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Congestive Heart Failure CHF

                    1. Pathophysiology




March 2013             ghennersdorf DGK ESC SES
Epidemiology 2000 (US Database)
        4.78 Mio. victims in USA
        16 Mio. victims world wide
        400.000 pts. incidence/year US
        1.5 Mio. pts. incidence/year world wide
        41810 deaths / year (USA)
        17.5 Bill. $ direct costs (USA):
          mainly by hospitalization
        Fourfold hospitalization within the
         last 15 years

        No valid data for Tanzania so far!
March 2013             ghennersdorf DGK ESC SES
Survival rates after CHF
                     (effect of medical therapy)



                 x




                     x

     Braunwald
                           x
       1988*
                                  x




March 2013               ghennersdorf DGK ESC SES
Definition of Heart Failure CHF (1)
• Inability of the heart to meet the peripheral
  demands under rest or exercise conditions
  caused by
     – muscular dysfunction (systolic/diastolic)
     – mechanical disorder (valve disease)
     – combination




March 2013             ghennersdorf DGK ESC SES
Definition of Heart Failure CHF (2)
• Definition by activity
     – resting HF
     – exercise HF

• Definition by time course
     – Acute
     – Chronic



March 2013           ghennersdorf DGK ESC SES
Definition of Heart Failure CHF (3)
• New York Heart Association (NYHA)
     – I  no visible signs and symptoms
     – II  signs and symptoms at high level exercise
     – III  signs and symptoms at low level exercise
     – IV  no physical exercise possible, bed rest
       necessary



             Most valid functional definition throughout the world!

March 2013                   ghennersdorf DGK ESC SES
Definition of Heart Failure CHF (4)
• Anatomical definition
     – Left sided heart failure
             • CHD (myocardial infarction)
             • disease of mitral or aortic valve
             • Cardiomyopathy of unknown origin (idiopathic)
     – Right sided heart failure
             • Pulmonary embolism
             • Pulmonary vascular hypertension
             • Mitral stenosis



March 2013                   ghennersdorf DGK ESC SES
acute heart failure: etiology
• acute HF (left sided: pulmonary edema)
     – Myocardial infarction (w/wo cardiogenic shock)
     – Hypertensive heart disease
             • Acute CHF: hypertensive crisis-pulmonary edema)
     – Inflammation
             • Acute valvular disease (endocarditis)
             • Acute (peri-)myocarditis
             • Combination (pancarditis)
     – Pulmonary embolism (right sided CHF)


March 2013                    ghennersdorf DGK ESC SES
Cardiogenic shock: etiology
• Special subset of HF:
  Cardiogenic shock
     – sudden onset with underlying disease (often triggered by
       large or multiple myocardial infarction); leading to:
             •   organ perfusion deficit
             •   organ failure
             •   fast development of irrevesibilty
             •   organ death, clinical death, biological death
     – Despite therapeutic improvement (PCI, IABP) 50-70%
       mortality rate


March 2013                         ghennersdorf DGK ESC SES
Left heart failure
• Acute                                  • Low output
     – Pulmonary edema                        – Classical term: CHD,
     – Cardiogenic shock                        HPT, RHD etc.
• Chronic                                • High output
     – NYHA I-IV                              –   Fever states
                                              –   Anemia
                                              –   Pregnancy
                                              –   Hyperthyreoidism
                                              –   Beri beri
                                              –   AV fistulas
                                              –   Paget disease
March 2013                 ghennersdorf DGK ESC SES
Chronic left heart failure

              Most common endpoint
              of multiple disorders
              of the left ventricle




March 2013           ghennersdorf DGK ESC SES
Etiology of HF
• chronic HF
     – Hypertensive heart disease: progressive muscle damage;
       hypertrophy; disatolic HF
     – Coronary heart disease: myocardial infarction
     – Valvular disease after acute/occult onset of endocarditis
     – Chronic myocarditis  „secondary“ cardiomyopathy
     – „Primary“ dilatative cardiomyopathy
     – Venous disease (deep vein thrombosis) right heart
       failure


