Congestive Heart Failure

What is the definition of heart failure and congestive heart failure (CHF)?

Heart Failure: heart’s inability to effectively fill and/or eject (pump) blood

Congestive Heart Failure (CHF): inadequate pump function leads to congestion as fluid accumulates in the lungs and peripheral tissues; a common end-point

​Hint: Inability to fill/pump adequately leading to fluid accumulation and congestion.

What are the four major pathophysiological categories of causes that can lead to heart failure?

● Inappropriate workloads placed on the heart (volume overload / pressure overload)

● ​Restricted filling of the heart

● ​Myocyte loss (e.g., myocardial infarction)

● ​Decreased myocyte contractility (e.g., dilated cardiomyopathy)

What are the three most common causes responsible for the vast majority of clinical heart failure cases?

● Ischaemic heart disease (IHD)

● ​Systemic hypertension

● ​Valvular heart disease

How is Ejection Fraction (EF) defined, and what is its normal resting value?

Definition: The percentage of blood volume ejected from the ventricle during systole

​Normal Value: Ventricles normally eject about 60–70% of the blood contained in them at the end of diastole.

What are the core pathophysiological and functional differences between Systolic Failure and Diastolic Failure?

Systolic Failure (HFrEF):

● Impaired cardiac contractility, “pump failure”

● reduced ejection fraction

Diastolic Failure (HFpEF):

● Impaired ventricular relaxation and filling

● ejection fraction remains preserved.

What are the primary forward and backward failure consequences of left-sided heart failure?

Forward failure : reduced cardiac output >> poor organ perfusion >> organ dysfunction

Backward failure : Increased left ventricular volumes or pressures >> backup of blood into lungs >>increased pulmonary capillary pressure >> pulmonary oedema & increased pulmonary artery pressure

What are the common clinical presentations of left-sided heart failure?

● Dyspnea (breathlessness)

● ​Orthopnea (shortness of breath when lying flat)

● ​Paroxysmal nocturnal dyspnea

● ​Fatigue and confusion

What are the gross and microscopic features of the lungs in left-sided heart failure (pulmonary edema and congestion)?

Gross appearance:

● Pulmonary oedema

● Heavy and boggy lungs

● Cut surface oozes out frothy fluid

Microscopic Appearance:

● Alveoli filled with smooth to slightly floccular pink edema fluid

● alveolar capillaries congested with red blood cells.

Heart Failure Cells:

● Presence of hemosiderin-laden macrophages in alveolar spaces due to leakage of blood into alveolar spaces

Hint: Heavy/boggy lungs, pink edema fluid, and hemosiderin-laden "heart failure cells".

What is the pathophysiology and clinical presentation of right-sided heart failure?

Pathophysiology: Increased pulmonary artery pressure >> reduced right-sided cardiac output >> systemic venous congestion >> peripheral oedema and progressive congestion of internal organs

Clinical Presentation: Bilateral pedal edema, raised jugular venous pressure (JVP), and hepatomegaly.

What is a "nutmeg liver", and what pathological process causes it?

"nutmeg" liver seen with chronic passive congestion of the liver; due to

right-sided heart failure.

Appearance: A mottled cut surface showing dark red congested centrilobular regions