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Congestive Heart Failure (CHF)
This document provides information on heart failure (CHF), including: 1) CHF is a clinical syndrome that results from any structural or functional cardiac disorder that impairs the ventricle's ability to fill or eject blood. 2) The main mechanisms of CHF are increased blood volume, increased resistance to blood flow, decreased contractility, and decreased filling. 3) CHF can be compensated initially through mechanisms like the Frank-Starling mechanism and neurohormonal activation, but these can eventually worsen heart failure.
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Congestive Heart Failure (CHF)
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- 2. Normal Heart • Weightof the heart varies with body weight & height. • Males: 300 to 350 grams • Females: 250 to 300 grams • Usual thickness of • Right Ventricle: 0.3 to 0.5 cm • Left Ventricle: 1.3 to 1.5 cm Hypertrophy: Greater heart weight or Ventricular thickness Dilation: Enlarged chamber size Cardiomegaly: Increase in cardiac weight or size owing to hypertrophy and/or dilation
- 3. HEART MAy DIE Congestive Heart Failure (CHF) Impairedcardiac pumping such that heart is unable to pump adequate amount of blood to meet metabolic needs. Not a disease but a “syndrome”
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- 5. • A complexclinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. • Four Basic Mechanisms • Increased Blood Volume (Excessive Preload) • Increased Resistant to Blood Flow (Excessive Afterload) • Decreased contractility • Decreased Filling
- 6. Increased Blood Volume •Mitral Regurgitation • Aortic Regurgitation • Volume Overload • Left to Right Shunts • Chronic Kidney Disease Decreased Contractility • Ischemic Cardiomyopathy – Myocardial Infarction – Myocardial Ischemia • Myocarditis • Toxins – Anthracycline – Alcohol – Cocaine Decreased Filling • Mitral Stenosis • Constriction • Restrictive Cardiomyopathy • Cardiac Tamponade • Hypertrophic Cardiomyopathy • Infiltrative Cardiomyopathy Increased Afterload • Aortic Stenosis • Aortic Coarctation • Hypertension
- 8. Compensated Heart Failure •Frank-Starling mechanism, in which increased filling volumes dilate the heart and thereby increase subsequent actin-myosin cross-bridge formation, enhancing contractility and stroke volume • Myocardial adaptations, including hypertrophy with or without cardiac chamber dilation …ventricular remodeling • Activation of neurohumoral systems to augment heart function and/or regulate filling volumes and pressures. • Release of norepinephrine by adrenergic cardiac nerves of the autonomic nervous system • Activation of the renin-angiotensin-aldosterone system • Release of atrial natriuretic peptide.
- 9. Cardiac Physiology Cardiac Output Preload AfterloadContractility Heart Rate Stroke Volume= X
- 10. HYPERTROPHY • PRESSURE OVERLOAD… concentric increase in wall thickness • VOLUME OVERLOAD … ventricular dilatation • 2X normal weight … ischemia • 3X normal weight … HTN • >3X normal weight … cardiomyopathy, aortic regurgitation
- 11. Wall thickness vs.Heart weight
- 13. Hypertrophied heart is vulnerableto ischemia-related decompensation.
- 14. Decompensated Heart Failure •Compensatory mechanisms may restore CO to near-normal. • But, if excessive, the compensatory mechanisms can worsen heart failure because . . . • Vasoconstriction: ↑ afterload • Na and water retention: ↑ preload • Excessive tachycardia: ↓ diastolic filling time → ↓ CO
- 16. Not types, butcharacteristics of CHF. FORWARD FAILURE Variable degrees of decreased cardiac output and tissue perfusion. BACKWARD FAILURE Pooling of blood in the venous capacitance system
- 18. Usually CHF isthe common end stage of many forms of chronic heart disease. Chronic Acute Coronary Artery Disease Hypertensive HD Rheumatic Heart Disorders Congenital Heart Disorders Cor pulmonale Cardiomyopathy Anemia Bacterial endocarditis Valvular disorders Acute MI Arrhythmias Pulmonary emboli Thyrotoxicosis Hypertensive crisis Rupture of papillary muscle VSD Myocarditis
- 22. Left Sided HeartFailure • Lungs • pulmonary congestion and edema • heart failure cells • Kidneys • pre-renal azotemia • salt and fluid retention • renin-aldosterone activation • natriuretic peptides • Brain • Irritability, decreased attention, stupor • coma
- 25. Right Sided HeartFailure • Liver & Spleen • passive congestion (nutmeg liver) • Centrilobular necrosis • congestive splenomegaly • Pleura/Pericardium/Peritoneum • Pleural and pericardial effusions • Ascites • Transudates • Peripheral tissues • Ankle and pretibial edema • Anasarca
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- 33. Two types ofleft heart failure.
- 39. When the abnormality isprimary in and localized to the myocardium, the condition is called CARDIOMYOPATHY.
- 41. Functional pattern Ejection Fraction Mechanism of heart Failure CausesMyocardial dysfunction Dilated <40% ↓ contractility (systolic) Idiopathic, Alcohol, Peripartum, Genetic, Myocarditis, Hemochromatosis, Chronic anemia, Doxorubicin, Sarcoidosis Ischemic HD, Valvular HD, Hypertensive HD, Congenital HD. Hypertrophic 50-80% ↓ compliance (diastolic) Genetic, Friedreich ataxia, storage diseases, infants of diabetic mothers. Hypertensive HD, Aortic stenosis Restrictive 45-90% ↓compliance (diastolic) Idiopathic, Amyloidosis, Radiation-induced fibrosis Pericardial constriction Cardiomyopathy & Indirect Myocardial Dysfunction
- 42. Dilated Cardiomyopathy. Four chamber dilatation andhypertrophy are evident. There is granular mural thrombus at the apex of the left ventricle (white arrow). The coronary arteries were unobstructed. 12-32
- 43. Dilated Cardiomyopathy: Histology demonstratingvariable myocyte hypertrophy and interstitial fibrosis. (Collagen is highlighted as blue in this Masson trichrome stain.) 12-32 B
- 44. Arrhythmogenic Right VentricularCardiomyopathy (Arrhythmogenic Right Ventricular Dysplasia)
- 45. Right ventricular dysplasia: Adiposetissue nearly replaces the myocardium. This may occur from uncontrolled apoptosis of myocardium.
- 46. Hypertrophic Cardiomyopathy with asymmetricseptal hypertrophy The septal muscle bulges into the left ventricular outflow tract, and the left atrium is enlarged. 12- 34 Banana-like configuration of left ventricular cavity due to asymmetrical septal hypertrophy 12- 34 LA LV
- 47. Hypertrophic Cardiomyopathy: Histologic appearancedemonstrating disarray, extreme hypertrophy and characteristic branching of the myocytes as well as interstitial fibrosis characteristic of the hypertrophic cardiomyopathy. 12-34 B
- 48. Restrictive Cardiomyopathy • Itis a rare entity with multiple etiologies marked by a restriction of ventricular filling leading to reduced cardiac output. • Interstitial myocardial fibrosis is usually present. • Specific entities include: • Endomyocardial fibrosis • Loeffler endocarditis • Endocardial fibroelastosis • Restrictive cardiomyopathy can be idiopathic or associated with distinct diseases that affect the myocardium (radiation fibrosis, amyloidosis, sarcoidosis, metastatic tumors, products of inborn error of metabolism, iron overload).