Slides 01 Cardiology Alpert

Cardiology An introduction
Heart Failure
With Joseph S. Alpert, M.D.
Kirubel Derib, kirupeace@gmail.com

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Heart Failure
Definition
Heart (or cardiac) failure (HF)
• Pathophysiological state in which the heart is unable to pump

blood at a rate commensurate with the requirements of the
metabolizing tissues
• An inadequate or decreased cardiac output causing an increase in

blood volume within the vascular system; the resulting vascular
congestion results in fluid accumulation in the tissue spaces
= edema
• HF is a clinical syndrome involving circulatory congestion and/or

inadequate tissue perfusion due to abnormal heart function and
associated neurohormonal abnormalities which result from the
compensate for the heart failure state

Heart Failure
Definition
Heart failure frequency in the U.S.
• More than 3 million people have congestive

heart failure (CHF) > 3 million
• More than 400,000 new patients present
yearly
• The prevalence rate is 1-2%

Heart Failure
Definition
Race and CHF
• African Americans are 1.5 times more likely

to die from HF compared to Caucasians
• Paradoxically, African American patients

appear to have similar or lower in-hospital
mortality rates compared to Caucasian
patients

Heart Failure
Definition
Heart failure frequency in the U.S.
• Approximately 30-40% of patients with

congestive
heart failure (HF) are hospitalized every year
65+
yrs
• HF is the leading diagnosis among
hospitalized patients
older than 65 years
• 35% will die within one year of diagnosis

Heart Failure
Definition
Age and Gender
• Prevalence of HF increases with increasing

age and affects about 10% of the population
older than 75 years of age
• Prevalence is greater in males than in

females in patients aged 40-75 yrs
• No sex predilection is noted among patients

older than 75 years

Heart Failure
Definition
Preload
• Passive stretch of the heart muscle prior to

contraction
• This is related to the blood volume filling the

ventricles
• Preload is affected by the elasticity or

compliance of the ventricle

Heart Failure
Definition
Afterload
• Force opposing or stretching muscle after

contraction begins
• For the left ventricle, this is related to level of

aortic blood pressure and also to the
magnitude of peripheral vascular resistance

Heart Failure
Definition
Left Ventricular Dysfunction
Systolic and Diastolic Heart Failure
• Systolic: Impaired contractility/ejection
• HF can be secondary to systolic dysfunction • Approx. 2/3 of heart failure
or diastolic dysfunction of the ventricles patients have systolic dysfunction
• Diastolic: Impaired filling/relaxation
• The number of patients with each form is
approximately 60% with systolic failure and
40% with diastolic failure
30%
• Patients with systolic heart failure have a low (EF > 40%)
left ventricular (LV) ejection fraction
70%
• Patients with diastolic heart failure have a (EF < 40%)
normal LV ejection fraction but abnormal LV
elasticity and abnormal diastolic function Diastolic Dysfunction
Systolic Dysfunction
1 Lilly, L Pathophysiology of Heart Disease Fourth Edition, 2007 p 197

Heart Failure
Pathophysiology
In order to maintain normal cardiac output in

the face of decreased myocardial contractile
function, a number of compensatory
mechanisms are called into play, for example
• Cardiac muscle hypertrophy
• Cardiac dilatation, or both
Tachycardia (that is, increased heart rate)

results from activation of the neurohumoral
system, the sympathetic nervous system
• Release of norepinephrine and atrial
natriuretic peptide
• Activation of the renin-angiotensin
aldosterone system

Heart Failure
Pathophysiology
LAW
= The rubber band law of the heart
• The force of ventricular contraction is a function of the end-diastolic

length of the cardiac muscle, which in turn is closely related to the
ventricular end-diastolic volume
• Increased contraction results by increasing the length of

sarcomeres in a dilated heart
• This increases myocardial contractility and thereby attempts to

maintain stroke volume

Heart Failure
Pathophysiology
Cardiac output in liters/minute

= stroke volume in cubic centimeters x heart rate

Heart Failure
Pathophysiology
• Heart failure results from DEPRESSION of myocardial and hence

ventricular contractility = depressed Starling function
• COMPENSATION occurs in the form of stretching of myocardial

fibers which leads to cardiac dilatation and hypertrophy

Heart Failure
Pathophysiology
Compensatory Mechanisms
Sympathetic nervous system stimulation Renin-angiotensin system activation
Myocardial hypertrophy Increased heart rate

