Heart Failure _ZhangQing,Heart Failure,上海交通大学医学院 附属仁济医院心内科 张 清 副教授,Heart failure is the pathophysiological state in which the heart is unable to pump sufficient blood to satisfy the metabolic demands of the body with enough preload.,The Progressive Development of Cardiovascular Disease,Endstage Heart Disease,Congestive Heart Failure,Ventricular Dilation,Remodeling,Arrhythmia & Loss of Muscle,Myocardial Infarction,Myocardial Ischemia,CAD,Atherosclerosis,Endothelial Dysfunction,Risk Factors,Coronary Thrombosis,For progressive duration,Congestive heart failure is classified into acute and chronic heart failure,Congestive heart failure is classified into left side, right side and biventricular heart failure,For anatomical type,Heart Failure _ZhangQing,Chronic heart failure,Causes,Fundamental causes: impairment of myocardium, such as AMI,cardiomyopathy,myocarditis overloading of the heart, such as hypertension, aortic stenosis, mitral stenosis,emphysema,aortic insufficiency,mitral insufficiency,VSD,PDA,ASD. diminished LV compliance, such as ventricular hypertrophy,Precipitating factors infection,especially pulmonary infection, fever physical,environmental,or emotional stress increased sodium load arrhythmia, pulmonary emboli pregnancy and delivery anemia,bleeding,excessive transfusion,Pathophysiology of heart failure,Impaired myocardium Cardiac output , heart failure Neurohumoral stimulation RAS and sympathetic-adrenergic Vasoconstriction increased heart rate Salt and water retention increased energy (augments preload) expenditure Hypertrophy Leads to deterioration and death of cardiac cell,Effects of Neurohormonal Stimulation in Heart Failure,Heart Heart rate Contractility Stroke volume Cardiac output Conduction velocity Myocardial oxygen consumption,Peripheral Circulation Arterial vasoconstriction Venoconstriction Systemic vascular resistance Redistribution of blood flow Renal vasoconstriction,Heart Failure _ZhangQing,Pathophysiology of Heart Failure: Left Ventricular Remodeling,Left-ventricular (LV) remodeling is defined as a change in LV geometry, mass and volume that occurs over a period of time,Ventricular Remodeling: Compensatory Mechanism,Dilation Hypertrophy Globular shape Short term: Compensatory Long term: Harmful,DETERMINANTS OF VENTRICULAR FUNCTION,STROKE VOLUME,PRELOAD,CONTRACTILITY,CARDIAC OUTPUT,HEART RATE,AFTERLOAD,Vicious Cycle of Heart Failure,Myocardial dysfunction,Diminished Cardiac output,Diminished renal blood flow,Renin release,Angiotensin II,Aldosterone,Increased Sympathetic Activity,Vasoconstriction,Increased force and rate of myocardial contraction,Increased cardiac workload,Renal retention of sodium and water,Increased venous return,Edema,Pathophysiology and Therapeutic Approaches to Heart Failure,LV Function,Cardiac Output,Neurohormonal Activation,Salt and Water Retention,Peripheral vasoconstriction Blood flow,Vasodialtors ACE Inhibitors,Diuretics,ACE Inhibitors Blockers,Digoxin,Common Symptoms of Heart Failure,Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea Fatigue Lower extremity edema Cough, usually worse at night Nausea, vomiting, anorexia, RUQ pain, ascites Nocturia Sleep disorders Increased abdominal girth,Common Physical Findings of Heart Failure,Elevated jugular venous pressure Hepatojugular reflux Displaced apical impulse S3 gallop Pulmonary rales Hepatomegaly Peripheral edema Ascites,Clinical manifestation,Left heart failure:SOB,cough,rales,gallop Right heart failure:gastrointestinal congestion,anorexia,nausea,a sense of fullness after meals,hepato-jugular reflux,swelling of feet or ankles Low cardiac output:fatigue and weakness,oliguria Biventricular heart failure:both clinical manifestation of left and right heart failure,one of which maybe predominant.,Functional Classification,A classification of patients with heart disease based on the relation between symptoms and the amount of effort required to provoke them has been developed by the New York Heart Association.,Class 1-No limitation Ordinary physical activity does not cause undue fatigue,dyspnea,or palpitation Class 2-Slight limitation of physical activity Such patients are comfortable at rest.Ordinary physical activity results in fatigue,palpitation,dyspnea,or angina,Class 3-Marked limitation of physical activity Although patients are comfortable at rest,less than ordinary activity will lead to symptoms. Class 4-Inability to carry on any physical activity Symptoms of congestive failure are present even at rest.With any physical activity,increased discomfort is experienced.,Complication,Pulmonary embolism, Congestive hepatomegaly, Ascites, Hepatic sclerosis, Imbalance of electrolytes,Laboratory Finding,Venous pressure:elevated Chest roentgenogram:cardiothoracic ratio,pulmonary edemaKerleys lines,perivascular and subpleural edema (butterfly and pleural effusion) Invasiv