1、1Congestive Heart FailureDao Wen Wang, MD, PhDDepartment of Internal Medicine, Tongji Hospital/Medical College, HUST2Basic Definition of Heart Failure(1) Heart failure is a medical term that describes an inability of the heart to keep up its work load of pumping blood to the lungs and to the rest of
2、 the body.http:/danilhammoudimd_ Heart (or Cardiac) Failure is the pathophysiological state which the heart is unable to pump blood at a commensurate with the requirements of the metabolizing tissues or can do so only from an elevated filling pressure. -Braunwards Heart Disease Chronic heart failure
3、 is complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. -JACC guidelineBasic Definition of Heart Failure(1)4Epidemiology It is estimated that as many as two million Americans suffer from c
4、ongestive heart failure (Morbidity: 1.2-2.0%) and that up to 29, 000 die annually from this chronic disorder. Cannobio, Mary. Cardiovascular Disorders. Missouri: C.V. Mosby Company, 1990. In the world, it is 2% Only in 35-74 years old people, it is estimated that as many as 3.6 million Chinese suffe
5、r from congestive heart failure (0.9%), Annual mortality is about 20%-50% and 5 year mortality is up to 67%. The morbidity increases as ages get older: such as the mortality in age 50 is 1%, but up to 10 times in 80. 5Etiology of Heart Failure Congestive heart failure is a syndrome that can be cause
6、d by multiple underlying diseases such as: Primary myocardial injury: (1) ischemic myocardial impairment-coronary heart disease or myocardial infarction (2) myocarditis and cardiomyopathy-hypertrophic, dilated cardiomyopathies, isolated left ventricular non-compaction and Arrhythmic right ventricle
7、cardiomyopathy (3) Metabolic disorders in myocardium-hypothyroidism, hyperthyroidism, diabetes Overload of heart: (1) pressure overload (afterload)-hypertension, aortic stenosis, pulmonary stenosis (2) volume overload (preload)-aortic or mitral regurgitation (insurficiency), congenital heart disease
8、s (left to right side fistula), over volume circulation status: chronic anemia, thyroidism6Population attributable risk for heart failure incidence Population attributable risk for heart failure incidence More cardiomyopathies in China: dilated or hypertrophic 7NT-proBNPOther disease8Predisposing fa
9、ctor of Heart FailureHeart failure patients usually have basic heart disease and heart failure occurs under following predisposing factors: Infection ! arrhythmias Elevated blood volume overfatigue or excited too much Progressing of heart disease9Pathophysiology1. Short-term adaptive mechanisms: Hem
10、odynomic and Circulatory Consequences of Heart failure10Frank-Starling CurveVascular Redistribution of Left Ventricular OutputEndothelial Dysfunction112. Chronic Myocardial Remodeling (1)Ventricular Remodeling, consisting of changes in mass, volume, shape, and composition, constitutes one of the pri
11、ncipal mechanisms by which the heart compensates for an increased load12 Patterns of Ventricular Remodeling: In early stage or compensatory phase, ventricle remodels and function can return to normal; In later stage or advanced phase (overload increases further), there is further aggravation in myoc
12、ardial function and later in “exhaustion” phase, several macroscopic events take place.2. Chronic Myocardial Remodeling (2)1314Structural changes in the left ventricle in systolic heart failure (SHF) and diastolic heart failure (DHF). AC, Autopsy examples of left ventricular (LV) remodeling that are
13、 common in patients with SHF (B) and DHF (C). D, Typical LV geometry with SHF or DHF. 15 Cellular Changes in myocardial remodeling (1) Cell size becomes larger (2) Mitochondria increases and expands decreases in number (3) Collagens in the extracellular matrix (ECM) increase (4) Apoptosis and necros
14、is of cardiomyocytes occurs, and cell number decreases2. Chronic Myocardial Remodeling (3)162. Chronic Myocardial Remodeling (4) Molecular Changes in myocardial remodeling (1) Myocytes loss: necrosis, apoptosis (classic apoptosis and endoplasmic reticulum (ER) Stress-induced apoptosis) (2) Changes i
15、n cardiac gene expression17183. Neurohormonal, Autocrine, and Paracrine Adjustments Autonomic nervous system: increased activation in sympathetic activity Change in Beta-receptor-G protein-adenylyl cyclase pathway: Beta-receptor, myocardial hypertrophy, attenuation of heart force Activation of renin
16、-angiotensin-aldosterone system (RAS): increase in vascular resistance, water and sodium re-absorption and ECM Inflammatory cytokines: TNF, IL-1,6, AngII192021Normal Heart and Circulation22How to Classify the Heart Failure23 Left-Sided Heart Failure? Involves the left ventricle of the heart Systolic
17、 failure The heart looses its ability to contract or pump blood into the circulation Diastolic failure The heart looses its ability to relax because it becomes stiff Heart cannot fill properly between each beat24 Left-Sided Heart Failure Systolic and diastolic heart failure are treated with differen
