Pathophysiology of Congestive Heart Failure Flashcards
Heart Failure
- Definition
- Systolic factors that contribute to HF
- Diastolic factors that contribute to HF
- Extracardiac factors that contribute to HF
- Definition
- Clinical syndrome
- Heart can’t pump blood at a rate commensurate w/ the metabolic requirements of the body (or does so only w/ elevated ventricular filling pressures)
- Systolic factors that contribute to HF
- Cardiomyopathies (e.g., ischemic, dilated, infeciton, peripartum, drug/toxin, inflammatory, late hypertropihc, cardiomyopathy, endocrinopathy)
- Valvular (e.g., aortic stenosis)
- Diastolic factors that contribute to HF
- Cardiomyopathies (e.g., infiltrative, hypertensive, early ischemia, hypertrophic)
- Valvular disease (e.g. mitral stenosis)
- Pericardial disease (e.g., constriction)
- Endocardial disease (e.g., endomyocardial fibrosis)
- Myocardial disease (e.g., amyloidosis)
- HTN w/o cardiomyopathy
- Age
- Gender (esp women)
- Extracardiac factors that contribute to HF
- Renal failure
- Excess hydration (e.g., IV fluids, blood transfusion)
- High output failure (e.g., anemia, hyperthyroidism)
- Liver disease
- Malnutrition (e.g., hypoalbuminemia)
Pathophysiology of HF
- Low cardiac output
- Reflects…
- Symptoms
- Signs
- Excess volume
- Reflects…
- Symptoms
- Signs
- Low cardiac output
- Reflects…
- Inability to delivery sufficient blood flow (& oxygen) to other organs
- Symptoms
- Decreased appetite
- Weakness & fatigue
- Poor sleep
- Forgetfulness
- Signs
- Decreased mentation & confusion
- Cool extremities
- Cyanosis / pallor
- Renal dysfunction
- Reflects…
- Excess volume
- Reflects fluid retention within…
- Intravascular spaces (distended jugular veins, elevated JVP, S3)
- Interstitial spaces (wet crackles or rales, dependent edema)
- Both intravascular & interstitial spaces (hepatic congestion)
- Symptoms
- Shortness of breath (orthopena when laying flat)
- Nocturnal dyspnea
- Dependent edema
- Abdominal bloating
- RUQ tenderness
- Signs
- Distended jugular veins
- Elevated JVP
- Wet crackles or rales
- S3
- Liver congestion
- Ascites
- Pedal or sacral edema
- Reflects fluid retention within…
HF Classifying & Staging Symptoms
- NYHA functional class
- ACC/AHA HF stages
- Comparison
- ACC/AHA HF stage A
- NYHA class
- ACC/AHA HF stage B
- NYHA class I
- ACC/AHA HF stage C
- NYHA class II
- NYHA class III
- ACC/AHA HF stage D
- NYHA class IV
- ACC/AHA HF stage A
- NYHA functional class
- Based on the ability or inability to perform routine daily activities
- Dependent on the level of physical incapacitation due to HF related symptoms at the time of evaluation
- Dynamic
- Respond well to medical therapy –> decrease NYHA class
- Symptoms worsen –> increase NYHA class
- ACC/AHA HF stages
- Progressive illness
- Begins w/ the presence of existing risk factors
- Stages aren’t reversible even if symptoms improve w/ medical therapy
- Comparison
-
ACC/AHA HF stage A: predisposing condition (e.g., HTN, CAD) for HF, no structural or funcitonal abnormalities
- NYHA class: no comparable class
-
ACC/AHA HF stage B: structural (e.g., valve disease) & functional abnormalities associated w/ HF, no signs/symptoms
- NYHA class I: no limitation of ordinary physical activity from fatigue, dyspnea, palpitations, etc.
-
ACC/AHA HF stage C: structural/functional abnormalities + prior/current signs/symptoms of HF
- NYHA class II: slight limitation of ordinary physical activity but still able to perform them, comfortable at rest
- NYHA class III: marked limitation & symptoms at less-than-ordinray physical activities (e.g., dressing, bathing)
-
ACC/AHA HF stage D: advanced structural/functional disease + marked HF symptoms at rest depsite max medical therapy, require specialized interventions
- NYHA class IV: unable to carry out any physical activity, symptoms of cardiac insufficiencty at rest, discomfort increased w/ minimal activity (e.g., talking, eating)
-
ACC/AHA HF stage A: predisposing condition (e.g., HTN, CAD) for HF, no structural or funcitonal abnormalities
HF vs. Cardiomyopathy
- Cardiomyopathies
- Depend on the nature of organ involvement & relative involvement of extra-cardiac disease
- Cause myocardial dysfunction & arrhythmias
- May or may not cause systolic myocardial dysfunction
- Ex. WPW syndrome manifests primarily w/ arrhythmias w/ no effect on systolic or diastolic function
- Cardioyopathies in literature
- Common to describe myocardial dysfunction resulting from other CV abnormalities (e.g., ischemic, valvulra, hypertensive, congenital) as specific cardiomyopathies
- Even though they’re not really included in the classificaiton of primary or secondary cardiomyopathies
- These diseases of myocardial dysfunction result from other primray CV diseases
- Common to describe myocardial dysfunction resulting from other CV abnormalities (e.g., ischemic, valvulra, hypertensive, congenital) as specific cardiomyopathies
Systolic vs. LV Diastolic Dysfunction
- Systolic dysfunction
- Defect in the ability of heart myofibrils to shorten against increased load
- Found in both symptomatic & asymptomatic patients
- Can occur after an MI due to cardiac structural changes (i.e., LV remodeling)
- Can occur as the end-stage of chronic heart disease (e.g., hypertensive or valvular heart disease)
- LV diastolic dysfunction
- Impaired LV filling at normal LA pressure
- More common in elderly & women
- Reponsible for up to 40-50% of HF in adults
- Many patients have both LV systolic & diastolic dysfunction
HF Epidemiology
- Cardinal manifestations of HF
- Age
- Gender
- LV dysfunction causes both…
- Patients w/ preserved EF
- Factors that impact HF mortality
- HF survival
- Medicaire
- Goals of therapy
- Short term
- Long term
- Cardinal manifestations of HF
- Dyspnea
- Fatigue
- Fluid retention
- Age
- Increase age –> increase HF incidence (esp after 45yo)
- Increase age –> increase other diseases (e.g., HTN, DM, obesity) –> survive early stage cardiac disease (ex. acute MI) –> old enough for HF
- Gender
- Women have better survival than men
- HF in women is more commonly associated w/ diastolic HF which has a better survival risk than systolic HF
- LV dysfunction causes both…
- Systolic dysfunction: imparied ability to pump blood (worse prognosis)
- Diastolic dysfunction: impaired ability to fill w/ blood (better prognosis)
- Patients w/ preserved EF
- Often have other co-morbidities that increase risk of death
- Directly related to HF (e.g., valvular disease, CHD, HTN)
- Indirectly related (e.g., renal disease, DM, obesity)
- Factors that impact HF mortality
- Etiology of cardiac & myocardial disease
- Severity of symptoms (not always related to cardiac disease severity)
- Severity of LV dysfunction
- Pharmacologica & non-pharmacologic therapies
- ICD: reduce risk of arrhythmic deat, allow HF paitens to survive later disease stages & pump failure
- Ventricular assist devices: increase survival w/o transplant, avoid pump failure related death, but may still develop arrhythmias or infection- or end-organ-failure-related death
- HF survival
- Improved but still dismal
- Poor prognosis
- Sudden death –> most deaths in patients w/ HF, esp in lower NYHA classes
- Better prognosis: dilated, non ischemic, asymptomatic
- Medicaire
- More $ is spent for diagnosing & treating HF than any other diagnosis
- Goals of therapy
- Short term: relieve symptoms & improve quality of life
- Long term: prolong life by slowing & reversing the progressive course of the disease
Normal Pressure-Volume Relationship
- Point A
- Line AB
- Point B
- Line BC
- Point C
- Line CD
- Point D
- Line DA
- Shaded area

