Heart Failure

Robbins Basic Pathology

Chapter 11

Lecture Outline

Introduction and Definition

Epidemiology

Cardiac Physiology Revisit

Aetiology

Left Sided Heart Failure

Causes
Pathophysiology
Hemodynamic Changes
Signs and Symptoms

Right Sided Heart Failure

Clinical Features

I. Introduction

Definition: A state in which the heart cannot provide sufficient

cardiac output to maintain the basic metabolic needs of the
body*

Can involve the left side, right side or both sides of the heart

Usually the left side is affected first

It is commonly termed congestive heart failure (CHF) since

symptoms of increase venous pressure are often prominent
*In a minority of cases the heart is unable to cope with increased tissue
demands (high output failure)

Introduction cont.

Common end point of many cardiac and cardiovascular

diseases
Most heart failure is secondary to systolic dysfunction i.e.
deterioration of myocardial contractile function
20% to 50% is secondary to diastolic dysfunction i.e. heart
contract normally but unable to relax normally
Onset is usually insidious but can be acute occasionally

II. Epidemiology

Frequency

Age

0.3/1000

< 45

3/1000

45-65

10/1000

>65

Increases with Age

Morbidity & Mortality

Dramatically Affects Quality and Length of Life

5 Year Mortality : Males

: Females

6 Year Mortality : Both Sexes

62%
42%
75%

Epidemiology

US Health and Human Services

5 million Americans suffer from CHF

$17.8 billion spent annually

400,000 new cases reported each year

III. Cardiac Physiology Revisited

Frank-Starling Mechanism

Cardiac Output

Stroke Volume x Heart Rate

Preload

Volume of Blood Delivered to Heart during Diastole (EDV)

1o Venous and Diastolic Function

Relationship between the EDV and force of contraction

Within limits, the greater the EDV, the greater the contraction during
systole (Frank-Starling Law)

Afterload

The pressure that must be overcome before a semilunar valve opens

Peripheral Vascular Resistance (1o arterial and systolic function)

IV. Aetiology: General Principles

Pathophysiological Causes

Inappropriate (increase) work load

Volume overload

Pressure overload

Myocardial dysfunction, myocyte loss

Decreased ventricular filling

In a mechanistic sense the heart is unable to pump blood delivered to

it by the venous circulation
inadequate CO i.e. forw ard failure
This is almost always followed by venous congestion
i.e. back w ard failure

Aetiology: General Principles cont.

Heart failure is a common end point for many diseases of the

heart and cardiovascular system (CVS)*

Ischaemic heart disease (IHD), myocardial infarction (MI)

Congenital heart disease

Hypertensive heart disease

Valvular heart disease

Primary myocardial disease

Pericardial disease

Heart disease secondary to intrinsic lung disease

Tachyarrhythmia

*R eview Heart Diseases

Causes of Heart Failure

Damage to the Heart and/or *Increase Workload

Coronary artery disease

IHD
Myocardial infarction (MI)

Heart muscle diseases

Cardiomyopathy (dilated, hypertrophic, restrictive)

Myocarditis (inflammatory, metabolic, immunologic)

*High blood pressure

*Abnormal heart valves (AS, AI, MI)

*Aortic coarctation

Causes of Heart Failure cont.

Other Causes

Congenital heart defects eg. ASD,VSD, PDA (shunted blood)

Pericardial disease eg. constrictive pericarditis (diastolic failure)

Severe lung parenchymal/vascular disease pulmonary

hypertension ( cor pulmonale)
Abnormal heart rhythms eg. atrial and ventricular fibrillation
(uncoordinated and inefficient contraction)

Diabetes mellitus (multiple effects)

Severe anemia (high output failure), hyperthyroidism

Causes of Heart Failure cont.

Coronary Artery Disease and MI

Ischaemia, necrosis, healing by fibrosis

Muscle weakness

Hypertension

Heart must pump harder to keep blood

circulating ( load)
hypertrophy, dilatation (decompensation)
Uncontrolled high blood pressure doubles the
risk of developing heart failure

Causes of Heart Failure cont.

Abnormal Heart Valves

Heart Muscle Disease

Rheumatic or infective endocarditis

Regurgitate and/or stenotic valves
Dilated cardiomyopathy impairment of contractility
systolic dysfunction
Hypertrophic and restricitve cardiomyopathy impairment of
compliance diastolic dysfunction
Myocarditis - drugs, alcohol, infections

Congenital Heart Disease

Eg. ASD, VSD, PDA

Abnormal shunts Volume overload

Causes of Heart Failure cont.

