CVS Pathology 2: Heart Failure.

Question 1

Heart failure is often called what?

Answer 1

Congestive heart failure CHF.

Question 2

When does CHF occur?

Answer 2

When the heart is unable to pump blood at a rate sufficient to meet the metabolic demands to the tissue or can do so only at an elevated filling pressure.

Question 3

CHF is the common end stage of what?

Answer 3

Many forms of chronic heart disease, often developing insidiously from the cumulative effects of chronic work overload or ischemic heart disease (following myocardial infarction with heart damage).

Question 4

Give examples of chronic work overload conditions that can cause CHF?

Answer 4

Valve disease or hypertension.

Question 5

List things that can participate in sudden CHF?

Answer 5

Acute hemodynamic stresses, such as fluid overload, abrupt valvular dysfunction, or myocardial infarction.

Question 6

Which physiologic mechanisms maintain arterial pressure and organ perfusion, when cardiac workload increases or cardiac function is compromised?

Answer 6

1- frank-starling mechanism.
2- myocardial adaptations, including hypertrophy with or without cardiac chamber dilation (ventricular remodeling).
3- activation of neurohumoral (norepinephrine, renin-angiotensin and atrial natriuretic peptide).

Question 7

Heart failure can result from what? (2)

Answer 7

1- systolic dysfunction.
2- diastolic dysfunction.

Question 8

Pathophysiology and progression to heart failure:
Sustained increase in mechanical work due to _____ or _______ ______, or ______ ____, cause _____ to increase in size (______); cumulatively this increases the _____ and ____ of the heart.

Answer 8

Sustained increase in mechanical work due to pressure or volume overload, or trophic signals, cause myocytes to increase in size (hypertrophy); cumulatively this increases the size and weight of the heart.

Question 9

Give an example of increased mechanical work due to pressure or volume overload?

Answer 9

Systemic hypertension or aortic stenosis.

Question 10

Give an example of trophic signals?

Answer 10

Those mediated through the activation of beta adrenergic receptors.

Question 11

In pressure overload there is __________.
In volume overload hypertrophy there is _________.

Answer 11

In pressure overload > there is increase in wall thickness.
In volume-overload hypertrophy > there is ventricular dilation.

Question 12

What is the best measure of hypertrophy in dilated hearts?

Answer 12

Heart weight, rather than wall thickness.

Question 13

List the changes at the tissue and cell level in cardiac hypertrophy?

Answer 13

1- myocyte hypertrophy and apoptosis.
2- interstitial fibrosis.

Question 14

List the changes at the functional level in cardiac hypertrophy?

Answer 14

• Heightened metabolic demands.
• Increase cardiac oxygen,

Question 15

As a result of functional level changes in cardiac hypertrophy what happens to the hypertrophied heart?

Answer 15

It is vulnerable to ischemia-related decompensation, which can evolve to cardiac failure and eventually lead to death.

Question 16

List the 5 main causes of left ventricular failure?

Answer 16

1- volume overload.
2- pressure overload.
3- loss of muscle.
4- loss of contractility.
5- restricted filling.

Question 17

List examples of volume overload which causes left ventricular failure?

Answer 17

Regurgitant valves (mitral or aortic).
High output states: anemia, hyperthyroidism.

Question 18

List examples of pressure overload which causes left ventricular failure?

Answer 18

Systemic hypertension.
Outflow obstruction: aortic stenosis.

Question 19

List examples of loss of muscle which causes left ventricular failure?

Answer 19

Myocardial infarction from coronary artery disease.
Connective tissue disease: SLE.

Question 20

List examples of loss of contractility which causes left ventricular failure?

Answer 20

Poisons: alcohol, cobalt.
Infections: viral, bacterial.

Question 21

List examples of restricted filling which causes left ventricular failure?

Answer 21

Pericardial disease: constrictive pericarditis.

Question 22

List the 4 most common causes of left-sided cardiac failure?

Answer 22

1- IHD.
2- systemic hypertension.
3- mitral or aortic valve disease.
4- primary disease of the myocardium.

Question 23

The macroscopic findings in left sided ventricular heart failure depends on what?

Answer 23

Depends on the disease process.

Question 24

List the macroscopic findings in the heart in left-sided ventricular heart failure?

Answer 24

Left ventricle is usually hypertrophied and often dilated, sometimes massively.

Question 25

What are the microscopic findings in the heart in left ventricular heart failure?

Answer 25

Nonspecific and include:
Primarily myocyte hypertrophy.
Interstitial fibrosis.

Question 26

Secondary enlargement of the left atrium with resultant atrial fibrillation can do what?

Answer 26

1- reduce stroke volume.
2- lead to blood stasis and thrombus formation.

