Pathophysiology of CHF

CHF

• What is CHF?

• Fix the underlying problem

• Heart is a 2 sided pump

• Both sides can fail independent of each other.

CHF

• What different types of pathophysiology cause it?

• Systolic Dysfunction

• Diastolic Dysfunction

• High Output States

CHF• Systolic Dysfunction – What is it? Is it only related to

events that occur in Systole?-1. Decreased Contractility

- a. Loss of Myocytes

- b. Over-stretched Heart

-2. Increased Afterload- a. Increased BP

- b. Stenotic Valve- Pulmonic Valve and carcinoid syndrome – 5HIAA

CHF

• Diastolic Dysfunction – What is it? – 1. Impaired Relaxation

– 2. Obstruction to filling

• Can systolic and diastolic functions coexist?

CHF

• Pressure volume loops are used to distinguish between systolic vs. diastolic dysfunction

CHF

• High Output States – What is it?– Paget’s Disease

– Anemia

– Thiamine Deficiency

– Hyperthyroidism

CHF

• The failing heart and how it compensates– What does a failing heart mean, and what is

decompensation? What does a failing heart look like?

– Compensations made by a failing heart• Frank Starling Forces• Neuro-Hormonal Changes• Ventricular Remodeling

CHFWhat is looks like:

CHF Compensations

• Frank Starling– Length Tension Mechanism

CHF Compensations

• L sided failure and Frank– Blood is not going to go forward

– Blood is going to back up into L atrium and pulmonary venous circulation

• L Atrium, what happens when it distends?

CHF Compensations

• Hoarseness:

CHF Compensations

• L sided Failure and Frank– Blood eventually backs up into the pulmonary

circulation• What happens there?

• What’s the deal with Frank Starling Forces?

CHF Compensation

• L sided failure and the lungs continued…– Pulmonary congestion

CHF Compensation

• L sided failure and lungs continued…– Pulmonary Hypertension– Does pulmonary hypertension happen

immediately?

L sided Compensation

• L sided failure and CXR– Cephalization

– Indistinct vessels, Kerly B-Lines

– Whited Out lungs fields

CHF Compensations

• L sided failure symptoms related to congestion– Blood not going forward:

• Muscle fatigue• Confusion

– Blood going backwards:• Atrial Distension

– Arrhythmias

– Thrombus formation

– Hoarseness

– Mitral Regurgitation

– S3

CHF Compensations

• L sided failure symptoms continued…– Blood going backwards continued…

• Pulmonary congestion– Pulmonary edema– Pulmonary hypertension – R sided failure– Dyspnea, Dyspnea at night– Nocturnal enuresis– Orthopnea– Cardiac Asthma– Hypoxia, cyanosis

CHF Compensations

• R sided failure and Frank:– Most Common Cause is?– Cor pulmonale?– Blood is going to eventually back up into the R atrium and systemic and portal venous

circulation.

CHF Compensations

• What happens when this blood backs up?– Liver Congestion

– Gastrointestinal Tract Nutmeg Liver

CHF Compensations

• What happens when this blood backs up continued…– Pitting Edema

• Frank Starling Forces

• Stasis Dermatitis

• P02?

CHF Compensations

• JVD – jugular venous pressure chart

CHF Compensations

• Acute R sided failure– Causes?– Would you expect to see any change to the R

ventricle?

CHF Compensations

• R sided failure symptoms from the backing up of blood:– Pitting Edema– JVD– GI discomfort– Liver congestion

• RUQ pain• Hepatojugular Reflex• Ascites – Puddle sign

CHF complications

• Would you expect someone with R sided failure only, that is, no L sided failure, to have pulmonary hypertension or pulmonary edema?

CHF Compensations

• Neurohormonal changes:– Renin-Angiotensin System

– Adrenergic System

– ADH

CHF Compensations

• Renin-Angiotensin System – raise EABV, and lower plasma oncotic p.

CHF Compensations

• Does the Renin-Angiotensin System restore EABV back to normal?

• Why is this harmful in the end?

CHF Compensations

• Adrenergic System:– Increased Sympathetic

outflow– Increased effects of

epinephrine on adrenergic receptors throughout your body

– What pathological process could keep the adrenergic system on even if the EABV is restored?

CHF Compensations

• Does the adrenergic system restore the EABV?

• Why is this harmful in the end?

CHF Compensations

• ADH secretion

– Why do its effects become blunted in long run?

CHF Compensations

• Ventricular Remodeling