March 2013               ghennersdorf DGK ESC SES
Pathophysiology of Heart Failure

• Manifestation types of heart failure
     – Systolic dysfunction
     – Diastolic dysfunction
     – Muscular hypertrophy
     – Dilatation and remodeling




March 2013            ghennersdorf DGK ESC SES
Pathophysiology of Heart Failure:
              function control
• Determinants of heart function
     – Normal conditions
             • Nervous (sympathetic) control
                – Heart rate
                – Contractility
     – Abnormal conditions
             • Pressure volume control: Frank-Starling mechanism
               FSM
                – Preload
                – Afterload


March 2013                        ghennersdorf DGK ESC SES
CHF: the heart muscle




March 2013         ghennersdorf DGK ESC SES
CHF: the heart muscle sarcomere




March 2013        ghennersdorf DGK ESC SES
Cardiac function curves, different conditions,
                       FSM
         Cardiac output                                                      1 diuretics
                                                                             2 vasodilators
                                                                             3 Digitalis
                                                    normal


                              3
                          2
                                                               HF, normal compliance:
                      1
                                                               systolic HF



                                                             HF, reduced
                                                             compliance


                                                             diast. filling pressures



March 2013                        ghennersdorf DGK ESC SES
Mortality and muscle damage: systolic CHF




March 2013     ghennersdorf DGK ESC SES
Pathophysiology of Heart Failure

• Schematic manifestation
  of systolic and diastolic
  dysfunction:
  stiff or enlarged ventricle
• Stiffness caused by either
  hypertrophy, inflammation
  or storage diseases (amyloid)
• Enlargement caused by increase
  of collagen (scar) deposition
  and/or tension load




  March 2013                ghennersdorf DGK ESC SES
Pathophysiology of chronic CHF: peripheral
                           effects
• Activation of the neurohumoral system
     – Activation of renal-adrenal system (renin-
       angiotensin system;RAS)
     – Activation of cardiac RAS
     – Deregulation of number and properties of cardiac
       ß-adrenoceptors (ß-AR)
                       Vicious circle




March 2013            ghennersdorf DGK ESC SES
Pathophysiology of Heart Failure:
        rebound effects


                                            RAS Activation,
             Myocardial Dysfunction
                                            ß-AR-activation




                              Deregulation




March 2013                 ghennersdorf DGK ESC SES
Neurohumoral activation
                       Organ damage
                                  Arteriosclerosis
                                  Vasocostriction
                                  Vascular hypertrophy
                                  Endothelial dysfunction

              Target              LV Hypertrophy
              organs              Fibrosis
                                  Remodeling
                                  Apoptosis


                                  GFR
                                  Proteinuria
                                  Aldosterone delivery
                                  Sclerosis of glomerula




March 2013              ghennersdorf DGK ESC SES
Acute heart failure


             • Some special issues




March 2013         ghennersdorf DGK ESC SES
Right heart failure
• Acute
     – Pulmonary embolism
     – Right atrial masses (myxoma)
• Chronic
     – Mitral stenosis
     – Pulmonary stenosis
     – Deep Vein Thrombosis
     – Idiopathic PAH
     – Acquired PAH

March 2013            ghennersdorf DGK ESC SES
Right heart failure, causes
                                                Pulmonary emboli, extracted
                                                by operation




                                                Ritght atrial myxoma causing
                                                acute right heart failure
                                                and syncope




March 2013           ghennersdorf DGK ESC SES
Right heart failure: mitral stenosis




                                  Valve stenosis




affecting right heart muscle


    March 2013                 ghennersdorf DGK ESC SES
Origin of pulmonary edema
• Increased pumonary venous pressure
  (cardiogenic)
• Decreased oncotic pressure (hypalbuminemia)
• Negative pleural pressures (pneumothorax
  removal)
• Permeability changes (alveolocapillary)
• Idiopathic: high altitude, neurogenic,
  pumonary embolism, etc.)