Heart Failure
Pathophysiology
Ventricular Remodeling
Left Ventricular Hypertrophy Left Ventricular Dilatation

Heart Failure
Types of Heart Failure
Type of heart failure Description
Left-sided heart failure • Most common form of heart failure

• Fluid may build up in the lungs, causing shortness of breath
= pulmonary edema
Right-sided heart failure • Often occurs with left-sided heart failure
• Fluid builds up in the abdomen, legs and feet, causing swelling
= peripheral edema
Systolic heart failure • The left ventricular contraction is abnormal
= low left ventricular ejection fraction
Diastolic heart failure • The left ventricle fails to relax or fill fully, indicating abnormal
diastolic function

Heart Failure
Types of Heart Failure
Cardioregulatory
center
Glossopharyngeal
and vagal afferents
from high-pressure
baroreceptors
Sympathetic
trunk
Sympathetic
ganglion AVP
Aldosterone
Sympathetic
nerves
Angiotensin II
release
Peripheral
Solute-free water excretion
vasoconstriction
Sodium excretion
Copyright 2005 by Elsevier Science

Heart Failure
The Heart Failure Milieu
Compensatory Mechanisms
Disease Process
Ventricular
dysfunction
Renal Hemodynamic Sympathetic

Renin-angiotensin-aldosterone abnormalities Increased contractility
Salt/Water retention Tachycardia
Increased venous tone
Ventricular Compensatory Increased arterial tone
Dilation Mechanisms
Hypertrophy

Heart Failure
Vicious Circle (clinical aspects)
Vasopressors Inotropes
Cardiac output
CPAP
Renal perfusion pressure Lung congestion
Diuretics
Water and salt retention,
Neurohormonal activation
vasoconstriction
β-Blockers, ACE inhibitors, AT II blockers Vasodilatators

Heart Failure
Pathophysiology
Stages in the Evolution of Heart Failure
A • Hypertension, Diabetes, Hypercholestolemia
• Heart disease (any)

B • Asymptomatic LV dysfunction (Systolic /
Diastolic)
C • Dyspnea, Fatigue, Reduced Exercise Tolerance
D • Marked Symptoms at rest despite max.

therapy

Heart Failure
Causes
Population attributable risk factors 3% 2%

8%
Ischemic heart disease
Cigarette smoking 10%
Hypertension (high blood

pressure)
Obesity
16% 62%
Diabetes
Valvular heart disease (much

higher in older populations)

Heart Failure
Causes
Rarer causes of Heart Failure

• Viral myocarditis (infection of the heart
muscle)
• Infiltration of heart muscle such as
amyloidosis
• HIV cardiomyopathy
• Connective tissue diseases such as systemic
lupus erythematosus
• Abuse of drugs such as alcohol and cocaine
• Pharmaceutical drugs such as
chemotherapeutic agents
• Arrhythmias

Heart Failure
Symptoms
Left Ventricular Heart Failure
Tachypnea Heart murmurs
Pulmonary edema aortic stenosis
mitral regurgitation
Cyanosis
tricuspid regurgitation
Enlarged apex beat
S3 gallop rhythm

Heart Failure
Symptoms
Right Ventricular Heart Failure
• Abdominal distension
• Right upper quadrant abdominal pain
• Epigastric fullness, early satiety, nausea,

vomiting (stomach congestion)
• Change of bowel habit constipation,

diarrhea, malabsorption
• Bilateral leg swelling
• Yellowish coloration of sclera (bilirubin)

