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HEART FAILURE (HF)
• Heart failure is the pathophysiological state in
which an abnormality of cardiac function is
responsible for failure of the heart to pump blood
at a rate commensurate with the requirements of
the metabolizing tissue, or to do so only from an
elevated filling pressure.
• Clinical syndrome due to different structural and
functional disease of the heart leading to
abnormality in filling or emptying of the left
ventricle.
• Myocardial insufficiency – related to
impaired contractility. Not every heart
failure is associated with myocardial
insufficiency.
• Circulatory failure – clinical syndrome
which is caused by abnormality of the
following components of circulation, such
as the heart, blood volume, Hb level,
vessels.
PATHOPHYSIOLOGY OF HF
Adaptive mechanisms
early
late
Early adaptive mechanisms
• Frank-Starling mechanism
• Activation of neurohormonal systems
NEUROHORMONAL MECHANISMS
• Elevation of norepinephrine leading to increased
contractility.
• Activation of renin-angiotensin-aldosterone
system (RAAS).
• Activation of arginine-vasopressin system.
• Activation of natriuretic peptides (ANP, BNP,
CNP).
• Elevation of endotheline.
• Elevation of cytokines (TNF-α, IL-1β).
• NO (NO synthethase –NOS1-3).
• Elevation of oxidative stress in the myocardium.
LATE ADAPTIVE MECHANISMS
• Left ventricular remodeling
Volume overload
Pressure overload
↑ Systolic strain
↑ Diastolic strain
↑ Activation of extracellular and intracellular signals
Left ventricular remodeling
Parallel arrangement of sarcomers
Concentric hyperthrophy
Serial arrangement of sarcomers
Excentric hyperthrophy
Normal
Framingham criteria for HF
Major criteria
• Paroxyzmal nocturnal dyspnoe
• Neck-vein distension
• Rales
• Cardiomegaly
• Acute pulmonary edema
• S3 gallop
• ↑ venous pressure(16 cm H2O)
• Hepatojugular reflux
• Loss of weight > 4,5 kg during
5 days
Minor criteria
• Ankle edema
• Night cough
• Dyspnoe on exertion
• Hepatomegaly
• Pleural effusion
• Tachyaardia (>120/min.)
FORMS OF HF
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Right-sided vs left-sided HF
Acute vs chronic HF
Low-output vs high-output HF
Systolic vs diastolic HF
Causes of HF
• Pericardial disease (tamponade,
constrictive pericarditis)
• Valvular heart disease
• Disease of the myocardium (dilated CMP)
• Coronary heart disease
• Arrhythmias (tachycardia-induced CMP)
Treatment of HF
Pharmacological
Nonpharmacological
Pharmacological treatment
• Diuretics
• Vasodilators
• Positive inotropic agents (digitalis, betablockers, phosphodiesterase inhibitors,
Ca-senzitisers)
• Neurohormonal inhibitors (ACEI, ARB,
beta-blockers)
Nonpharmacological treatment
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Intraaortic balloon contrapulsation
Mechanical support
CRT
Transplantation