- Point A: end diastole
- Line AB: isovolumic contraction during LV systole
- Myofibrils begin to contract but no ejection occurs
- Allows LV to generate enough pressure to overcome peripheral arterial resistance & deliver blood forward (cardiac output)
- Point B: aortic valve opening
- Line BC: ejection of blood into aorta
- Difference in LV volume = stroke volume
- Point C: aortic valve closure, end systole
- Line CD: isovolumic relaxation during LV diastole
- Myofibris relax/stretch to allow LV pressure to fall below LA pressure so blood can passively move across the mitral valve
- Factors that impair this phase (e.g., ishcemia, myocardial infiltration, inflammation) –> diastolic HF
- Point D: mitral valve opening
- Line DA: LV diastolic filling
- Shaded area: external LV stroke work
Pressure-Volume Relationship Dysfunction
- Systolic dysfunction
- PV loop changes
- How HF develops
- Diastolic dysfunction
- PV loop change
- How HF develops
- Coexisting systolic & diastolic dysfunction
- Systolic dysfunction
- PV loop changes
- PV loop shifts to the right
- Less steep nd-systolic PV relationship (contractility) –> increased LVEDP
- How HF develops
- LV requires increased LVEDP & LVEDV to maintain SV & CO
- PV loop changes
- Diastolic dysfunction
- PV loop changes
- Bottom curve shifts upward
- Decreased LVEDV –> increased LVEDP to maintain volume
- How HF develops
- LVEDP is increased during LV filling for any given blood volume
- LV compliance worsens –> increased LVEDP –> decreased SV (pre-load dependence)
- PV loop changes
- Coexisting systolic & diastolic dysfunction
- Systolic dysfunction –> hypertrophy & fibrosis –> decrease compliance –> impair LV filling –> disrupt diastolic function
- Underlying hemodynamic presses differ

