Lecture 16 and 17: Heart Failure with Reduced and Preserved Ejection Fraction

Heart Failure

inability of the heart to maintain sufficient cardiac output to perfuse the vital organs

Systolic Heart Failure

Systolic or Diastolic HF:

-impaired myocardial contractility

-dilated heart

Systolic Heart Failure

Systolic or Diastolic HF:

-reduced ejection fraction

Diastolic Heart Failure

Systolic or Diastolic HF:

-normal ejection fraction

Diastolic Heart Failure

Systolic or Diastolic HF:

-impaired relaxation and filling

-hypertrophied heart

Systolic Heart Failure

Systolic or Diastolic HF:

-volume overload

Diastolic Heart Failure

Systolic or Diastolic HF:

-Pressure overload

Right

pulmonary arterial hypertension -----> _______ Heart Failure

Left

stenoses or malignant hypertension -----> _______ Heart Failure

Left Heart Failure

most common cause of right heart failure

1. The adrenergic nervous system

2. RAAS

3. Increased production of antidiuretic hormone (ADH)

the three compensatory mechanisms for reduced CO

HFpEF

Decreases

Diastolic Heart Failure __________________ Compliance

Diastolic Heart Failure

• Ventricular concentric hypertrophy decreases ventricular compliance

• Ventricular filling pressure increases which lead to decreased ventricular filling and increased LVEDP.

• LV ---> Increased left atrial and pulmonary venous pressure ---> pulmonary congestion ---> pulmonary edema

• RV ---> Increased RAP and systemic venous pressure ---> peripheral edema

Sympathetics and RAAS

In Diastolic Heart Failure, decreased arterial BP leads to activation of _________________ and _____________

Left

Left or Right-sided HF:

-dyspnea

-orthopnea

-pasozysmal nocturnal dyspnea

-fatigue

Left

Left or Right-sided HF:

-diaphoresis

-tachycardia

-pulmonary crackles

-loud P2

-S3 gallop (in systolic dysfunction)

-S4 gallop (in diastolic dysfunction)

Right

Left or Right-sided HF:

-peripheral edema

-right upper quadrant pain

-hepatic enlargement

Right

Left or Right-sided HF:

-jugular venous distension

-hepatomegaly

-peripheral edema

Dyspnea

pulmonary edema, shunt, and hypercarbia leads to ______________

Orthopnea

dyspnea that occurs when lying flat and is relived by elevation of the head with pillows

- paroxysmal nocturnal dyspnea or orthopnea

- jugular vein distention

- rales (crackles, whistling, sloshing)

- cardiomegaly

- acute pulmonary edema

- S3 gallop

- increased venous pressure >16 cm

- circulation time >25 sec

- hepatojugular reflux

according to Framingham Criteria, what are some major criteria for heart failure

- ankle edema

- night cough

- dyspnea on exertion

- hepatomegaly

- pleural effusion

- vital capacity decreased 1/3 from maximum

- tachycardia (>120)

according to Framingham Criteria, what are some minor criteria for heart failure

(2) major or (1) major and (2) minor criteria

what is the Framingham criteria requirements for diagnosing heart failure?

Echocardiogram

the best single diagnostic test for assessment of valves and ventricular function

• Wall thickness

• Chamber size

• Wall motion abnormalities

• Valvular structure and function

• Ejection fraction

• Pericardial effusion

what are some echocardiogram findings that are indicative of Heart Failure?

• Cardiomegaly (including chambers)

• Pulmonary vascular redistribution

• Pleural effusion

• Kerley B lines

what are some CXR findings that are indicative of Heart Failure?

Cardiac Catheterization

best assessment of coronary arteries and hemodynamic function

Cardiac Catheterization

- Assess presence of CAD

- Wall motion abnormalities

- Ejection fraction

- Assess intracardiac pressures

Exercise Testing

- Assess ischemia

- Assess exercise capacity

- Assess cardiac reserve (MaxVO2)

- Assess blood pressure and heart rate response to stress

- Hematocrit

- Thyroid function

- Neurohormones (research mainly)

- BNP

what things should you look at when blood testing that can be indicative of heart failure?

