Heart Failure

Hamid Bayeh, M.D.

 Heart Failure
• Outline
• Definition of Heart Failure
• Pathophysiology of Heart Failure
• Right Sided vs Left sided Heart Failure
• Low Output vs High Output Cardiac Failure
• Systolic vs Diastolic Heart Failure
• Chronic vs Acute Cardiac Failure
 Heart Failure
Definition:
Heart failure is the inability of the Heart to maintain
an output adequate to meet the metabolic demands
of the body.
It is an increasingly common condition associated
with extremely high Morbidity and Mortality.
 Heart Failure
Pathophysiology of heart failure.
- The clinical syndrome of Heart failure manifests as
organ hypoperfusion and inadequate tissue oxygen
delivery due to low cardiac output and decreased
cardiac reserve, as well as pulmonary and systemic
venous congestion.
 Cardiac Reserve
Cardiac Reserve is the work that the heart is able to perform
beyond that required of it under the ordinary circumstances
of daily life, depending upon the state of the myocardium and
the degree to which, within physiologic limits, the cardiac
muscle fibers can be stretched by the volume of blood
reaching the heart during diastole.
 Cardiac Output
Cardiac Output (CO)= HR X SV:
The quantity of blood pumped by the heart each
minute. Normal output in an adult is 3.5-5.5 L/min.
Stroke Volume (SV): EDV-ESV
 Cardiac Index
Cardiac Index (CI):
Cardiac output divided by the patient’s body surface area.
It is used to compensate for body size.
The normal cardiac index is 2.8-4.2 L/min/m2.
A cardiac index of less than 2.5 requires immediate assessment and
treatment.
 Determinants of Cardiac Output
Cardiac output is determined by heart rate and
stroke volume. Stroke volume depends on:
–Preload
–Afterload
–Contractility
 Starling’s Law
Starling’s Law:
When the myocardial muscle cell is stretched, the
developed tension increases to a maximum and then
declines as the stretch become more extreme.
 Heart failure with reduced ejection fraction (HFrEF)
Heart failure with reduced ejection fraction (HFrEF), formerly called "systolic heart
failure," is defined as a left ventricular Ejection fraction < 40%. Symptoms of dyspnea
and fatigue result from reduced cardiac output.
The body responds with sodium and water retention, vasoconstriction, and
ventricular remodeling. These responses initially improve symptoms but eventually
contribute to worsening heart function.Treatment goals include
Reducing symptoms
Improving functional status
Improving quality of life
Reducing hospitalizations and mortality
Heart failure with reduced ejection fraction (HFrEF)
HFrEF results primarily from several endogenous
Neurohormonal mechanisms:
The renin-angiotensin-aldosterone system (RAAS)

The sympathetic nervous system

The natriuretic peptide system

 Impaired LV filling pressure Peripheral
edema
LV function

Afterload Blood
(LV impedance) Cardiac output volume
Stroke volume

Systemic
Vascular
Resistance NaCl and H2O
retention
Reflex arteriolar Renal perfusion
vasoconstriction

Renin
- - - - - - - - - - - - - - - - Angiotensin II
Aldosterone
Vasoppressin - - - - - - - -
Evolution of pharmacologic approaches in Heart Failure
Neprilysin inhibition as a new therapeutic strategy1

SNS β-blockers

Epinephrine α1, β1, β2

receptors
Norepinephrine
Neprilysin Vasoconstrictio
inhibitors n
RAAS activity
NP system HF SYMPTOMS & Vasopressin
PROGRESSION Heart rate
NPRs NPs Contractility

Vasodilation
Blood pressure RAAS inhibitors
Sympathetic tone RAAS (ACEI, ARB, MRA)
Natriuresis/diuresi
s Ang II AT1R
Vasopressin INACTIVE
Aldosterone FRAGMENTS Vasoconstriction
Fibrosis Blood pressure
Hypertrophy Sympathetic tone
Aldosterone
Hypertrophy
Fibrosis