Question 27

List the macroscopic findings in the lungs in left ventricular heart failure?

Answer 27

Pulmonary congestion and edema produce heavy, wet lung.

Question 28

List the microscopic findings in the lungs in left ventricular heart failure?

Answer 28

1- perivascular and interstitial edema.
2- progressive edematous widening of alveolar septa.
3- accumulation of edema fluid in the alveolar spaces.
4- hemosiderin-laden macrophages in alveoli (heart failure cells).

Question 29

List the clinical features of left ventricular heart failure?

Answer 29

1- cough and dyspnea.
2- paroxysmal nocturnal dyspnea.
3- atrial fibrillation.
4- orthopnea.

Question 30

List the 4 main causes of right ventricular failure?

Answer 30

1- left sided failure.
2- precapillary obstruction.
3- primary right ventricular failure.
4- cor pulmonale.

Question 31

List examples of precapillary obstruction which causes right ventricular failure?

Answer 31

1- congenital (shunts).
2- idiopathic pulmonary hypertension.

Question 32

List an example of primary right ventricular failure which causes right ventricular failure?

Answer 32

Right ventricular infarction.

Question 33

List examples of cor pulmonale which causes right ventricular failure?

Answer 33

1- hypoxia-induced vasoconstriction.
2- pulmonary embolism.
3- chronic obstructive lung disease.

Question 34

List the 4 most common causes of right sided heart failure?

Answer 34

1- left ventricular failure.
2- intrinsic disease of the lung.
3- primary pulmonic or tricuspid valve disease.
4- congenital heart diseases (in the setting of left-to-right shunts).

Question 35

The cardiac morphology of right sided heart failure varies with what?

Answer 35

Varies with cause.
(same as left)

Question 36

Isolated right heart failure is most often caused by what?

Answer 36

Caused by lung disease.

Question 37

Since isolated right heart failure is most often caused by lung disease, most cases exhibit which morphology in the heart?

Answer 37

Only hypertrophy and dilation of the right atrium and ventricle.

Question 38

Bulging of the ventricular septum to the left causes what?

Answer 38

Causes dysfunction of the left ventricle.

Question 39

What is the morphology of the liver and portal system in right sided heart failure?

Answer 39

1- increased in size and weight (congestive hepatomegaly).
2- nutmeg appearance (congested red-brown pericentral zones, with relatively normal-colored tan periportal regions).

Question 40

When left sided heart failure is also present, what happens in the morphology of the liver and portal system in right sided heart failure?

Answer 40

Severe central hypoxia produces centrilobular necrosis.

Question 41

With longstanding severe right sided heart failure, the central areas can become ______, eventually culminating in _______?

Answer 41

Central areas can become fibrotic, eventually culminating in cardiac cirrhosis.

Question 42

Portal venous hypertension also causes what in right sided heart failure?

Answer 42

Causes enlargement of the spleen with platelet sequestration (congestive splenomegaly), and can also contribute to chronic congestion and edema of the bowel wall.

Question 43

What is the morphology of the pleural, pericardial, and peritoneal spaces in right sided heart failure?

Answer 43

1- systemic venous congestion can lead to fluid accumulation in the pleural, pericardial, or peritoneal spaces.
2- large pleural effusions can cause lung atelectasis.
3- the edema fluid in CHF has a low protein content.

Question 44

Peritoneal effusions are also called what?

Answer 44

Ascites.

Question 45

What is the morphology of the subcutaneous tissues in right sided heart failure?

Answer 45

1- edema of the peripheral and dependent portions of the body especially ankle (pedal) and pretibial edema.
2- chronically bedridden patients presacral edema may predominate.
3- generalized massive edema (anasarca) may also occur.

Question 46

What is the hallmark of right sided heart failure?

Answer 46

Edema of the peripheral and dependent portions of the body, especially (pedal) and pretibial edema.

Question 47

List the 2 management of heart failure?

Answer 47

1- mainly pharmacologic.
2- improving cardiac function by mechanical assist devices, and resynchronization of electrical impulses to maximize cardiac efficiency are newer approaches.

Question 48

List the 3 pharmacologic management of heart failure?

Answer 48

1- drugs that relieve fluid overload.
2- drugs that block renin-angiotensin-aldosterone axis.
3- drugs that lower adrenergic tone.

Question 49

Give an example of a drug that relieves fluid overload?

Answer 49

Diuretics.

Question 50

Give an example of a drug that blocks renin-angiotensin-aldosterone axis?

Answer 50

ACE inhibitors.

Question 51

Give an example of a drug that lowers adrenergic tone?

Answer 51

Beta 1 adrenergic blockers.