Frank-Starling Curve
- Normal ventricles
- LV systolic dysfunction
- Effect of decreased contractility
- Curve changes
- Mild vs. severe dysfunction
- Factors that may contribute to a plateau in the presence of pressure-volume curve
- Normal ventricles
- Steep & positive relationship b/n LV filling pressures (LVEDP) & SV or CO
- LV systolic dysfunction
- Decrease contractility –> decrease CO & SV
- –> increase sympathetic activity –> increase contractility & HR –> restore cardiac output
- –> renal salt & water retention –> expand blood volume –> increase end-diastolic pressure –> enhance ventricular performance –> restore SV
- Curve changes
- Curve shifts to the right: higher filling pressures are needed to achieve the same CO
- Curve flattens: increasing LV filling pressures has less of an effect on increasing CO
- Mild vs. severe dysfunction
- Mild: initial reduction in cardiac function can be overcome by raising the LVEDP & via fluid retention
- Severe: stroke volume isn’t recoverable, & continued incresaed in LVEDP & fluid retention –> pulmonary edema
- Decrease contractility –> decrease CO & SV
- Factors that may contribute to a plateau in the presence of pressure-volume curve
- Heart reaches its max capacity to increase contractility in response to increasing stretch
- Sarcomeres lengthen to more-than-optimal degree of overlap of thick & thin myofilaments
- –> decrease Ca2+ affinity for / binding to troponin C
- –> decrease Ca2+ available within myocardial cells
- –> prevents LV from increasing contractile force in response to increased load
- Reduce in cardiac complicance
- Reduced compliance –> small increase in volume produces a large elevation in LVEDP –> not substantial stretching of the cardiac muscle –> little change in cardiac output
- Heart reaches its max capacity to increase contractility in response to increasing stretch

Determinants of Cardiac Performance
- Preload
- Afterload
- Contractility
- Relaxation
- Heart rate
- Preload, afterload, contractility & relaxation influence SV
- HR * SV = CO
Preload
- Definition
- Determined by…
- Effect on SV & LVEDV
- Factors that influence preload (venous return to the heart)
- Total body volume
- Body position
- Venous tone
- Atrial contraction
- Skeletal muscle contraction
- Intrapericardial pressure
- Intrathoracic pressure
- Measures of preload
- Effect on myocardial fibers
- Definition
- Hemodynamic load on the myocardial wall (or fiber stretch) at the end of diastole just before contraction begins
- Creates wall tension
- Determined by…
- Venous return to the ventricle
- Any regurgitant blood across the aortic valve (LV preload) or pulmonic valve (RV preload)
- Effect on SV & LVEDV
- Decrease preload
- –> decrease SV (normal individuals)
- –> increase SV (patients w/ HF
- –> decrease LVEDV
- Factors that influence preload (venous return to the heart)
- Venous return
- Decrease venous return –> decrease preload
- Increase venous return –> increase preload
- Total body volume
- Dehydration / blood loss –> decrease preload
- Hydration / transfusion –> increase preload
- Body position
- Supine to upright –> decrease preload
- Upright to sitting/supine –> increase preload
- Venous tone
- Venodilation –> decrease preload
- Venoconstriction –> increase preload
- Atrial contraction
- Atrial fibrillation –> loss of atrial contraciton –> decrease preload
- Sinus rhythm –> restore atrial contraction –> increase preload
- Skeletal muscle contraction
- Muscle inactivity –> decrease venous return –> decrease preload
- Muscle activity –> increase venous return –> increase preload
- Intrapericardial pressure
- Cardiac tamponade –> decrease preload
- Pericardiocentesis –> increase preload
- Intrathoracic pressure
- Expiration / pneumothorax –> decrease preload
- Inspiration –> increase preload
- Venous return
- Measures of preload
- Key measure: LVEDV
- Other measures
- LVEDP
- Pulmonary capillary wedge pressure –> LA pressure
- Central venous pressure –> RA pressure
- LVED diameter
- End-diastolic wall tension
- Sarcomere length
- Effect on myocardial fibers
- Decrease preload –> insufficient ventricle filling during diastole –> submaximal stretch –> myocardial ocntraction doesn’t occur w/ optimal force
- Increase preload –> ventricle overfilling –> overstretch mycoardial fibers –> exceed contractile capacity

