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Understanding Heart Failure: Concepts, Complications, and Treatments

This chapter delves into the various aspects of heart failure, covering its etiology, compensatory responses, effects on the body, and principles of prevention and treatment. It explores the underlying causes, such as impaired myocardium and overload, along with the classification and pathogenesis of heart failure. The compensatory responses, including cardiac, systemic, and neurohormonal adaptations, are discussed in detail to shed light on the body's response to heart failure. The chapter also touches on the effects of heart failure on the body, such as decreased myocardial contractility and pump function, leading to systemic and pulmonary congestion. Furthermore, it outlines the principles of prevention and treatment, including removing the causative factors, improving cardiac function, and the use of inotropic agents and vasodilators. Lastly, the chapter sheds light on the historical progression of treating heart failure from the 1940s to present-day approaches with ACE inhibitors and beta-blockers.

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Understanding Heart Failure: Concepts, Complications, and Treatments

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  1. Chapter 12 Heart failure Zhao Mingyao BMC.ZZU.

  2. Comparison of relative concepts heart failure heart pump failure myocardial failure chronic congestive heart failure

  3. Heart pump function myocardial contractility myocardial relaxility preload (VR) afterload (ejection impedance) SV CO Prolonged overload metabolism structure change HR

  4. The concept of HF Shock Pericarditis HF is the inability of the heart to generate a CO sufficient to meet the metabolic demands of the body

  5. Section 1 Etiology and Classification

  6. 1.Underling causes (1) myocardium impaired ? ? ? (2) myocardium overload over preload over afterload

  7. 2. Precipitating factors O2 supply of myocardia↓ O2 consumption and myocardial work↑ Infection Arrhythmia Pregnancy Disorder of water, electrolytes and acid-base Over fatigue

  8. 3. Classification of heart failure Severity: symptomatic heart failure Progress velocity Cardiac output Site Function impaired

  9. NYHA Classification

  10. Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult (ACC/AHA, 2005)

  11. Section 2 Pathogenesis of HF

  12. 1. Myocardial Contractility↓ Damaged cardiomyocyte Metabolic disorder of energy production ↓ utilization ↓

  13. Insufficiency of vitamin B1 lead to heart failure ~ decarboxylase Pyruvic acid acetyl Co A Krebs citric acid cycle ATP

  14. (3)Dysfunction of excitation-contraction coupling( Ca2+ delivery disorder ) 1) reduced Ca2+ intake, reserve and release of SR (Ry-R) 2) reduced influx of extracellular Ca2+ 3) dysfunction of Ca2+ binding to troponin Ca2+waves and oscillations

  15. Ca2+ intake, reserve and release of SR (Ry-R)

  16. 2. Diastolic dysfunction ↓ (1) delayed reposition of Ca2+ (2) blocked dissociation of the actin-myosin complex (3) decreased ventricular diastolic potential (4) Reduced ventricular compliance

  17. Diastolic properties ↓ Diastolic process = Relaxility compliance diastolic load

  18. Section 3 Compensatory responses

  19. 1. Cardiac compensation (1) Heart rate↑ (2) Frank-Starling mechanism (3) myocardial hypertrophy

  20. (1) HR increased in HF CO = SV × HR

  21. Contractile power Contractility (2)Frank-Starling law

  22. Ventricular Performance Frank-Starling Curve End-Diastolic Volume Position Intra-Thoracic Body Total Blood Pressure Volume Stretch of Atrial Pericardial Pressure, Contribution Compliance Myocardium Pumping Action of Venous Skeletal Muscle Tone

  23. (3)Myocardial hypertrophy concentric eccentric sarcomeres in parallel or in series

  24. concentric eccentric chamber radius wall thickness

  25. 2. Systemic compensation (1) blood volume (2) redistribution of blood flow (3) erythrocyte↑ (4) ability of tissue to utilize O2↑

  26. 3. Neurohormonal compensation (1)sympathetic nervous system (2)RAAS (3)atrial natriuretic peptide (4)endothelin

  27. fibril, mit, vol↑ but collagen(~ I, thick , stiff; ~III ) ↑ phenotype change α- MHC ↓, β- MHC↑ Two side effects of heart hypertrophy (myocardial remodeling ) MHC: Myosin heavy chain

  28. myocyte hypertrophy and widening of interstitial spaces due to depostion of collagen, inflammatory cells and amyloid.

  29. Section 4 Effects on body Good hearts support them. How is your heart ?

  30. Effects of heart failure on body myocardial contractility↓ diastolic properties↓ heart pump↓ VR↓ CO ↓ systemic congestion pulmonary congestion ? ? ?

  31. 1.Congestion of pulmonary circulation (1) dyspnea ------ pulmonary edema Mechanism: ①Pulmonary compliance↓ ②Airway resistance↑ ③Alveolar juxta-capillary receptor ++ ④Hypoxia and acidosis

  32. Types of dyspnea 1) exertional ~: 2) orthopnea 3) paroxysmal nocturnal ~

  33. 1) Exertional ~ Short breath and heart-throb

  34. 2) Orthopnea • Mechanism: when lying • Venous returing↑ • Diaphragm upshift

  35. 3) Paroxysmal nocturnal dyspnea 1. Fluid returning ↑and chest limited due to prostration 2. Airway resistance↑ due to vagus nerve tension ↑ 3. CNS response ↓ during sleep Cardiac asthma

  36. (2) Pulmonary edema

  37. 2. Congestion of systemic circulation (1)systemic venous congestion and hypertension (2)edema (3)hepatomegaly and hepatic dysfunction

  38. 3. Low cardiac output Fatigue and limb weakness Mental confusion and disturbed behavior Cyanosis? Nocturia Anasarca Cardiogenic shock

  39. Section 5 Principle of prevention and treatment 1. removal cause 2. prevent predisposing factor 3. improving cardiac function: inotropic agent digitalis Ca 2+ channel antagonist or Ca 2+ receptor blocker vasodilator agents 4. anti-remodeling of ventricle 5. stem cell and heart transplantation

  40. The Progressive Development of Cardiovascular Disease Risk Factors Endothelial Dysfunction Atherosclerosis CAD Myocardial Ischemia Coronary Thrombosis Myocardial Infarction Arrhythmia & Loss of Muscle Remodeling Ventricular Dilation Congestive Heart Failure Endstage Heart Disease

  41. Brief history about treating heart failure 1940 times heart + kidney mode 1970 times heart + circulation mode 1990 times heart + endocrine mode ACEI, β-receptor blocker ,α- receptor blocker

  42. thanks

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