Heart failure 2013 Pathophysiology

Congestive Heart Failure CHF

1. Pathophysiology

March 2013 ghennersdorf DGK ESC SES

Epidemiology 2000 (US Database)


4.78 Mio. victims in USA4.78 Mio. victims in USA16 Mio. victims world wide16 Mio. victims world wide400.000 pts. incidence/year US400.000 pts. incidence/year US1.5 Mio. pts. incidence/year world wide1.5 Mio. pts. incidence/year world wide41810 deaths / year (USA)41810 deaths / year (USA)17.5 Bill. $ direct costs (USA): 17.5 Bill. $ direct costs (USA): mainly by hospitalization mainly by hospitalizationFourfold hospitalization within theFourfold hospitalization within the last 15 years last 15 years

No valid data for Tanzania so far!No valid data for Tanzania so far!

Survival rates after CHF (effect of medical therapy)


Braunwald 1988*

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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



• Definition by activity– resting HF– exercise HF

• Definition by time course– Acute – Chronic



• 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!


• 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


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)


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


Left heart failure

• Acute– Pulmonary edema– Cardiogenic shock

• Chronic– NYHA I-IV

• Low output– Classical term: CHD,

HPT, RHD etc.• High output

– Fever states– Anemia– Pregnancy– Hyperthyreoidism– Beri beri– AV fistulas– Paget disease


Chronic left heart failure


Most common endpoint of multiple disorders of the left ventricle

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


Pathophysiology of Heart Failure

• Manifestation types of heart failure– Systolic dysfunction– Diastolic dysfunction– Muscular hypertrophy– Dilatation and remodeling


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


CHF: the heart muscle


CHF: the heart muscle sarcomere


Cardiac function curves, different conditions, FSM


Cardiac output

diast. filling pressures

normal

HF, normal compliance:

systolic HF

HF, reduced compliance

1

23

1 diuretics2 vasodilators3 Digitalis

Mortality and muscle damage: systolic CHF


Pathophysiology of Heart Failure

• Schematic manifestationof systolic and diastolic dysfunction:stiff or enlarged ventricle

• Stiffness caused by eitherhypertrophy, inflammation or storage diseases (amyloid)

• Enlargement caused by increase of collagen (scar) deposition and/or tension load


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

RAS Activation, ß-AR-activation

Deregulation

Myocardial Dysfunction


Pathophysiology of Heart Failure: rebound effects

Neurohumoral activation


Organ damage

Target organs

ArteriosclerosisVasocostrictionVascular hypertrophyEndothelial dysfunction

LV HypertrophyFibrosisRemodelingApoptosis

GFR ProteinuriaAldosterone deliverySclerosis of glomerula

Acute heart failure

• Some special issues


Right heart failure

• Acute– Pulmonary embolism– Right atrial masses (myxoma)

• Chronic– Mitral stenosis– Pulmonary stenosis– Deep Vein Thrombosis– Idiopathic PAH– Acquired PAH


Right heart failure, causes


Pulmonary emboli, extracted by operation

Ritght atrial myxoma causingacute right heart failure and syncope

Right heart failure: mitral stenosis


Valve stenosis

affecting right heart muscle

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.)


Heart failure and heart rate

• Primary rhythm disturbances causing HF– VF/VT (rare)– Atrial fibrillation, supraventricular tachycardia

• Secondary rhythm disturbances– Atrial fibrillation


Heart failure and heart rate


The End


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Heart failure 2013 Pathophysiology