Heart Failure
Symptoms
Dilated pupils, a sympathetic Skin pale gray, or cyanotic

nervous system response
Dyspnea, SOB is early symptom
Decreased blood pressure from pulmonary congestion
stimulates sympathetic Orthopnea, cannot breathe unless
nervous system, which acts sitting up
on heart to increase rate and
increase force of contraction Crackles, wheeze are adventitious
breath sounds
Cough, frothy pink or white sputum
Ascites fluid in
peritoneal cavity
Dependent, pitting Nausea and vomiting as peristalsis
edema, in sacrum, legs slows and bile and fluids back up
into stomach

Heart Failure
Symptoms
Anxiety, gasping from pulmonary

congestion
Infarct, may be cause of
decreased cardiac output Falling O saturation
Fatigue, weakness from Confusion, unconsciousness from

decreased cardiac output decreased O to brain
Enlarged spleen and Jugular vein distention from

liver from venous venous congestion
congestion. This causes
pressure on breathing S gallop, tachycardia
Decreased urine output Weak pulse,

cool, moist skin

Heart Failure
Symptoms
What physical finding

is demonstrated on the image?
a) An S3 gallop
b) Pulmonary crackles
c) An enlarged cardiac impulse
d) Elevated jugular venous pressure

Heart Failure
Symptoms
What physical finding

is demonstrated on the image?
a) An S3 gallop
b) Pulmonary crackles
c) An enlarged cardiac impulse
d) Elevated jugular venous pressure
e) Peripheral edema

Heart Failure
Testing on patients with suspected Heart Failure
• Blood tests, including renal and

liver function as well as troponin
• EKG for signs of myocardial

infarction and / or hypertrophy
• Chest x-ray
• Echocardiogram
normal sized heart abnormally large

heart (cardiomegaly)

Heart Failure
Pulmonary edema

Heart Failure
Cephalization of pulmonary
vasculature
Peribronchial cuffing
Perihilar haze
Kerley A lines
Kerley B lines
Pleural
effusion

Heart Failure
2-D echocardiography in CHF
All 4 chambers dilated

with poor contractility

Heart Failure
Therapy
Treatment Goals
• Improve symptoms to enhance well-being

and quality of life
• Increase exercise tolerance and try to

improve survival
• Prevent progressive heart failure
• Prevent sudden death
• Prevent thromboembolic episodes

Heart Failure
Therapy
Stage D Hospice
Prominent symptoms VAD, transplantation
Stage C Inotropes
No symptoms or mild to moderate Aldosterone antagonist, nesiritide
symptoms
Stage B Consider multidisciplinary team
No symptoms or mild Revascularization, mitral valve surgery
symptoms
Cardiac resynchronization if bundle branch block present
Stage A
No symptoms Dietary sodium restriction diuretics and digoxin
ACE inhibitors or ARBs in all patients
ACE inhibitors or ARBs in all patients, beta-blockers in selected patients
Treat hypertension, diabetes, dyslipidemia, ACE inhibitors or ARBs in some patients
Risk-factor reduction, patient and family education

Heart Failure
Therapy
Lifestyle Changes that can help prevent HF
• Smoking cessation
• Controlling high blood pressure,

high cholesterol and diabetes
• Staying physically active
• A heart healthy diet
• Maintaining a healthy weight
• Reducing and managing stress

Heart Failure
Therapy
Treatment (medicaments)
• Beta Blockers
• ACE Inhibitors
• Diuretics
• Inotropic Agents only as a last resort

Heart Failure
Therapy
Drugs used to treat Heart Failure
Vasodilators Diuretics Inotropic Agents

• Captopril • Bumetanide • Digoxin
• Enalapril • Furosemide • Dobutamine/dopamine
• Fosinopril
• Hydrochlorothiazide • Amrinone
• Lisinopril
• Metalazone • Milrinone
• Quinapril
• Spironolactone
• Hydralazine
• Isosorbide
• Angiotensin receptor
blockers, for example,
losartan