▪ Neprilysin inhibitors: natriuretic and other vasoactive peptides enhancement

ACEI=angiotensin-converting enzyme inhibitor; Ang=angiotensin; ARB=angiotensin receptor blocker; 1. McMurray et al. Eur J Heart Fail. 2013;15:1062–73;
AT1R = angiotensin II type 1 receptor; HF=heart failure; MRA=mineralocorticoid receptor antagonist; Figure references: Levin et al. N Engl J Med 1998;339:321–8; Nathisuwan & Talbert.
NP=natriuretic peptide; NPRs=natriuretic peptide receptors; RAAS=renin-angiotensin-aldosterone system; Pharmacotherapy 2002;22:27–42; Kemp & Conte. Cardiovascular Pathology 2012;365–
SNS=sympathetic nervous system 71; Schrier & Abraham N Engl J Med 2009;341:577–85
Forms of Heart Failure
 Right Sided Versus Left-Sided Heart Failure

▪ Right ventricular failure

It is associated with Blood damming up in the systemic
venous circuit includes symptoms and signs of:
- Edema.
- Congestive Hepatomegaly.
- Ascites.
 Right ventricular failure

Most common cause of Right Heart Failure is left sided

Heart Failure.

Also Diseases that affect the right ventricle primarily .

Like ( primary pulmonary hypertension)
 Left-sided Heart failure

Dyspnea
Left sided: Orthopnea
Pulmonary congestion
 Left ventricular failure

Left ventricular failure

Symptoms and signs are due to Blood damming up
behind the left ventricle and due to pulmonary
congestion. Long standing left ventricular failure may
eventually results in signs of right ventricular failure
with generalized accumulation of fluid.
 Low Versus High Output Cardiac Failure

Heart failure causing low cardiac output is the

most common form of Heart failure
 Low output failure
▪ Low output failure is characterized by:
a. Reduced stroke volume.
b. Peripheral vasoconstriction.
c. Cold and pale extremities.
d. Reduced or narrow pulse pressure.
If the pulse pressure (Systolic pressure – Diastolic pressure)
is extremely low, i.e. 25 mmHg or less, the cause may be low stroke volume,
as in Congestive Heart Failure and/or shock.
• A narrow pulse pressure is also caused by aortic valve stenosis and cardiac
tamponade.
 Causes of Low output failure
Ischemic heart disease

Low output: Hypertension (end stage)

( SVR) Dilated cardiomyopathy

Valvular and pericardial disease

 Causes of High output cardiac failure
Hyperthyroidism

Anemia

High output Pregnancy

( SVR) Arterio venous fistulas

Beriberi

Paget’s disease
 High output cardiac failure
Causes of High output cardiac failure
A. Beriberi (severe thiamine deficiency)
( C.O 2º to reduced SVR,  venous return).
B. Paget’s disease (extremely rapid bone formation and
resorption associated with increase in Blood flow and
significant augmentation of cardiac output).
 High output cardiac failure

C . Thyrotoxicosis.

D .Arteriovenous fistula ( Plasma volume SVR).

E. Anemia.
 High output cardiac failure
▪ High output failure is characterized by:
a. Peripheral vasodilatation.
b. Warm and flushed extremities.
c. Widened or normal pulse pressure.
The resting pulse pressure in healthy adults, sitting position,
is about 30-40 mmHg
 Systolic vs diastolic failure

Impaired contraction: systolic failure.

Impaired relaxation: diastolic failure.

 The concept of diastolic Heart failure
- Heart failure is usually associated with an abnormality of
systolic function (reduced ability to expel blood from the
ventricular cavities).

- It may occur with an abnormality of diastolic function

(reduced ability of the left ventricle to accept or fill with
blood) despite normal systolic function.
 Diastolic Heart failure

- When the ventricles fail to relax adequately to

accept blood, ventricular diastolic pressures increase,
causing atrial pressures to increase and leading to
systemic or pulmonary congestion.
 Diastolic Heart failure
Impaired ventricular relaxation can be due to:
- Acute myocardial ischemia.
- Myocardial fibrosis.
- Infiltrative disease.
Diastolic Heart Failure occurs more frequently in women
than man, especially elderly women with hypertension.
 Diastolic HF can be caused by:
-Increased resistance to ventricular inflow and reduced
ventricular diastolic capacity:
- Constrictive pericarditis.
- Restrictive disease
- Hypertensive disease
- Hypertrophic cardiomyopathy
 Heart Failure

Abnormality both of contraction and relaxation

coexist in most patients.
 Acute vs chronic Heart failure
Acute Sudden rupture of cardiac valve leaflet
Heart (Trauma, infective endocarditis,massive MI)
Failure

Chronic Dilated Cardiomyopathy.

Heart Multivalvular Heart Disease
Failure