Afterload
- Definition
- Determined by…
- Drugs that improve cardiac output
- Effect on SV & LVEDV
- Measures of afterload
- Definition
- Force that resists myocardial contraction & blood volume ejection out of the ventricle during systole
- Force that mycoardial fibers must overcome in order to shorten
- Tension in the myocardium during active contraction
- Determined by…
- Resistance against which the myocardium is contracting
- Degree of myocardial shortening
- Increase afterload –> decrease myocardial shortening –> decrease SV
- Systolic HF: ventricle is very sensitive to afterload, so increase afterload –> greater decrease in SV
- Drugs that improve cardiac output
- Arterial vasodilators (ACE-Is, angiotensin receptor blockers) increase SV
- Effect on SV & LVEDV
- Decrease afterload
- –> increase SV
- –> decrease ESV –> decrease LVEDV
- LV doesn’t need to generate the same pressure to eject blood forward, so LV can decrease EDV
- Measures of afterload
- Total systemic peripheral resistance (arterial BP)
- More convenient & readily obtainable estimate of afterload in absence of aortic stenosis or atherosclerosis
- LV pressure (aortic valve stenosis)
- More comprehensive measure of LV afterload w/ aortic stenosis or atherosclerosis
- RV pressure (pulmonic valve stenosis, pulmonary hypertension))
- Aortic pressure
- Arterial impedance
- Myocardial peak wall stress (affected by LV geometry)
- Total systemic peripheral resistance (arterial BP)

Contractility
- Inotropy
- Contractility
- Effect on SV & LVEDV
- Measures of contractility
- Inotropy / contractility
- Increase myocardial contractility –> increase SV
- Describes the forces created by Ca2+ dependent binding b/n myosin & actin
- Contractility vs. afterload & preload
- Increase afterload –> increase contractility to maintain SV
- Also increase LV pressure during isovolumic contraction to maintain systolic ejection
- Increase preload –> don’t necessarily need to adjust contractility to maintain SV
- Increase afterload –> increase contractility to maintain SV
- Effect on SV & LVEDV
- Increase contractility
- –> increase SV & CO –> decrease ESV
- –> decrease LVEDV but not to the same degree as afterload reduction (essentially no effect)
- LV still needs to generate higher pressures to eject blood volume into the aorta than if there were also afterload reduction
- Need to maintain a greater LV volume in systolic HF
- Measures of contractility
- Fractional shortening
- Ejection fraction
- Cardiac output
- Stroke volume

Relaxation & Heart Rate
- Compliance
- Compliance vs. pressure
- Heart rate
- Compliance = ∆V / ∆P
- ∆V = ∆ volume = LVEDV - LVESV
- ∆P = ∆ pressure = LVEDP - LVESP
- Compliance vs. pressure
- Increase compliance –> decrease pressure for any increase in volume
- Decrease compliance –> increase pressure for any increase in volume
- Heart rate
- CO = SV * HR

Wall tension
- Increased & decreased by…
- Transient vs. chronic changes
- Laplace relationships
- What happens in a chronically volume overloaded state
- Increased & decreased by…
- Increased by…
- Signs of failing LV
- Intracardiac diameter/radius of the LV from remodeling
- Intracardiac pressure from volume overload
- Decreased by…
- Increased wall thickness
- Increased by…
- Transient vs. chronic changes
- Transient changes –> little damage or injury
- Chronic changes –> persistent or permanent changes to the myocardium over time (ex. HTN)
- Laplace relationships
- How risk factors for HF –> copmensatory changes ot the myocardium & LV over time
- Ex. HTN –> increased afterload –> increased pressure –> chornic exposure to increased wall tension –> LV wall thickening –> hypertrophy
- What happens in a chronically volume overloaded state
- Increase volume –> increase preload –> increase LVEDP –> decrease SW –> dilated LV
- –> LV can accommodate increased volumes at reduced pressure & still maintain optimal interaction b/n myosin & actin

