CVPR 03-27-14 08-09am Heart Failure-Pathophysiology - Allen

Question 1

Poor forward blood flow in HF

Answer 1

= Low flow (decreased cardiac output) = Key requirement of HF

Question 2

Backward buildup of pressure in HF

Answer 2

= Congestion (increased filling pressures; retention of salt/fluids –> swelling); typically a response to low flow; almost always present as well

Question 3

Heart Failure – definition

Answer 3

A constellation of signs & symptoms caused by many possible abnormalities of heart function (i.e., it is a junk term); Inability of heart to pump blood forward at a sufficient rate to meet metabolic demands of the body (forward failure – low flow), or the ability to do so only if the cardiac filling pressures are abnormally high (backward failure - congestion)

Question 4

The Heart as a Displacement pump – function & dysfunction

Answer 4

Displacement pumps Squeeze (contraction/systole) and Relax (filling /diastole); Failure of either systole or diastole causes HF

Question 5

The heart as double pumps – function & dysfunction

Answer 5

The heart is a double pump, with right (body to lungs; less work) and left (lungs to body) sides in series; In HF, the left, right or both can fail

Question 6

Electrical coordination of the heart - – function & dysfunction

Answer 6

Heart rate & contraction is coordinated in the heart; In HF, it can be too slow, too fast, or asynchronous, all of which decrease the efficiency of the heart & dysfunction

Question 7

Valves of the heart – function & dysfunction

Answer 7

The heart contains 4 valves (inflow valve + outflow valve for each ventricle) to ensure a unidirectional flow of blood through; In HF, a pt may have regurgitation (backflow) or stenosis (resistance), which both stress the heart

Question 8

Coronary arteries of the heart – function & dysfunction

Answer 8

The heart is supplied by coronary arteries; In HF, myocardium will die in minutes w/out adequate blood flow (very metabolically active); cause ex: atherosclerotic coronary artery disease

Question 9

Pericardium – function & dysfunction

Answer 9

The pericardium encases the heart; If there is fibrosis or other pericardial problems that compress the heart, there may be HF

Question 10

Key mediators of Blood Flow

Answer 10

Inotropy (contraction), Preload increase Stroke Volume, while Afterload decreases SV…..SV (100mL/squeeze) and HR (60 bpm) increase Cardiac Output (6L; which is the job of the heart = to pump blood)… in real pts, all of these factors can be changing at the same time (Pt has MI —> stiffer walls = can’t squeeze or fill as well, at the same time)

Question 11

Preload & the Force Tension Relationship

Answer 11

Greater filling (Increased Preload) —> Greater stretch of cardiac myocytes (diastolic pressure) —> Greater ventricular output; Frank Starling Curves show Left Ventricular End-Diastolic pressure (LVEDP, i.e. filling) vs. Stroke Volume (contraction/output); Thus increased Preload produces increased SV (& thus CO) for the same inotropic state.

Question 12

Inotropy and SV/CO

Answer 12

Aka contractility; Same filling (preload) of left ventricle produces greater squeeze of contraction (determined by catecholaminergic/adrenergic stimulation & Ca2+); Thus, greater Inotropy produces increased SV (& thus CO) for the same level of preload

Question 13

Major divisions of HF

Answer 13

Systolic HF (Dilated heart – increased space inside) vs. Diastolic HF (Hypertrophied heart – increased wall muscle mass); Left-sided vs. Right-sided

Question 14

Loss of contractility (inotropy) – mechanism & type of HF

Answer 14

Weak/damaged myocardium —> systolic failure (heart isn’t squeezing as well and so volume has gotten bigger/dilated)

Question 15

Systolic dysfunction – basic problem & hallmarks

Answer 15

A problem with squeezing (decreased contraction/inotropy); To solve, try to make up for it by increased filling (preload; via salt/water retention) Hallmark = decreased ejection fraction (“HF with reduced ejection fraction,” HFrEF, or “left ventricular systolic dysfunction,“ LSVD) AND Ventricular enlargement/dilation (“dilated cardiomyopathy,” DCM)

Question 16

Primary causes of systolic HF

Answer 16

1. Direct destruction of heart muscle cells (MI, viral myocarditis, alcohol, etc.)…….2. Overstressed heart muscle (Tachycardia-mediated HF, Meth/Cocaine, Stress-provoked or tako-tsubo cardiomyopathy, etc.)…….3. Volume overloaded heart muscle (Mitral regurgitation, High CO – shunting of blood, wet beriberi [thiamine B1 deficiency], etc.)