March 2013           ghennersdorf DGK ESC SES
Heart failure and heart rate
• Primary rhythm disturbances causing HF
     – VF/VT (rare)
     – Atrial fibrillation, supraventricular tachycardia
• Secondary rhythm disturbances
     – Atrial fibrillation




March 2013               ghennersdorf DGK ESC SES
Heart failure and heart rate




March 2013            ghennersdorf DGK ESC SES
The End




March 2013   ghennersdorf DGK ESC SES

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Heart failure 2013 Pathophysiology

  • 1. Congestive Heart Failure CHF 1. Pathophysiology March 2013 ghennersdorf DGK ESC SES
  • 2. Epidemiology 2000 (US Database) 4.78 Mio. victims in USA 16 Mio. victims world wide 400.000 pts. incidence/year US 1.5 Mio. pts. incidence/year world wide 41810 deaths / year (USA) 17.5 Bill. $ direct costs (USA): mainly by hospitalization Fourfold hospitalization within the last 15 years No valid data for Tanzania so far! March 2013 ghennersdorf DGK ESC SES
  • 3. Survival rates after CHF (effect of medical therapy) x x Braunwald x 1988* x March 2013 ghennersdorf DGK ESC SES
  • 4. Definition of Heart Failure CHF (1) • Inability of the heart to meet the peripheral demands under rest or exercise conditions caused by – muscular dysfunction (systolic/diastolic) – mechanical disorder (valve disease) – combination March 2013 ghennersdorf DGK ESC SES
  • 5. Definition of Heart Failure CHF (2) • Definition by activity – resting HF – exercise HF • Definition by time course – Acute – Chronic March 2013 ghennersdorf DGK ESC SES
  • 6. Definition of Heart Failure CHF (3) • New York Heart Association (NYHA) – I  no visible signs and symptoms – II  signs and symptoms at high level exercise – III  signs and symptoms at low level exercise – IV  no physical exercise possible, bed rest necessary Most valid functional definition throughout the world! March 2013 ghennersdorf DGK ESC SES
  • 7. Definition of Heart Failure CHF (4) • Anatomical definition – Left sided heart failure • CHD (myocardial infarction) • disease of mitral or aortic valve • Cardiomyopathy of unknown origin (idiopathic) – Right sided heart failure • Pulmonary embolism • Pulmonary vascular hypertension • Mitral stenosis March 2013 ghennersdorf DGK ESC SES
  • 8. acute heart failure: etiology • acute HF (left sided: pulmonary edema) – Myocardial infarction (w/wo cardiogenic shock) – Hypertensive heart disease • Acute CHF: hypertensive crisis-pulmonary edema) – Inflammation • Acute valvular disease (endocarditis) • Acute (peri-)myocarditis • Combination (pancarditis) – Pulmonary embolism (right sided CHF) March 2013 ghennersdorf DGK ESC SES
  • 9. Cardiogenic shock: etiology • Special subset of HF: Cardiogenic shock – sudden onset with underlying disease (often triggered by large or multiple myocardial infarction); leading to: • organ perfusion deficit • organ failure • fast development of irrevesibilty • organ death, clinical death, biological death – Despite therapeutic improvement (PCI, IABP) 50-70% mortality rate March 2013 ghennersdorf DGK ESC SES
  • 10. Left heart failure • Acute • Low output – Pulmonary edema – Classical term: CHD, – Cardiogenic shock HPT, RHD etc. • Chronic • High output – NYHA I-IV – Fever states – Anemia – Pregnancy – Hyperthyreoidism – Beri beri – AV fistulas – Paget disease March 2013 ghennersdorf DGK ESC SES
  • 11. Chronic left heart failure Most common endpoint of multiple disorders of the left ventricle March 2013 ghennersdorf DGK ESC SES
