Heart Failure Pathology

What is Congestive Heart Failure?
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What is Congestive Heart Failure?
Inability of the heart to pump blood at a rate to meet the needs of active tissues
-Or can do so only from an elevated filling pressure
What is the Pathogenesis of CHF?
Usually results from a slowly developing intrinsic deficit in contraction, (but occasionally occurs acutely)
What are the mechanisms of CHF?
1) Abnormal Load presented to the Heart
2) Impaired ventricular filling
3) Obstruction d/t valve stenosis
What is the acute mechanism of Abnormal Load presented to the Heart?
Fluid overload, MI, valve dysfunction
What is the chronic mechanism of Abnormal Load presented to the Heart?
Ischemic heart disease, dilated cardiomyopathy, hypertension
What is the acute mechanism of Impaired ventricular filling?
Pericarditis or tamponade
What is the chronic mechanism of Impaired ventricular filling?
Restrictive cardiomypathy, severe left ventricular hypertrophy
What is the chronic mechanism of obstruction d/t valve stenosis?
Rheumatic valve disease (usually mitral valve)
What is systolic dysfunction?
(CHF Characterization)
Progressive deterioration of cardiac (contractile) function
What is diastolic dysfunction?
(CHF Characterization)
Inability of heart to relax, expand, and fill sufficiently during diastole
What are causes of *Systolic dysfunction*?1) Ischemic Heart Disease 2) Pressure or Volume overload 3) Dilated CardiomyopathyWhat are causes of *Diastolic dysfunction*?1) Massive Left Ventricular Hypertrophy 2) Amyloidosis 3) Myocardial Fibrosis 4) Constrictive PericarditisWhat is the Frank-Starling mechanisms of Rapid Compensation?Increased preload dilation (increased end diastolic filling volume) helps to sustain cardiac performance by enhancing contractility (lengthened fibers contract more forcibly) *Does result in increased wall tension & increased oxygen requirements*What are three neurohormonal systems that act as compensatory mechanisms for CHF?1) Release of Norepinephrine by cardiac nerves 2) Activation of Renin-Angiotensin-Aldosterone system 3) Release of Atrial Natriuretic peptideWhat does the release of Norepinephrine by cardiac nerves do? (*Neurohormonal systems that act as compensatory mechanisms for CHF*)1) Increase HR 2) Increase Myocardial Contractility 3) Increase Vascular resistanceWhat does the Activation of the Renin-Angiotensin-Aldosterone system do? (*Neurohormonal systems that act as compensatory mechanisms for CHF*)1) Increased Na and Water resorption 2) Increases Cardiac output 3) Increased VasoconstrictionWhat does the Release of Atrial Natriuretic peptide do? (*Neurohormonal systems that act as compensatory mechanisms for CHF*)Secreted from atrial myocytes when the atrium is dilated 1) Vasodilation 2) DiuresisWhat is a chronic compensatory mechanism of CHF?Cardiac Hypertrophy 1) Compensatory response to increased load occurring over weeks to months 2) Increased numbers of sacromeres makes fibers visably bigger 3) No hyperplasiaThe Extent of hypertrophy: 600 Gram Club1) Pulmonary Hypertension 2) Ischemic Heart DiseaseThe Extent of hypertrophy: 800 Gram Club1) Systemic hypertension 2) Aortic Stenosis 3) Mitral Regurgitation 4) Dilated CardiomyopathyThe Extent of hypertrophy: 1000 Gram Club1) Aortic Regurgitation 2) Hypertrophic CardiomyopathyWhat type of hypertrophy occurs with Pressure overload?Concentric hypertrophy (Left) -HTN, Aortic StenosisWhat type of hypertrophy occurs with Volume overload?Hypertrophy accompanied by dilatation (Right) -Mitral or aortic regurgitationWhat is the difference between Eccentric and Concentric Hypertrophy?What is the difference between pressure versus volume hypertrophy?T/F: Sustained cardiac hypertrophy often evolves to cardiac failureTrue 1) Increased myocyte size results in decreased capillary density, increased intercapillary distance and increased fibrous tissue 2) High cardiac oxygen consumption 3) Altered gene