This document discusses congestive heart failure (CHF). It provides epidemiological data on CHF, showing it affects millions of people worldwide and costs billions of dollars annually. It defines CHF as the heart's inability to meet circulatory demands and classifies it based on location (left vs right heart) and time course (acute vs chronic). Causes of acute and chronic CHF include myocardial infarction, hypertension, valvular diseases, and cardiomyopathies. The pathophysiology of CHF involves systolic and diastolic dysfunction that can lead to ventricular hypertrophy, dilation, and neurohormonal activation causing further organ damage.

1. Congestive Heart Failure CHF
1. Pathophysiology
March 2013 ghennersdorf DGK ESC SES

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. Survival rates after CHF
(effect of medical therapy)
x
x
Braunwald
x
1988*
x
March 2013 ghennersdorf DGK ESC SES

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)
– combination
March 2013 ghennersdorf DGK ESC SES

5. Definition of Heart Failure CHF (2)
• Definition by activity
– resting HF
– exercise HF
• Definition by time course
– Acute
– Chronic
March 2013 ghennersdorf DGK ESC SES

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. 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 stenosis
March 2013 ghennersdorf DGK ESC SES

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. 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 rate
March 2013 ghennersdorf DGK ESC SES

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 disease
March 2013 ghennersdorf DGK ESC SES

11. Chronic left heart failure
Most common endpoint
of multiple disorders
of the left ventricle
March 2013 ghennersdorf DGK ESC SES

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
failure
March 2013 ghennersdorf DGK ESC SES

13. Pathophysiology of Heart Failure
• Manifestation types of heart failure
– Systolic dysfunction
– Diastolic dysfunction
– Muscular hypertrophy
– Dilatation and remodeling
March 2013 ghennersdorf DGK ESC SES

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
– Afterload
March 2013 ghennersdorf DGK ESC SES

15. CHF: the heart muscle
March 2013 ghennersdorf DGK ESC SES

16. CHF: the heart muscle sarcomere
March 2013 ghennersdorf DGK ESC SES

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 pressures
March 2013 ghennersdorf DGK ESC SES

18. Mortality and muscle damage: systolic CHF
March 2013 ghennersdorf DGK ESC SES

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. 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 circle
March 2013 ghennersdorf DGK ESC SES

21. Pathophysiology of Heart Failure:
rebound effects
RAS Activation,
Myocardial Dysfunction
ß-AR-activation
Deregulation
March 2013 ghennersdorf DGK ESC SES

22. Neurohumoral activation
Organ damage
Arteriosclerosis
Vasocostriction
Vascular hypertrophy
Endothelial dysfunction
Target LV Hypertrophy
organs Fibrosis
Remodeling
Apoptosis
GFR
Proteinuria
Aldosterone delivery
Sclerosis of glomerula
March 2013 ghennersdorf DGK ESC SES

23. Acute heart failure
• Some special issues
March 2013 ghennersdorf DGK ESC SES

24. Right heart failure
• Acute
– Pulmonary embolism
– Right atrial masses (myxoma)
• Chronic
– Mitral stenosis
– Pulmonary stenosis
– Deep Vein Thrombosis
– Idiopathic PAH
– Acquired PAH
March 2013 ghennersdorf DGK ESC SES

25. Right heart failure, causes
Pulmonary emboli, extracted
by operation
Ritght atrial myxoma causing
acute right heart failure
and syncope
March 2013 ghennersdorf DGK ESC SES

26. Right heart failure: mitral stenosis
Valve stenosis
affecting right heart muscle
March 2013 ghennersdorf DGK ESC SES

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. Heart failure and heart rate
• Primary rhythm disturbances causing HF
– VF/VT (rare)
– Atrial fibrillation, supraventricular tachycardia
• Secondary rhythm disturbances
– Atrial fibrillation
March 2013 ghennersdorf DGK ESC SES

29. Heart failure and heart rate
March 2013 ghennersdorf DGK ESC SES

30. The End
March 2013 ghennersdorf DGK ESC SES