Transcript document
Pathophysiology of CHF CHF • What is CHF? • Fix the underlying problem • Heart is a 2 sided pump • Both sides can fail independent of each other. CHF • What different types of pathophysiology cause it? • Systolic Dysfunction • Diastolic Dysfunction • High Output States CHF • Systolic Dysfunction – What is it? Is it only related to events that occur in Systole? -1. Decreased Contractility - a. Loss of Myocytes - b. Over-stretched Heart -2. Increased Afterload - a. Increased BP - b. Stenotic Valve - Pulmonic Valve and carcinoid syndrome – 5HIAA CHF • Diastolic Dysfunction – What is it? – 1. Impaired Relaxation – 2. Obstruction to filling • Can systolic and diastolic functions coexist? CHF • Pressure volume loops are used to distinguish between systolic vs. diastolic dysfunction CHF • High Output States – What is it? – Paget’s Disease – Anemia – Thiamine Deficiency – Hyperthyroidism CHF • The failing heart and how it compensates – What does a failing heart mean, and what is decompensation? What does a failing heart look like? – Compensations made by a failing heart • Frank Starling Forces • Neuro-Hormonal Changes • Ventricular Remodeling CHF What is looks like: CHF Compensations • Frank Starling – Length Tension Mechanism CHF Compensations • L sided failure and Frank – Blood is not going to go forward – Blood is going to back up into L atrium and pulmonary venous circulation • L Atrium, what happens when it distends? CHF Compensations • Hoarseness: CHF Compensations • L sided Failure and Frank – Blood eventually backs up into the pulmonary circulation • What happens there? • What’s the deal with Frank Starling Forces? CHF Compensation • L sided failure and the lungs continued… – Pulmonary congestion CHF Compensation • L sided failure and lungs continued… – Pulmonary Hypertension – Does pulmonary hypertension happen immediately? L sided Compensation • L sided failure and CXR – Cephalization – Indistinct vessels, Kerly B-Lines – Whited Out lungs fields CHF Compensations • L sided failure symptoms related to congestion – Blood not going forward: • Muscle fatigue • Confusion – Blood going backwards: • Atrial Distension – – – – – Arrhythmias Thrombus formation Hoarseness Mitral Regurgitation S3 CHF Compensations • L sided failure symptoms continued… – Blood going backwards continued… • Pulmonary congestion – – – – – – – Pulmonary edema Pulmonary hypertension – R sided failure Dyspnea, Dyspnea at night Nocturnal enuresis Orthopnea Cardiac Asthma Hypoxia, cyanosis CHF Compensations • R sided failure and Frank: – – – Most Common Cause is? Cor pulmonale? Blood is going to eventually back up into the R atrium and systemic and portal venous circulation. CHF Compensations • What happens when this blood backs up? – Liver Congestion – Gastrointestinal Tract Nutmeg Liver CHF Compensations • What happens when this blood backs up continued… – Pitting Edema • Frank Starling Forces • Stasis Dermatitis • P02? CHF Compensations • JVD – jugular venous pressure chart CHF Compensations • Acute R sided failure – Causes? – Would you expect to see any change to the R ventricle? CHF Compensations • R sided failure symptoms from the backing up of blood: – Pitting Edema – JVD – GI discomfort – Liver congestion • RUQ pain • Hepatojugular Reflex • Ascites – Puddle sign CHF complications • Would you expect someone with R sided failure only, that is, no L sided failure, to have pulmonary hypertension or pulmonary edema? CHF Compensations • Neurohormonal changes: – Renin-Angiotensin System – Adrenergic System – ADH CHF Compensations • Renin-Angiotensin System – raise EABV, and lower plasma oncotic p. CHF Compensations • Does the Renin-Angiotensin System restore EABV back to normal? • Why is this harmful in the end? CHF Compensations • Adrenergic System: – Increased Sympathetic outflow – Increased effects of epinephrine on adrenergic receptors throughout your body – What pathological process could keep the adrenergic system on even if the EABV is restored? CHF Compensations • Does the adrenergic system restore the EABV? • Why is this harmful in the end? CHF Compensations • ADH secretion – Why do its effects become blunted in long run? CHF Compensations • Ventricular Remodeling