Heart Failure
Therapy
Patient Counseling
• Lifestyle changes
• Smoking cessation
• Weight loss
• Avoid or limit alcohol
• Eat a low-fat, low-sodium diet
• Exercise, moderate
• Home monitoring of weight and blood

pressure

Heart Failure
Therapy
Patient Counseling
• Medications
• Surgery/Catheter intervention (bypass or

valve replacement or angioplasty)
• Reduce stress possible interventions such

as meditation, tai chi
• Keep track of symptoms and weight and

report any changes or concerns to the
healthcare providers
• Limit fluid intake, modest
• Regular follow-up with healthcare providers

Heart Failure
Conclusions
• Heart failure is a syndrome caused by many diseases;

it is not a disease itself
• Sophisticated diagnostic and therapeutic approaches have

markedly improved the care of heart failure patients over recent
decades
• Newer device therapies are showing promise for symptom relief

and improved survival
• Biventricular pacing
• Transplants remain rare, but technology for mechanical assist

devices continues to improve stay tuned

Dieses Dokument gehört: Kirubel Derib
Hinweis: Dieses Dokument ist urheberrechtlich geschützt. Die Vervielfältigung,

Verbreitung, Wieder- bzw. Weitergabe und sonstige Nutzung ist ohne die schriftliche
Genehmigung der Lecturio GmbH nicht gestattet.


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Cardiology An introduction

With Joseph S. Alpert, M.D.

Kirubel Derib, kirupeace@gmail.com

Heart (or cardiac) failure (HF)

• Pathophysiological state in which the heart is unable to pump

• An inadequate or decreased cardiac output causing an increase in

• HF is a clinical syndrome involving circulatory congestion and/or

Kirubel Derib, kirupeace@gmail.com

Heart failure frequency in the U.S.

• More than 3 million people have congestive

• The prevalence rate is 1-2%

Kirubel Derib, kirupeace@gmail.com

Race and CHF

• African Americans are 1.5 times more likely

• Paradoxically, African American patients

Kirubel Derib, kirupeace@gmail.com

Heart failure frequency in the U.S.

• Approximately 30-40% of patients with

• 35% will die within one year of diagnosis

Kirubel Derib, kirupeace@gmail.com

Age and Gender

• Prevalence of HF increases with increasing

• Prevalence is greater in males than in

• No sex predilection is noted among patients

Kirubel Derib, kirupeace@gmail.com

• Passive stretch of the heart muscle prior to

• This is related to the blood volume filling the

• Preload is affected by the elasticity or

Kirubel Derib, kirupeace@gmail.com

• Force opposing or stretching muscle after

• For the left ventricle, this is related to level of

Kirubel Derib, kirupeace@gmail.com

1 Lilly, L Pathophysiology of Heart Disease Fourth Edition, 2007 p 197

Kirubel Derib, kirupeace@gmail.com

In order to maintain normal cardiac output in

Tachycardia (that is, increased heart rate)

Kirubel Derib, kirupeace@gmail.com

= The rubber band law of the heart

• The force of ventricular contraction is a function of the end-diastolic

• Increased contraction results by increasing the length of

• This increases myocardial contractility and thereby attempts to

Kirubel Derib, kirupeace@gmail.com

Cardiac output in liters/minute

Kirubel Derib, kirupeace@gmail.com

• Heart failure results from DEPRESSION of myocardial and hence

• COMPENSATION occurs in the form of stretching of myocardial

Kirubel Derib, kirupeace@gmail.com

Sympathetic nervous system stimulation Renin-angiotensin system activation

Myocardial hypertrophy Increased heart rate

Kirubel Derib, kirupeace@gmail.com

Left Ventricular Hypertrophy Left Ventricular Dilatation

Kirubel Derib, kirupeace@gmail.com

Type of heart failure Description

Left-sided heart failure • Most common form of heart failure

Kirubel Derib, kirupeace@gmail.com

Copyright 2005 by Elsevier Science

Kirubel Derib, kirupeace@gmail.com

Renal Hemodynamic Sympathetic

Kirubel Derib, kirupeace@gmail.com

Renal perfusion pressure Lung congestion

β-Blockers, ACE inhibitors, AT II blockers Vasodilatators

Kirubel Derib, kirupeace@gmail.com

Stages in the Evolution of Heart Failure