Severe Lung Disease

Intrinsic disease of the lung parenchyma and/or

vasculature chronic pulmonary hypertension

Chronic obstructive or interstitial lung disease

Recurrent pulmonary emboli

Primary, idiopathic pulmonary hypertension

Abnormal Heart Rhythm

If the heart beat is too fast, too slow or irregular it

may not be able to pump enough blood to the body

Causes of Heart Failure cont.

Diabetes: Tend to have other conditions that make the

heart work harder

Obesity

Hypertension

High cholesterol

Severe anemia

Inadequate number of red blood cells to carry oxygen

tachycardia and workload for the heart

Hyperthyroidism

Body metabolism is increased and overworks the heart

V. Left Ventricular Failure (LVF)

Pathophysiology and Causes

Volume over load * : Regurgitate valve eg. aortic incompetence (AI)

High output status eg. severe anaemia

Pressure overload * : Systemic hypertension

Outflow obstruction eg. aortic stenosis (AS)

Loss of muscles

: Impairment of contractility eg. post MI, chronic

ischaemia, cardiomyopathy, myocarditis

Restricted Filling

: Impairment of compliance eg. constrictive

pericarditis, restrictive cardiomyopathy
Tachyarrhythmia

* i.e. inappropriate increase in workload

LVF: Pathophysiologic Changes

Hemodynamic Changes

Neurohormonal Changes

Redistribution of Blood to the Brain

Cellular Changes

LVF: Pathophysiology
Hemodynamic Changes

Hemodynamic Changes: From the hemodynamic stand point HF

can be secondary to:

Systolic dysfunction

Diastolic dysfunction

In either case, blood may back up in the lungs causing fluid to

leak into the lungs (pulmonary edema)

Fluid may also build up in tissues throughout the body

Lower limb edema

Ascites

Sacral edema

LVF: Pathophysiology
Neurohormonal (NH) Changes
NH Changes

Favorable Effect

Unfavorable Effect

Sympathetic activity*
n-epinephrine

HR , contractility
Vasoconstn Venous
return (VR)
VR diastolic filling

Arteriolar constriction
after load workload
O2 consumption

Renin-AngiotensinAldosterone*

Salt & water retention

VR
VR diastolic filling

Vasoconstriction
after load (i.e. peripheral
resistance)

Vasopressin*

Water retention VR
a/a

atrial natriuretic
peptide (ANP)

Natriuresis, diuresis,
vasodilatation alleviate
pressure or volume overload

Endothelin

Vasoconstriction VR
a/a

*Review physiology of BP control

After load

Pathophysiology : Myocardial Structural

and Cellular Changes
Hypertrophy of myocytes
May be able to maintain CO in the face of worsening heart function

With sustained or worsening heart function structural and functional

abnormalities occur

Changes in Ca++ handling

Changes in adrenergic receptors
Slight in 1 receptors
1 receptors desensitization followed by down regulation
Changes in contractile proteins
Program cell death (Apoptosis)
Increase amount of fibrous tissue

Compensatory Mechanisms to Failure

Increased Heart Rate and Contractility

Dilation

Sympathetic = Norepinephrine

Frank Starling = Contractility

Neurohormonal

Redistribution of Blood to the Brain

Decompensation

Increased Pulmonary Venous Pressure

Interstitial Edema

Alveolar Edema

Morphology: Pulmonary Congestion and

Edema

Congestive Heart Failure Vicious Cycle

Low Output

Preload
4B

Salt/H2O
3B

After load

n-epinephrine

4A

Renal blood flow

Vasoconstriction
3A

Note: Preload = diastolic volume

After load = peripheral resistance

Renin
Angiotensin
Aldosterone

Signs and Symptoms of Left Heart Failure

Shortness of breath (SOB),
orthopnea, paroxysmal
nocturnal dyspnea (PND)

Cough
Low cardiac output
symptoms

Abdominal symptoms:
Anorexia, nausea

Abdominal fullness
Right hypochondrial pain

Signs and Symptoms of Heart

Failure

Shortness of Breath (Dyspnea)

WHY?

Blood backs up in the pulmonary veins because the

heart is unable to keep up with the supply

hydrostatic pressure

Fluid leaks into the lungs (pulmonary edema)

SYMPTOMS

Dyspnea on exertion or at rest

Difficulty breathing when lying flat (orthopnea)

Waking up due to attacks of severe shortness of breath

(PND)

Signs and Symptoms of Heart

Failure

Persistent Cough or Wheezing

WHY?

