 6. Definition of Heart Failure CHF (3)• New York Heart Association (NYHA) – I  no visible signs and symptoms – II  signs and symptoms at high level exercise – III  signs and symptoms at low level exercise – IV  no physical exercise possible, bed rest necessary Most valid functional definition throughout the world!March 2013 ghennersdorf DGK ESC SES
  7. 7. Definition of Heart Failure CHF (4)• Anatomical definition – Left sided heart failure • CHD (myocardial infarction) • disease of mitral or aortic valve • Cardiomyopathy of unknown origin (idiopathic) – Right sided heart failure • Pulmonary embolism • Pulmonary vascular hypertension • Mitral stenosisMarch 2013 ghennersdorf DGK ESC SES
  8. 8. acute heart failure: etiology• acute HF (left sided: pulmonary edema) – Myocardial infarction (w/wo cardiogenic shock) – Hypertensive heart disease • Acute CHF: hypertensive crisis-pulmonary edema) – Inflammation • Acute valvular disease (endocarditis) • Acute (peri-)myocarditis • Combination (pancarditis) – Pulmonary embolism (right sided CHF)March 2013 ghennersdorf DGK ESC SES
  9. 9. Cardiogenic shock: etiology• Special subset of HF: Cardiogenic shock – sudden onset with underlying disease (often triggered by large or multiple myocardial infarction); leading to: • organ perfusion deficit • organ failure • fast development of irrevesibilty • organ death, clinical death, biological death – Despite therapeutic improvement (PCI, IABP) 50-70% mortality rateMarch 2013 ghennersdorf DGK ESC SES
  10. 10. Left heart failure• Acute • Low output – Pulmonary edema – Classical term: CHD, – Cardiogenic shock HPT, RHD etc.• Chronic • High output – NYHA I-IV – Fever states – Anemia – Pregnancy – Hyperthyreoidism – Beri beri – AV fistulas – Paget diseaseMarch 2013 ghennersdorf DGK ESC SES
  11. 11. Chronic left heart failure Most common endpoint of multiple disorders of the left ventricleMarch 2013 ghennersdorf DGK ESC SES
  12. 12. Etiology of HF• chronic HF – Hypertensive heart disease: progressive muscle damage; hypertrophy; disatolic HF – Coronary heart disease: myocardial infarction – Valvular disease after acute/occult onset of endocarditis – Chronic myocarditis  „secondary“ cardiomyopathy – „Primary“ dilatative cardiomyopathy – Venous disease (deep vein thrombosis) right heart failureMarch 2013 ghennersdorf DGK ESC SES
  13. 13. Pathophysiology of Heart Failure• Manifestation types of heart failure – Systolic dysfunction – Diastolic dysfunction – Muscular hypertrophy – Dilatation and remodelingMarch 2013 ghennersdorf DGK ESC SES
  14. 14. Pathophysiology of Heart Failure: function control• Determinants of heart function – Normal conditions • Nervous (sympathetic) control – Heart rate – Contractility – Abnormal conditions • Pressure volume control: Frank-Starling mechanism FSM – Preload – AfterloadMarch 2013 ghennersdorf DGK ESC SES
  15. 15. CHF: the heart muscleMarch 2013 ghennersdorf DGK ESC SES
  16. 16. CHF: the heart muscle sarcomereMarch 2013 ghennersdorf DGK ESC SES
  17. 17. Cardiac function curves, different conditions, FSM Cardiac output 1 diuretics 2 vasodilators 3 Digitalis normal 3 2 HF, normal compliance: 1 systolic HF HF, reduced compliance diast. filling pressuresMarch 2013 ghennersdorf DGK ESC SES
  18. 18. Mortality and muscle damage: systolic CHFMarch 2013 ghennersdorf DGK ESC SES
  19. 19. Pathophysiology of Heart Failure• Schematic manifestation of systolic and diastolic dysfunction: stiff or enlarged ventricle• Stiffness caused by either hypertrophy, inflammation or storage diseases (amyloid)• Enlargement caused by increase of collagen (scar) deposition and/or tension load March 2013 ghennersdorf DGK ESC SES
  20. 20. Pathophysiology of chronic CHF: peripheral effects• Activation of the neurohumoral system – Activation of renal-adrenal system (renin- angiotensin system;RAS) – Activation of cardiac RAS – Deregulation of number and properties of cardiac ß-adrenoceptors (ß-AR) Vicious circleMarch 2013 ghennersdorf DGK ESC SES
  21. 21. Pathophysiology of Heart Failure: rebound effects RAS Activation, Myocardial Dysfunction ß-AR-activation DeregulationMarch 2013 ghennersdorf DGK ESC SES
  22. 22. Neurohumoral activation Organ damage Arteriosclerosis Vasocostriction Vascular hypertrophy Endothelial dysfunction Target LV Hypertrophy organs Fibrosis Remodeling Apoptosis GFR Proteinuria Aldosterone delivery Sclerosis of glomerulaMarch 2013 ghennersdorf DGK ESC SES
  23. 23. Acute heart failure • Some special issuesMarch 2013 ghennersdorf DGK ESC SES
  24. 24. Right heart failure• Acute – Pulmonary embolism – Right atrial masses (myxoma)• Chronic – Mitral stenosis – Pulmonary stenosis – Deep Vein Thrombosis – Idiopathic PAH – Acquired PAHMarch 2013 ghennersdorf DGK ESC SES
  25. 25. Right heart failure, causes Pulmonary emboli, extracted by operation Ritght atrial myxoma causing acute right heart failure and syncopeMarch 2013 ghennersdorf DGK ESC SES
  26. 26. Right heart failure: mitral stenosis Valve stenosisaffecting right heart muscle March 2013 ghennersdorf DGK ESC SES
  27. 27. Origin of pulmonary edema• Increased pumonary venous pressure (cardiogenic)• Decreased oncotic pressure (hypalbuminemia)• Negative pleural pressures (pneumothorax removal)• Permeability changes (alveolocapillary)• Idiopathic: high altitude, neurogenic, pumonary embolism, etc.)March 2013 ghennersdorf DGK ESC SES
  28. 28. Heart failure and heart rate• Primary rhythm disturbances causing HF – VF/VT (rare) – Atrial fibrillation, supraventricular tachycardia• Secondary rhythm disturbances – Atrial fibrillationMarch 2013 ghennersdorf DGK ESC SES
  29. 29. Heart failure and heart rateMarch 2013 ghennersdorf DGK ESC SES
  30. 30. The EndMarch 2013 ghennersdorf DGK ESC SES

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