Hemodynamic Pathophysiology Summary
- Pressure-volume loops describe…
- Frank-Starling curves describe…
- Preload affects…
- Afterload affects…
- Stroke volume
- Contractility
- Laplace relationship
- LV compliance
- Pressure-volume loops describe…
- Pressure-volume relationship throughout the cardiac cycle
- Systolic & diastolic dysfunction separately (may co-exist)
- Frank-Starling curves describe…
- Impact of LVEDV on SV
- Preload affects…
- End-diastolic measurements (volume & pressure)
- Afterload affects…
- End-systolic measurements & LV systolic pressure during isovolumic contraction
- Stroke volume
- Increased by increasing preload & decreasing afterload
- Doesn’t necessarily mean increased CO unless HR is maintained or increased
- Contractility
- Not affected by preload
- If contractility is kept constant, increasing preload increases SV
- HF: may not be able to maintain contractility –> decrease SV
- Increased by increasing afterload to maintain SV
- Inability to increase contractility decreases SV & CO
- Not affected by preload
- Laplace relationship
- Relates wall diameter & intracardiac pressure to wall tension
- Hypertrophy –> increase wall thickness –> decrease wall tension/stress
- LV compliance
- Increase LV compliance –> LV can fill w/ greater volume in diastole while maintaining constant LVEDP
Compensatory Mechanisms
- HF
- –> insults (ischemic injury, HTN, infiltration, valvular heart disease, etc.)
- –> increase preload &/or afterload
- LV remodeling changes size & shape of heart in response to…
- Excessive neurohormonal activation
- Altered loading conditions
- Myocardial injury
Ventricular Remodeling
- Benign adaptive response
- Ex. trained athlete
- Ex. increased metabolic efficiency
- Adverse changes to copmensate for decreased myocardial performance
- Ex. initial MI
- Ex. LV hypertrophy
- Ex. LV dilation
- Benign adaptive response
- Ex. trained athlete
- Enlarged, muscular heart –> decreased EF & HR + maintained SV
- Due to physiologic hypertrophy of muscles & increased compliance of blood vessels
- Ex. increased metabolic efficiency
- –> decrease oxygen demand in peripheral muscle
- –> enhance oxygen delivery int he myocardium to improve cardiac performance
- Ex. trained athlete
- Adverse changes to copmensate for decreased myocardial performance
- Ex. initial MI
- Gradual scarring & thinning in the area of infarction –> global remodeling of the LV (ex. dilation)
- Ex. LV hypertrophy
- Negatively affects compliance –> systolic dysfunction –> dilation
- Ex. LV dilation
- Hallmark change in CHF
- Initial dilation –> accommodate increaed volume w/o increasing LVEDP –> maintain SV
- Doesn’t imply sarcomere lengthening
- May include myocyte hypertrophy & increased myocyte spacing w/ increased interstitial fibrosis & collagen deposition
- Long term dilation –> increased wall stress –> histologic changes
- As cellular function –> dysfunctional, disrupted actin/myosin interaction –> decreased power of filament shortening
- –> clinical decompensation & progression of HF (stage C or D)
- Ex. initial MI

Compensatory Changes
- Goal of compensatory changes
- Compensatory mechanisms to adapt & maintain LV function
- Ex. of how adverse compensatory mechanisms: neurohormonal activation
- Types of initial insults
- Causes of cardiac injury/dysfunction
- Goal of compensatory changes
- Restore LV function following an initial myocardial insult that adversely affects ventricular function
- Recover LV performance & delay the onset/progression of HF
- Long term exposure to these mechanisms may –> adverse remodeling –> secondary myocardial damage –> further LV decline
- Compensatory mechanisms to adapt & maintain LV function
- Salt & water retention –> increase circulating volume & maintain SV
- SNS activation –> preserve CO
- Release of circulating vasodilatory molecules (ex. NO, prostaglandins, & natriuretic peptides) –> increase preload & decrease afterload
- Ex. of how adverse compensatory mechanisms: neurohormonal activation
- Underlying cardiac disease –> declining LV contractility –> decreased CO
- Goal: maintain BP & tissue perfusion by increasing peripheral vascular resistance & LV afterload
- Long term response –> hasten myocardial deterioration –> worsen ventricular performance
- Types of initial insults
- Acute (ex. MI)
- Insidious (ex. HTN, valvular heart disease)
- Causes of cardiac injury/dysfunction
- Hereditary (ex. hypertrophic cardiomyopathy)
- Acquired (ex. peripartum cardiomyopathy)

Cellular Basis of Myocardial Dysfunction in HF
- Contractile proteins of the heart
- Normal resting energy supply
- Myocardial contraction
- Metabolic & energetic derangements in HF
- Contractile proteins of the heart
- Lie within myocaridal muscle cells (cardiomyocytes or myocytes)
- Each myocyte has myofibrils & mitochondria to resist fatigue & maintain aerobic metabolism
- Normal resting energy supply
- 2/3: free fatty acids & triglycerides
- 1/3: carbohydrates
- Trace amount: amino acids & ketons
- Myocardial contraction
- Na+ ions initiate APs propogated along the sarcolemma
- Ca2+ influx –> myocardial contraction –> release of additional Ca2+ from the SR
- Ca2+ binds to troponin C –> shift in troponin I & T –> tropomyosin release from the actin –> exposed myosin binding sites
- Binding of myosin to actin: energy dependent
- Metabolic & energetic derangements in HF
- Adversely affect AP propogation, Ca2+ homeostasis, & ATP balance