Fluid backs up in the lungs (fluid transudation into air

spaces)

SYMPTOMS

Coughing that produces white or pink blood-tinged

sputum

Signs and Symptoms of Heart

Failure

Edema

WHY?

Decreased blood flow out of the weak heart

Blood returning to the heart from the veins backs up
hydrostatic pressure fluid to leak out into tissues

SYMPTOMS

Swelling in feet, ankles, legs or abdomen

Weight gain

Signs and Symptoms of Heart

Failure

Tiredness, Fatigue

WHY?

Heart is unable to pump enough blood to meet needs

of bodies tissues
Body diverts blood away from less vital organs
(muscles in limbs) and sends it to the heart and brain

SYMPTOMS

Constant tired feeling

Difficulty with everyday activities

Signs and Symptoms of Heart

Failure

Lack of Appetite / Nausea

WHY?

The digestive system receives less blood causing

problems with digestion

SYMPTOMS

Feeling of being full or sick to the stomach

Signs and Symptoms of Heart

Failure

Confusion / Impaired Thinking

WHY?

Water electrolyte disturbances (sodium)

SYMPTOMS

Memory loss or feeling of disorientation

Relative or caregiver may notice this first

Signs and Symptoms of Heart

Failure

Increased Heart Rate

WHY?

The heart beats faster to make up for the loss in

pumping function

SYMPTOMS

Heart palpitations

May feel like the heart is racing or throbbing

New York Heart Association (NYHA)

Functional Classification

Class

% of
patients

Symptoms

35%

No symptoms or limitations in ordinary physical activity

II

35%

Mild symptoms and slight limitation during ordinary

activity

III

25%

Marked limitation in activity even during minimal

activity. Comfortable only at rest

IV

5%

Severe limitation. Experiences symptoms even at rest

Physical Signs: General

Pale and anxious

Cold, clammy skin

Breathless

Edema of lower extremities

May be confused

May have cyanosis

Physical Signs: CVS and Lung

High diastolic BP and occasional decrease in systolic BP

(decapitated BP)

Increased heart rate

Displaced and sustained apical impulse (enlarged heart)

Rales (Inspiratory)

Systolic murmur due to atrial regurgitation

Third heart sound low pitched sound that is heard

during rapid filling of ventricle

Forms of Heart Failure

Systolic vs Diastolic (see next slide)

Acute vs Chronic

Acute - Large MI, aortic valve dysfunction

Chronic - CHF usually chronic
The heart tries to compensate for the loss in
pumping function by muscle mass (hypertrophy)
and heart rate

High Output Failure

Pregnancy, severe anemia, thyrotoxisis, A/V fistula, beriberi,

Pagets disease

Forms of heart failure cont.

Right vs Left Sided Heart Failure

Left Heart Failure :

Involves the left ventricle

Systolic failure

The heart loses the ability to contract / pump blood into

the circulation

Diastolic failure

The heart loses the ability to relax because it becomes

stiff
Unable to fill properly between each beat

Forms of heart failure cont.

Left Heart Failure
Systolic and Diastolic Failure cont.

In both types, blood may back up in the lungs causing

fluid to leak into the lungs (pulmonary edema)
Fluid may also build up in tissues throughout the body
(edema)

Forms of heart failure cont.

Right Heart Failure

Right sided heart failure:

Usually presents with:

M ost com m on cause is

left sided failure

Lower limb/ankle edema

Ascites

Occasionally isolated right

heart failure can be due to

Hepatic congestion

- Pulmonary embolisms
- Other causes of
pulmonary hypertension
- Rt Ventricular infarction
- Mitral stenosis

Cardiac cirrhosis (in the

long run)

Minimal or no pulmonary
congestion or edema

Laboratory Investigations

CXR - Single most useful

clinical tool

EKG - Non Specific

Lab - Non Specific

Principles of Managment

Correction of reversible causes (treat underlying

cause)

Myocardial ischemia

Valvular heart disease

Thyrotoxicosis and other high output status

Shunts

Arrhythmia

Principles of Management cont.

Life Style Change: Diet and Activity

Salt restriction
Fluid restriction
Daily weight (tailor therapy)
Gradual exertion programs

Medications

Diuretics
Inhibitors of the renin-angiotensin-aldosterone system
Digitalis
-blokers
Vasodilators
Ionotropic agents