Class I

Classification of chronic heart failure:

-no limitation of physical activity

Class II

Classification of chronic heart failure:

-slight limitation of activity

-dyspnea and fatigue with moderate exertion

Class III

Classification of chronic heart failure:

-marked limitation of activity

-dyspnea with minimal exertion

Class IV

Classification of chronic heart failure:

-severe limitation of activity

-symptoms are present even at rest

STEMI

• Injured and dying cells leak K+ into the extracellular space

• The Na+-K+ ATPase cannot maintain the K+ gradient in the injured cells

• Increased extracellular K+ causes peripheral healthy myocytes to depolarize

Local Reflex (short term compensatory mechanism for MI)

-increase in interstitial metabolites that allow all immediate resistance vessels to dilate reflexively

Central Reflex (short term compensatory mechanism for MI)

-death of myocytes impairs myocardial contractility

-reduction in SV adn CO

-decreased MAP

-trigger of baroreceptor reflex

decreased in MAP which activates RAAS

describe long term compensatory mechanism for MI

Preloading

____________________ the heart increases CO through length-dependent activation of sarcomeres

Increases

Preloading ________________ wall tension

Systolic Heart Failure

Preload penalty is associated with which HF?

Preloading

-increases wall stress

-predisposes myocardium to potentially fatal dysrhythmias and arrhythmias

-stretches and distorts cartilaginous valve rings and unseats the valves

-edema

filtration

CVP elevation raises mean capillary pressure (↑Pc) and favors _______________ from capillary into the interstitium

Pulmonary Congestion

fluid filters from pulmonary capillaries and collected in alveolar sacs where it interferes with gas exchange

Congestive Heart Failure

-retention of fluid to compensate for impaired EF and attempt to maintain sufficient tissue perfusion

-NaCl and water are retained due to increased RAAS aldosterone

ANP/BNP

the plasma level of ___________________ is increased in congestive heart failure

Systolic Heart Failure

-depressed left ventricular ejection fraction (LVEF)

-dilated/eccentric remodeling

-S3 gallop

-HFrEF

Coronary Artery Disease with subsequent myocardial damage

the most common cause of systolic heart failure

Systolic Heart Failure

Diastolic Heart Failure

-pressure overload induces concentric hypertrophy

-impaired filling

-decreased EDV

-increased contraction force

-increased afterload

-S4 heart sound

thick wall helps offset the effects of high IV pressure on wall stress

what is the advantage of cardiac hypertrophy

LaPlace's Law

P = 𝑟/2𝑇

Diastolic Heart Failure

Inhibits Na+/K+ ATPase

what is the mechanism of Digoxin

Digoxin

-causes an increase in intracellular sodium levels

-increases cytosolic calcium

-decreases HR

-increases SR calcium stores

-CICR of greater magnitude

-leads to increased contractility without increasing heart energy expenditure

ACE Inhibitors

first line therapy for systolic dysfunction

ACE Inhibitors

-prevents adverse remodeling

-improves afterload

-reduces risk for MU and progression of CHF

-may raise potassium, precipitate renal dysfunction in some cases, and cause dry cough

β-blockers

second line therapy in systolic dysfunction

β-blockers

-may raise RF by 10% or more

-for stable patients only

Inotropes

-increase contractility and CO

-oral and IV agents

Digoxin

all inotropes EXCEPT ___________________ increase mortality in CHF

Diuretics

• Needed by most patients to correct water retention

• Use minimum doses required to remove excess volume

• May cause magnesium/potassium depletion, raise uric acid levels, and induce gout, hyperlipidemia, and renal failure

ACEi

ARBs

Beta-blockers

Diurectics (edema)

initial therapies for HFrEF