expression and proteins 4) Loss of myocytes d/t apoptosisWhat is an independent risk factor for sudden death? a) RVH b) LVH c) Smoking d) ETOH useb) LVH (Left Ventricular Hypertrophy)What is the connection between hypertrophy and HF?What is Left Sided Heart failure?Effects primarily d/t progressive *damming of blood within the pulmonary circulation* and diminished peripheral blood pressure and flowWhat are the causes of Left Sided Heart Failure?1) Ischemic Heart Disease 2) HTN 3) Aortic and mitral valve diseases 4) Non-ischemic myocradial diseases -Cardiomyopathies -MyocarditisWhat are the clinical effects and morphology of Left sided heart failure? (*Heart*)1) Left ventricular hypertrophy and often dilation, often resulting in mitral valve insufficiency 2) Secondary enlargement of left atrium => atrial fibrillation => stagnant blood in atrium => thrombus, embolic strokeWhat are the clinical effects and morphology of Left sided heart failure? (*Lung*)Increased pressure in pulmonary veins which is transmitted to capillaries and arteries 1) Pulmonary congestion and edema 2) Heart failure cells 3) Dyspnea, Orthopnea, PND (When supine, venous return increases and diaphram elevates) 4) Rales on examWhat are the clinical effects and morphology of Left sided heart failure? (*Kidneys*)Decreased Renal perfusion activates renin-angiotension-aldosterone system => increased blood volume -If perfusion deficit is severe =? prerenal azotemia (impaired kidney function d/t low perfusion)What are the clinical effects and morphology of Left sided heart failure? (*Brain*)Cerebral hypoxia and encephalopathyWhat are heart failure cells?Hemosiderin-laden macrophages ("heart-failure" cells)What is Right-sided Heart Failure?Effects are primarily d/t engorgement of systemic and portal venous systemsWhat are the causes of right-sided heart failure?1) *Secondary to left-sided heart failure usually* 2) Pulmonary HTN 3) Primary mycocardial disease 4) Tricuspid or pulmonary valvular diseaseWhat are the clinical effects and morphology of Right sided heart failure? (*Heart*)Right ventricle responds to the increased workload with hypertrophy and often dilatationWhat are the clinical effects and morphology of Right sided heart failure? (*Liver and portal system*)Elevated pressure in the portal vein leads to congestive hepatosplenomegaly, cardiac cirrhosis, ascitesWhat are the clinical effects and morphology of Right sided heart failure? (*Kidneys*)Congestion, fluid retention, peripheral edema, azotemia (*More marked w/ right sided HF than left)What are the clinical effects and morphology of Right sided heart failure? (*Brain*)Venous congestion and hypoxic electroencephalographyWhat type of HF is characterized by: 1) Pleural and pericardial effusion, atelectasis 2) Peripheral edema (at ankle, presacral) 3) Eventual anasarca (generalized massive edema)Right sided HFWhat does Right sided hypertrophy look like?What does a liver with centrilobular congestion look like?Nutmeg liver (indicative of HF)What are the hallmarks of Left sided HF?1) Pulmonary congestion and edema prominent 2) Kidneys: Reduced perfusion, fluid retention, azotemia *Less* prominent 3) Brain: Reduced perfusion, cerebral hypoxia and encephalopathyWhat are the hallmarks of Right sided HF?1) Systemic and portal venous congestion -Hepatosplenomegaly -Peripheral Edema -Pleural effusion -Ascites 2) Kidneys: Congestion, fluid retention and azotemia *more* prominent 3) Brain: Venous congestion, hypoxia and encephalopathyT/F: Right sided HF causes venous congestion of the kidneysTrue 1) More impairment of function than with left sided HF 2) Secondary to lack of removal of metabolites in venous circulation (and, if congestion is severe, decrease and/or stasis on arterial side)T/F: Left sided HF causes low arterial flow to the kidneysTrue 1) Usually less severe impairment than secondary to right sided HF 2) Decrease and/or lack of nutrient supply to kidneys causes less damage than lack of metabolite removal