Question 17

Difficulty filling – mechanism & type of HF

Answer 17

Stiff/noncompliant heart (decreased lusitropy/relaxation/filling) —> diastolic heart failure (heart can’t relax as well, so the heart muscle hypertrophies – size of wall increases, heart size may be normal, no dilation; must raise filling pressure to get blood in and fill)

Question 18

Diastolic dysfunction – basic problem & hallmarks

Answer 18

Impaired filling (decreased lusitropy/relaxation); Hallmarks: Normal ejection fraction (“HF with preserved ejection fraction,” HFpEF, or “preserved systolic function,” PSF) AND Ventricular wall thickening (“left ventricular hypertrophy,” LVH)

Question 19

PV Loop in Systolic HF

Answer 19

Loss of inotropy produces decreased SV and decreased generated systolic BP

Question 20

PV Loop in Diastolic HF

Answer 20

Increased stiffness requires increased pressure to achieve same LV filling volume —> produces decreased SV

Question 21

Primary causes of diastolic HF

Answer 21

1. High afterload/pressure overload (long-standing HTN, aortic stenosis, dialysis w/inadequate volume removal)…….2. Myocardial thickening/fibrosis (Hypertrophic cardiomyopathy, Primary restrictive cardiomyopathy)…….3. External compression (Pericardial fibrosis/constrictive pericarditis, Pericardial effusion)

Question 22

Normal Right-sided heart function vs Left (amount of work/pressure)

Answer 22

Normally, the right ventricle pumps the same amount of blood as the left ventricle, but does so against much lower pressure (normal systolic BP = 120/80; Normal pulmonary BP = 22/10)….RV work is much less and thus RV is a thin-walled structure

Question 23

Right-sided heart failure - types

Answer 23

Stresses to the RV can cause it to fail to adequately pump blood through the lungs, which causes….1. Decreased circulating blood flow (forward RV HF)….2. Increased venous pressures (backward RB HF)

Question 24

Primary causes of Right-Sided HF

Answer 24

1. Left HF (backward HF from LV dysfunction stresses the right side by increases pulmonary venous pressures)…..2. Lung disease/pulmonary HTN/RV pressure overload (RV HF is called “cor pulmonale” when caused by primary lung disease– COPD, primary pulmonary HTN, sleep apnea)…..3. RV volume overload (shunt b/c of interarterial septal defect; tricuspid regurgitation)…..4. Damage to RV myocardium (isolated RV infarct, Myocarditis)

Question 25

Clinical Coexistance of HF forms

Answer 25

Systolic dysfunction is typically accompanied by diastolic dysfunction and vice versa—Examples: Fibrosis (scar tissue can’t contract/relax); Ischemia (relaxation is energy dependent); …..LV failure often causes RV failure.

Question 26

The cycle of heart failure – problem & body’s solutions

Answer 26

Problem: Decreased cardiac output…..Solution: Compensatory responses (Neurohormonal activation, Increased preload via Frank-starling mechanism, Ventricular hypertrophy & dilation)

Question 27

The two types of Neurohormal responses to decreased CO

Answer 27

1. Renin-Angiotensin-Aldosterone System (RAAS); 2. Autonomic NS / Adrenergic activation

Question 28

Mechanism of normal neurohormonal response to decreased CO

Answer 28

Dehydration/Bleeding —> decreased LV filling —> decrease CO —> 1. Juxtaglomerular apparatus in kidney senses low flow & Renin-Angiotensin-Aldosterone system kicks in to cause Na+ retention & vasoconstriction….2. The carotid sinus / aortic baroreceptors sense low pressure and the autonomic nervous system / adrenergic system is activated to increase HR and cause vasoconstriction —> Both of these processes cause increase volume

Question 29

Neurohormonal activation in Hear Failure

Answer 29

The body can’t distinguish between low blood flow from dehydration vs. from HF; goes through same mechanism in HF as it would w/dehydration –> Shorter gain for Long-term loss…RAAS causes Na+ retention & vasoconstriction, Carotid sinus / aortic baroreceptors activate ANS / adrenergic system to increase HR & cause vasoconstriction —> Both cause increased volume —> HOWEVER, in this case there are SUPRANORMAL FILLING PRESSURES added to the HF problems, causing high filling pressures that push fluid into lungs & cause pulmonary edema

Question 30

Decreased Contractility in HF & Frank Starling Compensations

Answer 30

Stoke volume decreases in HF with decreased contractility; Frank Starling allows SV to be preserved by increasing End-Diastolic Filling/Pressure

Question 31

Chronic Neurohormonal Activation Promotes HF

Answer 31

HF begets HF b/c short-term responses is causing long-term problem; Increased Cardiac workload or Metabolic demands, Ventricular hypertrophy/dilation, Myocardial damage/fibrosis —> Heart Failure —> 1. Adrenergic Activation leading to Vasoconstriction, Tachycardia, Inotropic augmentation….2. Renin-Angiotensin Activation leading to Vasoconstriction, Salt/Water Retention —> more HF

Question 32

Cardiac Remodeling

Answer 32

Late: Mechanical stress & Neurohormonal activation (Norepi, Angiotensin, Aldosterone) on Cardiac muscle cells —> “Remodeling” Growth (Hypertrophy, Hyperplasia), Necrosis, Fibrosis —> Consequences: Decreased contractile force & dynamic function, Increased diastolic stiffness

Question 33

Compensation for low CO – Decreased Contractility

Answer 33

Hypertrophy / Dilation

Question 34

Compensation for low CO – Decreased Preload

Answer 34

Sodium/fluid retention

Question 35

Compensation for low CO – Decreased Heart Rate

Answer 35

Tachycardia