HEART FAILURE

Dr.K.Sathish Kumar, MD(Hom).,

Heart Failure
• Called as congestive heart failure (CHF)
• CHF occurs when the heart is unable to pump blood at a rate
sufficient to meet the metabolic demands of the tissues.
• Heart failure results from progressive deterioration of myocardial
contractile function (systolic dysfunction), this may be due to
ischemic injury, pressure or volume overload due to valvular disease
or hypertension, or dilated cardiomyopathy. Sometimes, failure
results from an inability of the heart chamber to expand and fill
sufficiently during diastole (diastolic dysfunction), as can occur with
massive left ventricular hypertrophy, myocardial fibrosis, deposition
of amyloid, or constrictive pericarditis

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• When cardiac function is impaired or the work load increases, several
physiologic mechanisms maintain arterial pressure and perfusion of
vital organs. The most important of these are the following:
 The Frank-Starling mechanism – the degree of stretching of
muscle is directly proportional to the contraction.
 Myocardial adaptations - including hypertrophy with or without
cardiac chamber dilation.
 Activation of neurohumoral system - especially
1. release of norepinephrine by adrenergic cardiac nerves
2. activation of the renin-angiotensin-aldosterone system
3. release of atrial natriuretic peptide.
• These adaptive mechanisms may be adequate to maintain normal
cardiac output in the face of heart disease

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• CHF is characterized by variable degrees of decreased cardiac output
and tissue perfusion (called as forward failure), as well as pooling of
blood in the venous system (backward failure)
• The cardiovascular system is a closed circuit.
• Thus, although left-sided and right-sided failure can occur
independently, failure of one side (particularly the left) often produces
excessive strain on the other, terminating in global heart failure.

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Left-sided Heart Failure
• Left-sided heart failure is caused by ischemic heart disease,
hypertension, aortic and mitral valvular diseases and myocardial
diseases.
Morphology
• Heart - myocardial infarcts or a deformed, stenotic, or regurgitant
valve may be present. Left ventricle is usually hypertrophied and
often dilated. The microscopic changes include myocyte hypertrophy
and interstitial fibrosis. Dilation of the left atrium and atrial fibrillation.
• Lungs - Pulmonary congestion and edema produce heavy, wet lungs.
Pulmonary changes include
1. perivascular and interstitial edema, particularly in the interlobular
septa, which is responsible for the characteristic Kerley B lines
2. progressive edematous widening of alveolar septa
3. accumulation of edema fluid in the alveolar spaces.
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Clinical Features
• In early left-sided heart failure symptoms are often related to
pulmonary congestion and edema. Cough and dyspnea
(breathlessness), initially with exertion and later at rest.
• As failure progresses, pulmonary edema may lead to orthopnea or
paroxysmal nocturnal dyspnea,
• Atrial fibrillation and increases the risk of thrombosis and
thomboembolic stroke.
• Decreased cardiac output causes a reduction in renal perfusion,
which leads to the activation of the renin-angiotensin-aldosterone
system which in turn induces the retention of salt and water causing
pulmonary edema.
• If the hypoperfusion of the kidney is severe it causes azotemia.
• In advanced CHF, cerebral hypoxia can give rise to hypoxic
encephalopathy, progresses to stupor and coma.
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Right-Sided Heart Failure
• Most commonly caused by left-sided heart failure, as any increase in
pressure in the pulmonary circulation incidental to left-sided failure
inevitably burdens the right side of the heart.
• Usually occurs in patients with any one of a variety of disorders
affecting the lungs; hence, it is often referred to as cor pulmonale.

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Morphology
• Heart - valvular abnormalities or endocardial fibrosis are present. Hypertrophy
and dilation of the right atrium and ventricle.
• Liver and Portal System - The liver is usually increased in size and weight
(congestive hepatomegaly) due to prominent passive congestion. Congestion
is most prominent around central veins within hepatic lobules, which show
red-brown centrilobular discoloration and paler, fatty, peripheral regions, with
characteristic appearance referred to as “nutmeg liver”. Portal hypertension
produces enlargement of the spleen (congestive splenomegaly), which often
weighs from 300 to 500 gm (normal, <150 gm).
• Pleural, Pericardial, and Peritoneal Spaces - can lead to accumulation of fluid
in the pleural, pericardial, or peritoneal spaces (effusions).
• Subcutaneous Tissues - pedal and pretibial edema, is a hallmark of right-sided
heart filure. In chronic bedridden patients presacral edema may be seen.

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Nutmeg Liver Histologic appearance of atrophy
and necrosis of cells in the
central part of the liver in CVC

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Clinical Features
• Are related to systemic (and portal) venous congestion, and include
hepatosplenomegaly, peripheral edema, pleural effusions, and ascites.
• Organs that are prominently affected in right-sided heart failure include the
kidney and the brain.
• Congestion of the kidneys is more marked with right-sided than left-sided heart
failure, leading to greater fluid retention and peripheral edema, and more
pronounced azotemia.
• Venous congestion and hypoxia of the central nervous system can produce
deficits of mental function

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 THANK YOU

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