Myocytes
- Held together by…
- Excess collagen
- Myocardial dysfunction results from…
- These changes lead to…
- Held together by…
- Surrounding collagen connective tissue (major component of the ECM) bundled into muscle fibers
- Damage to these –> remodeling
- Excess collagen
- Causes LV diastolic dysfunction
- Accumulates as part of hte growth response to LV pressure overload
- Myocardial dysfunction results from…
- Loss of myocytes by necrosis or apoptosis
- Replacement of myocytes w/ collagen & fibrosis
- Dysfunction of viable myocardium
- These changes lead to…
- Electrical derangements (ex. atrial or ventricular arrhythmias, conduction defects)
- Systemic processes affecting other orgnas & tissues (ex. pulmonary contestion, prerenal azotemia)
- Further myocardial damage
- Imbalance of neurohomonal release is due to…
- Increased circulating catecholamine levels
- Change in cytokine expression patterns & inflammatory pathways
- Release of vascular mediators like endothelin-1

Myocytes
- Imbalance of neurohomonal release is due to…
- Myocyte necrosis
- Loss of myocytes resulting in cardiac remodeling involves…
- Extracellular changes that contribute to LV dysfunction
- Imbalance of neurohomonal release is due to…
- Increased circulating catecholamine levels
- Change in cytokine expression patterns & inflammatory pathways
- Release of vascular mediators like endothelin-1
- Myocyte necrosis
- Occurs following myocardial injury (ex. infarction, toxins, inflammation)
- Triggered by programmed cell death due to…
- Genetic mutations
- Induced cell signaling by cytokines, circulating catecholamines, or angiotensin
- Results in cytoskeletal changes & fibrosis that may be histologically tracked or have no evidence
- Loss of myocytes resulting in cardiac remodeling involves…
- Early: cardiac myocyte hypertrophy w/ new sarcomeres & elongated/thickened cells
- Later: myofilament density within myocytes decreases
- Extracellular changes that contribute to LV dysfunction
- Deposition of replacement & reparative collagen –> stiffer walls
- Myocyte hypertrophy + increased extracellular collagen deposition –> ventricular enlargement –> decreased capillary density –> reduced coronray blood flow reserve –> further damage

HF that Doesn’t Present w/ Typical Sequence of Events
- Heart failure w/ preserved EF (diastolic HF)
- Dysfunction of residual viable myocardium in HF
- Stress-related cardiomyopathies
- Heart failure w/ preserved EF (diastolic HF)
- HF patients that experience progressive symptoms in the absence of LV systolic impairment
- LV structural abnormalities w/o ventricular dilation or systolic dysfunction
- Progressive hyeprtrophy or increasing chamber wall stiffness –> less compliant LV –> both systolic & diastolic HF
- Dysfunction of residual viable myocardium in HF
- LV enlargement + increased wall tension –> progressive ischemia w/o obstructive epicardial disease
- Metabolic derangements occur in acute & chronic HF
- Stress-related cardiomyopathies
- Reduced free fatty acid use –> affected myocardium undergoes a “hibernating” process
- Reduced myocardial contractility despite excess intramyocyte Ca2+
- No cellular necrosis or ECM changes –> myocardial impairments are metabolic
Neurohormonal Activation in HF
- Neurohormonal pathway consists of…
- Neurohormonal pathway cross-talk
- Vasoactive mediators
- Adaptive responses
- Neurohormonal pathway consists of…
- Adrenergic nervous system (mediated by NE & Epi)
- Renin-angiotensin-aldosterone system (RAAS)
- Antidiuretic hormone system (vasopressin)
- Neurohormonal pathway cross-talk
- Cross-talk occurs b/n different rogans (brian, heart, peripheral circulation, & kidneys)
- Vascular, central, & peripheral sensory mechanisms respond to changes in BP to regulate sympathetic & parasympathetic tone
- Vasoactive mediators
- Maintain normal homeostatic conditions
- Recruited in HF to maintain SV
- Adaptive responses
- Initially helpful
- Over time contribute to progressive HF & LV remodeling
- Happens when counter-regultaory hormones fail to restore balace against vasoactive hormones
Sympathetic (Adrenergic) Nervous System
- General
- Effects to deliver increased blood flow to peripheral muscles
- Predominant mediators
- Heart failure syndrome
- Beta-adrenergic desensitization
- Goal of increasing sympathetic tone
- Mechanism
- Effects of cycle where SNS stimulation necessitates more SNS stimulation
- General
- Initially adaptive compensatory response to myocardial injury & stress
- Responds to stress w/ physiologic changes evolved to protect & preserve life
- Activated by central & peripheral stimuli
- Effects to deliver increased blood flow to peripheral muscles
- Increase HR & splanchnic vascular resistance
- Decrease peripheral vascular resistance
- Predominant mediators
- NE & Epi
- Heart failure syndrome
- Increased catecholamines
- Increased myocardial tissue levels
- Beta-adrenergic desensitization
- SNS response is reduced despite excess catecholamines
- Goal of increasing sympathetic tone
- Preserve perfusion pressure & BP
- Mechanism
- Decreased mean arterial pressure –> increae contractility & HR to maintain SV –> arteriolar vasoconstriction –> increase afterload –> myocardial stress
- Effects of cycle where SNS stimulation necessitates more SNS stimulation
- Increase catecholamines in blood & tissue
- Dysregulated adrenergic beta-receptors on myocardial surface
- Myocardial necrosis & apoptotic signaling