  • 12. Etiology of HF • chronic HF – Hypertensive heart disease: progressive muscle damage; hypertrophy; disatolic HF – Coronary heart disease: myocardial infarction – Valvular disease after acute/occult onset of endocarditis – Chronic myocarditis  „secondary“ cardiomyopathy – „Primary“ dilatative cardiomyopathy – Venous disease (deep vein thrombosis) right heart failure March 2013 ghennersdorf DGK ESC SES
  • 13. Pathophysiology of Heart Failure • Manifestation types of heart failure – Systolic dysfunction – Diastolic dysfunction – Muscular hypertrophy – Dilatation and remodeling March 2013 ghennersdorf DGK ESC SES
  • 14. Pathophysiology of Heart Failure: function control • Determinants of heart function – Normal conditions • Nervous (sympathetic) control – Heart rate – Contractility – Abnormal conditions • Pressure volume control: Frank-Starling mechanism FSM – Preload – Afterload March 2013 ghennersdorf DGK ESC SES
  • 15. CHF: the heart muscle March 2013 ghennersdorf DGK ESC SES
  • 16. CHF: the heart muscle sarcomere March 2013 ghennersdorf DGK ESC SES
  • 17. Cardiac function curves, different conditions, FSM Cardiac output 1 diuretics 2 vasodilators 3 Digitalis normal 3 2 HF, normal compliance: 1 systolic HF HF, reduced compliance diast. filling pressures March 2013 ghennersdorf DGK ESC SES
  • 18. Mortality and muscle damage: systolic CHF March 2013 ghennersdorf DGK ESC SES
  • 19. Pathophysiology of Heart Failure • Schematic manifestation of systolic and diastolic dysfunction: stiff or enlarged ventricle • Stiffness caused by either hypertrophy, inflammation or storage diseases (amyloid) • Enlargement caused by increase of collagen (scar) deposition and/or tension load March 2013 ghennersdorf DGK ESC SES
  • 20. Pathophysiology of chronic CHF: peripheral effects • Activation of the neurohumoral system – Activation of renal-adrenal system (renin- angiotensin system;RAS) – Activation of cardiac RAS – Deregulation of number and properties of cardiac ß-adrenoceptors (ß-AR) Vicious circle March 2013 ghennersdorf DGK ESC SES
  • 21. Pathophysiology of Heart Failure: rebound effects RAS Activation, Myocardial Dysfunction ß-AR-activation Deregulation March 2013 ghennersdorf DGK ESC SES
  • 22. Neurohumoral activation Organ damage Arteriosclerosis Vasocostriction Vascular hypertrophy Endothelial dysfunction Target LV Hypertrophy organs Fibrosis Remodeling Apoptosis GFR Proteinuria Aldosterone delivery Sclerosis of glomerula March 2013 ghennersdorf DGK ESC SES
  • 23. Acute heart failure • Some special issues March 2013 ghennersdorf DGK ESC SES
  • 24. Right heart failure • Acute – Pulmonary embolism – Right atrial masses (myxoma) • Chronic – Mitral stenosis – Pulmonary stenosis – Deep Vein Thrombosis – Idiopathic PAH – Acquired PAH March 2013 ghennersdorf DGK ESC SES
  • 25. Right heart failure, causes Pulmonary emboli, extracted by operation Ritght atrial myxoma causing acute right heart failure and syncope March 2013 ghennersdorf DGK ESC SES
  • 26. Right heart failure: mitral stenosis Valve stenosis affecting right heart muscle March 2013 ghennersdorf DGK ESC SES
  • 27. Origin of pulmonary edema • Increased pumonary venous pressure (cardiogenic) • Decreased oncotic pressure (hypalbuminemia) • Negative pleural pressures (pneumothorax removal) • Permeability changes (alveolocapillary) • Idiopathic: high altitude, neurogenic, pumonary embolism, etc.) March 2013 ghennersdorf DGK ESC SES
  • 28. Heart failure and heart rate • Primary rhythm disturbances causing HF – VF/VT (rare) – Atrial fibrillation, supraventricular tachycardia • Secondary rhythm disturbances – Atrial fibrillation March 2013 ghennersdorf DGK ESC SES
  • 29. Heart failure and heart rate March 2013 ghennersdorf DGK ESC SES
  • 30. The End March 2013 ghennersdorf DGK ESC SES