HEART FAILURE

Heart failure
• Heart failure is a pathophysiologic state in
which impaired cardiac function is unable to
maintain an adequate circulation for the
metabolic needs of the tissues of the body
Etiology
1. Intrinsic Pump Failure
• Weakening of the ventricular muscle due to
disease so that the heart fails to act as an
efficient pump
1. Ischaemic heart disease
2. Myocarditis
3. Cardiomyopathies
4. Metabolic disorders e.g. Beriberi
5. Disorders of the rhythm e.g. atrial fibrillation
and flutter
Etiology
2. Increased workload on the Heart
• Increased mechanical load on the heart
results in increased myocardial demand
resulting in myocardial failure.
• Increased load on the heart may be in the
form of pressure load or volume load
Increased workload cont’d
• Increased pressure load may occur in the
following states
1. Systemic and pulmonary arterial
hypertension
2. Valvular disease e.g. mitral stenosis, aortic
stenosis, pulmonary stenosis.
3. Chronic lung diseases
Increased workload cont’d
• Increased volume load occurs when a
ventricle is required to eject more than
normal volume of the blood resulting in
cardiac failure
1. Valvular insufficiency
2. Thyrotoxicosis
3. Arteriovenous shunts
4. Hypoxia due to lung diseases
Etiology
3. Impaired filling of cardiac chambers
• Decreased cardiac output and cardiac failure
may result from extra-cardiac causes or
defect in filling of the heart.
1. Cardiac tamponade e.g. haemopericardium,
hydropericardium
2. Constrictive pericarditis
Types of Heart Failure
1. Acute or chronic heart failure
2. Right-sided or left – sided heart failure
Acute heart failure cont’d
• Sudden and rapid development of heart
failure occurs
• In acute heart failure, there is sudden
reduction in cardiac output resulting in
systemic hypotension but oedema does not
occur
• Instead, a state of cardiogenic shock and
cerebral hypoxia develops
Acute heart failure
• Etiology
1. Larger myocardial infarction
2. Valve rupture
3. Cardiac tamponade
4. Massive pulmonary embolism
5. Acute viral myocarditis
6. Acute bacterial toxaemia
Chronic heart failure
• More often, heart failure develops slowly
• In chronic heart failure, compensatory
mechanisms like tachycardia, cardiac
dilatation and cardiac hypertrophy try to
make adjustments so as to maintain
adequate cardiac output
• This often results in well-maintained arterial
pressure and there is accumulation of
oedema
Chronic heart failure
• Etiology
1. Myocardial ischaemia from atherosclerotic
coronary artery disease
2. Multivalvular heart disease
3. Systemic arterial hypertension
4. Chronic lung diseases resulting in hypoxia
and pulmonary arterial hypertension
5. Progression of acute into chronic failure
LEFT-SIDED AND RIGHT-SIDED HEART
FAILURE
• Functionally, the left and right heart act as
independent units.
• The clinical manifestations of left or right
heart failure result from accumulation of
excess fluid upstream to the left or right
cardiac chamber whichever is initially
affected
Left-sided heart failure
• It is initiated by stress to the left heart
• Etiology
1. Systemic hypertension
2. Mitral or aortic valve disease (stenosis)
3. Ischaemic heart disease
4. Myocardial diseases e.g. cardiomyopathies,
myocarditis
5. Restrictive pericarditis
Left-sided heart failure cont’d

• Clinical manifestations
• Pulmonary congestion and oedema causes
dyspnoea and orthopnoea
• Decreased left ventricular output causes
hypoperfusion and diminished oxygenation
of tissues
Clinical manifestations of left HF cont’d

• In Kidneys hypoperfusion leads to ischaemic

acute tubular necrosis
• In the Brain it leads to hypoxic
encephalopathy
• In Skeletal muscles it causes muscular
weakness and fatigue
 RIGHT-SIDED HEART FAILURE
• Etiology
• As a consequence of left ventricular failure
• Cor pulmonale in which right heart failure
occurs due to intrinsic lung diseases
• Pulmonary or tricuspid valvular disease
• Pulmonary hypertension secondary to
pulmonary thromboembolism
• Myocardial disease affecting right heart
• Congenital heart disease with left-to-right shunt
 RIGHT-SIDED HEART FAILURE
• Clinical manifestation
• Systemic venous congestion in different tissues and
organs
1. Subcutaneous oedema on dependent parts
2. Passive congestion of the liver, spleen, and kidneys
3. Ascites
4. Hydrothorax
5. Congestion of leg veins and neck veins
6. Reduced cardiac output resulting in circulatory
stagnation causing anoxia, cyanosis and coldness of
extremities
Clinical manifestation of right HF cont’d

• In summary, in early stage the left HF

manifests with features of pulmonary
congestion and decreased left ventricular
output, while the right HF presents with
systemic venous congestion and involvement
of the liver and spleen
• Congestive HF, however, combines the
features of both left and right heart failure.
 COMPENSATORY MECHANISMS IN HF

• In order to maintain normal cardiac output,

several compensatory mechanisms come into
play
1. Cardiac hypertrophy
2. Cardiac dilatation
3. Tachycardia
Tachycardia
• Increased heart rate due to activation of
neurohumoral system e.g.
1. Release of norepinephrine
2. Activation of renin-angiotensin aldosterone
mechanism
Cardiac Hypertrophy
• This is an increase in size and weight of the
myocardium
• Pathogenesis
• It generally results from increased pressure load
• The atria may also undergo compensatory
changes due to increased workload.
• It appears that stretching of myocardial fibres in
response to stress induces the cells to increase
in length.
Pathogenesis of Cardiac Hypertrophy cont’d

• The elongated fibres receive better nutrition

and thus increase in size
• Other factors which may stimulate increase
in size of myocardial fibres are anoxia (in
coronary atherosclerosis) and influence of
certain hormones (e.g. catecholamines,
pituitary growth hormone)
Etiology
• Left ventricular hypertrophy
1. Systemic hypertension
2. Aortic stenosis and insufficiency
3. Mitral insufficiency
4. Coarctation of the aorta
5. Occlusive coronary artery disease
6. Congenital septal defects and patent ductus
arteriosus
7. Conditions with increased cardiac output e.g.
thyrotoxicosis, arteriovenous fistulae
Etiology cont’d
• Right ventricular hypertrophy
1. Pulmonary stenosis and insufficiency
2. Tricuspid insufficiency
3. Mitral stenosis and/or insufficiency
4. Chronic lung diseases e.g. chronic emphysema,
bronchiectasis, pneumoconiosis, pulmonary
vascular disease
5. Left ventricular hypertrophy and failure of the
left ventricle
Cardiac Dilatation
• Hypertrophy of the heart is accompanied by
cardiac dilatation
• Pathogenesis
• Stress leading to accumulation of excessive
volume of blood in a chamber of the heart
causes increase in length of myocardial fibres
and hence cardiac dilatation as a
compensatory mechanism.
Etiology
1. Valvular insufficiency (mitral and/or aortic
insufficiency in left ventricular dilatation,
tricuspid and/or pulmonary insufficiency in
right ventricular dilatation)
2. Left-to-right shunts e.g. in VSD
Etiology cont’d
• Conditions with high cardiac output e.g.
thyrotoxicosis, arteriovenous shunt
• Myocardial diseases e.g. cardiomyopathies,
myocarditis
• Systemic hypertension