Vascular Effects of Adrenergic Stimuli
- alpha1
- Location
- Effect of SNS
- beta1
- Location
- Effect of SNS
- beta2
- Location
- Effect of SNS
- Dopamine 1 & 2
- Location
- Effect of SNS
- alpha1
- Location
- Vascular wall
- Effect of SNS
- Arterial vasoconstriction –> increased afterload
- Venous vasoconstriction –> increased return & increased preload
- Location
- beta1
- Location
- Myocardium
- Effect of SNS
- Increase HR & contractility –> increase CO
- Increase relaxation & improve LV filling
- Location
- beta2
- Location
- Vascular wall
- Effect of SNS
- Peripheral skeletal muscle vasodilatoin –> decrease afterload
- Location
- Dopamine 1 & 2
- Location
- Vascular wall
- Effect of SNS
- Heart: increase HR & contractility
- Peripheral circulation: vasoconstriction –> increase afterload
- Splanchnic circulation: low doses increase splanchnic flow
- Location

Renin-Angiotensin-Aldosterone System (RAAS)
- Goal
- Activated by…
- Pathway
- Positive feedback loop
- Goal
- Restore adequate circulating volume & BP during dehydration or volume depletion
- Activated by…
- Volume contraction
- Occurs during true volume depletion or diminished CO
- Pathway
- Kidney releases renin
- Mediates cleavage of angiotensinogen to angiotensin I
-
ACE
- Converts angiotensin I into angiotensin II
- Found predominantly in lung tissue
- Also found in the kidney, adrenal gland, brian, & vascular endothelium
-
Angiotensin II
- Increases Na+ reabsorption & water retention in proximal renal tubules
- Stimulates aldosterone secretion from the adrenal cortex
- Increases Na+ & water retention
- Stimulates myocardial fibrosis & cellular hypertrophy mediated by endothelin & tumor necrosis factor (TNF)
- Causes arterial vasoconstriction –> increases afterload
- Kidney releases renin
- Positive feedback loop
- RAAS increases sympathetic tone –> activates RAAS
- Short term: RAAS restores homeostasis in response to decreased intravascular tone
- Long term: RAAS becomes dysregulated in HF & further contributes to volume overload
- Ex. patient becomes volume overload
- Diminished SV & CO –> renal perfusion drops –> kidney perceives volume depletion –> RAAS activation
- RAAS increases sympathetic tone –> activates RAAS

Antidiuretic Hormone (Vasopressin) Systems
- Vasopressin
- Effects mediated by…
- V1 receptors
- V2 receptors
- Vasopressin in HF
- Natriuretic peptide hormones relevant to HF
- C-type natriuretic peptide (CNP)
- Atrial natriuretic peptide (ANP)
- B-type natriuretic peptide (BNP)
- Both ANP & BNP
- ANP & BNP at the kidneys
- ANP & BNP within the myocardium & other organs
- Synthetic natriuretic peptide (nesiritide)
- Vasopressin
- Peptide hormone
- Synthesized in the hypothalamus
- Stored in the pituitary gland
- Release stimulated by increased plasma osmolality or decreased effective circulating volume
- Effects mediated by…
- V1 receptors
- Vascular responses to vasopressin –> vasoconstriction
- V2 receptors
- Increase membrane permeability in renal cortical & medullary collecting tubules in the kidney –> increased water reabsorption
- V1 receptors
- Vasopressin in HF
- high circulating vasopressin levels –> increased afterload & hyponatremic volume overload
- Natriuretic peptide hormones relevant to HF
- C-type natriuretic peptide (CNP)
- Released in response to vascular shear stress
- Provides a counterbalance by inhibiting the effects of the vasoconstrictor endothelin
- Vasodilatory response
- Atrial natriuretic peptide (ANP)
- Stored in myocardium within granules
- Secreted by atrial & ventricular myocardium & kidneys
- Shorter half-life –> levels fluctuate more rapidly
- B-type natriuretic peptide (BNP)
- Responds to genetic up-regultaion before being released
- Secreted by ventricular ventricular myocardium
- Longer half-life –> levels don’t fluctuate as much
- Both ANP & BNP
- Biomarkers in HF
- Released in response to myocardial stretch
- Decrease peripheral vascular tone & increase venous capacitance –> decrease afterload & preload –> decrease intracardiac pressures
- ANP & BNP at the kidneys
- Sodium excretion (natriuresis) & diuresis
- Increases glomerular filtration
- Vasodilate afferent arterioles going into the renal tubule
- Constrict efferent arterioles exiting the renal tubules
- ANP & BNP within the myocardium & other organs
- Antiproliferative & antifibrotic effects
- Counter the adverse remodeling changes induced by excess catecholamiens & other molecules like endothelin & TNF
- Synthetic natriuretic peptide (nesiritide)
- No clinical benefits compared to conventional HF therapy
- C-type natriuretic peptide (CNP)

Endothelium-Derived Vasoactive Substances & Cytokines
- Endothelium
- Endothelium-derived relaxing factors (EDRF): vasodilators
- Endothelium-derived constricting factors (EDCF): vasoconstrictors
- Cytokines
- Examples of cytokines
- Endothelium
- Thin lining of cells within arteries & veins
- Endothelium-derived relaxing factors (EDRF): vasodilators
- NO
- Bradykinin
- Prostacyclin
- Endothelium-derived constricting factors (EDCF): vasoconstrictors
- Endothelin I
- Cytokines
- Small protein molecules produced by a variety of tissues & cells
- Negative inotropes
- Elevated levels associated w/ worse clinical outcomes
- Examples of cytokines
- TNF-alpha
- IL-1-alpha
- IL-2
- IL-6
- Interferon-alpha
Ventricular Remodeling in HF: Summary
- Adverse ventricular remodeling
- Pathologic myocardial hypertrophy
- Interstitial fibrosis & abnormal cardiac myocyte changes
- Compensatory mechanisms
- Cellular function & decreased contractile response
- Neurohormonal model of HF
- Adrenergic nervous system
- RAAS pathway
- Vasopressin
- Natriuretic peptides
- Adverse ventricular remodeling
- Effect of chronic adaptive changes of compensatory mechanisms becoming maladaptive
- Pathologic myocardial hypertrophy
- Structural change that doesn’t provide functional improvement
- As opposed to benign hypertrophy in an athletic heart
- Interstitial fibrosis & abnormal cardiac myocyte changes
- Underlie remodeling processes that can occur over months to years before progressive HF symptoms develop
- Compensatory mechanisms
- Contribute to adverse remodeling
- Often result in maladaptive cycles contributing to disease progression
- Cellular function & decreased contractile response
- Results from structurla canges to myofilaments, derangements in AP propagation, Ca2+ homeostasis, & energy metabolism by cardiac myocytes
- Neurohormonal model of HF
- Involves deleterious imbalances of the adrenergic nervous system, RAAS pathway, & circulating vasoactive & inflammatory molecules
- Results in cell necrosis, apoptosis, tissue fibrosis, & adverse ventricular remodeling
- Adrenergic nervous system
- Stimulated by decreases in MAP
- RAAS pathway
- Initiated by perceived decrease in intravascular volume
- Vasopressin
- Released in response to increased plasma osmolality & decreased effective circulating volume
- Effects are mediated by V1 (vasoconstriction) & V2 (increased water reabsorption) receptors
- Natriuretic peptides
- Provide counter regulatory responses to the adrenergic & RAAS systems
- Response may become overwhelmed in HF syndrome
Neurohormonal Basis for Pharmacotherapy
- Beta blockers
- ACE inhibitors (ACE-Is)
- Angiotensin receptor blockers (ARBs)
- Aldosterone antagonists
- Inotropes (dobutamine & milrinone) & oral glycosides (digoxin)
- Vasopressin V2 receptor antagonist (tolvptan) & human recombinant B-type natriuretic peptide (nesiritide)
- Beta blockers
- Taget beta-adrenergic receptors on the myocardial surface in competitive inhibition
- Diminish excess catechol stimulation from the SNS
- Reduce mortality
- ACE inhibitors (ACE-Is)
- Block the conversion of angiotensin I to angiotensin II
- Reduce mortality
- Angiotensin receptor blockers (ARBs)
- Inhibit the RAAS pathway by inhibiting the effects of angiotensin II
- Reduce mortality
- Aldosterone antagonists
- Block the effects of aldosterone in the kidneys
- Prevent sodium reabsorption
- Weak diuretic effects
- Reduce mortality
- Inotropes (dobutamine & milrinone) & oral glycosides (digoxin)
- Provide added contractility to failing myocardium
- May eventually relieve HF symptoms
- Don’t directly address the neurohormonal pathway
- Don’t reduce mortality
- Vasopressin V2 receptor antagonist (tolvptan) & human recombinant B-type natriuretic peptide (nesiritide)
- Improve acute HF symptoms
- Don’t reduce survival when combined w/ beta blockers, ACE-Is, or ARBs