18、t types of medications In both types, blood may “back up” in the lungs causing fluid to leak into the lungs (pulmonary edema) Fluid may also build up in tissues throughout the body (edema)25 Right-Sided Heart Failure Usually occurs as a result of left heart failure The right ventricle pumps blood to
19、 the lungs for oxygen Occasionally isolated right heart failure can occur due to lung disease or blood clots to the lung (pulmonary embolism)26 How fast does heart failure develop? Usually a chronic disease The heart tries to compensate for the loss in pumping function by: Developing more muscle mas
20、s Enlarging Pumping faster Having more blood volume27Acute verse Chronic Heart Failure Acute heart failure: the syndrome develops very fast without enough time to compensate when the acute congestion occur after sudden attack such as acute massive infarction, acute myocarditis or acute aggravation o
21、f chronic heart failure because of infection or other reasons. Chronic heart failure: the heart failure develops for long time with compensation.28Low-output or High-output Heart Failure Low-output heart failure: cardiomyopathy, myocardial infarction, diabetic cardiomyopathy and so on. Low-output he
22、art failure is characterized by clinical evidence of systemic vasoconstriction with cold, pale and sometimes cyanotic extremities, reduction in pulse pressure with low stroke volume. High-output heart failure: such as hyperthyroidism, arteriovenous fistulas, anemia. The extremities are warm usually,
23、 and flushed and pulse pressure is widened or normal.29How to Assess Functional CapacityNew York Heart Association (NYHA) Functional ClassificationLimitations: this system is subject to considerable interobserver variability and is insensitive to important changes in exercise capacity. These limitat
24、ions may be overcome by formal tests of exercise tolerance. Measurement of the distance that a patient can walk in 6 minutes may have prognostic significance and may help to assess the level of functional impairment in the very sick, but serial changes in walking distance may not parallel changes in
25、 clinical status. Class% of patientsSymptoms I 35%No symptoms or limitations in ordinary physical activity II 35%Mild symptoms and slight limitation during ordinary activity III 25%Marked limitation in activity even during minimal activity. Comfortable only at rest IV 5%Severe limitation. Experience
26、s symptoms even at rest3031Causes of Heart Failure What Causes Heart Failure? Health conditions that either damage the heart or make it work too hard Coronary artery disease Heart attack High blood pressure Abnormal heart valves Heart muscle diseases (cardiomyopathy) Heart inflammation (myocarditis)
27、32Heart Failure What Causes Heart Failure? Congenital heart defects Severe lung diseases Diabetes Severe anemia Overactive thyroid gland (hyperthyroidism) Abnormal heart rhythmsLifestyles, Fitnessand Rehabilitation33Heart Failure What Causes Heart Failure? Coronary artery disease Cholesterol and fat
28、ty deposits build up in the hearts arteries Less blood and oxygen reach the heart muscle This causes the heart to work harder and occasionally damages the heart muscleLifestyles, Fitnessand Rehabilitation 34Heart Failure What Causes Heart Failure? Heart attack An artery supplying blood to the heart
29、becomes blocked Loss of oxygen and nutrients damages heart muscle tissue causing it to die Remaining healthy heart muscle must pump harder to keep upLifestyles, Fitnessand Rehabilitation35Heart Failure What Causes Heart Failure? High blood pressure Uncontrolled high blood pressure doubles a persons
30、risk of developing heart failure Heart must pump harder to keep blood circulating Over time, chamber first thickens, then gets larger and weaker 36Heart Failure What Causes Heart Failure? Abnormal heart valves Heart muscle disease Damage to heart muscle due to drugs, alcohol or infections Primary ca
31、rdiomyopathies Congenital heart disease Severe lung disease 37Heart Failure What Causes Heart Failure? Diabetes Tend to have other conditions that make the heart work harder Obesity Hypertension High cholesterol Insulin resistanceLifestyles, Fitnessand Rehabilitation 38Heart Failure What Causes Hear
32、t Failure? Severe anemia No enough red blood cells to carry oxygen Heart beats faster and can become overtaxed with the effort Hyperthyroidism Body metabolism is increased and overworks the heart Abnormal Heart Rhythm If the heart beats too fast, too slow or irregular it may not be able to pump enou
33、gh blood to the bodyLifestyles, Fitnessand Rehabilitation 39Signs and Symptoms of Heart Failure Shortness of Breath (dyspnea) WHY? Blood “backs up” in the pulmonary veins because the heart cant keep up with the supply an fluid leaks into the lungs SYMPTOMS Dyspnea on exertion or at rest Difficulty i
34、n breathing when lying flat Waking up short of breath Orthopnea, trepopnea Paroxysmal nocturnal dyspnea40Signs and Symptoms of Heart Failure Persistent Cough or Wheezing WHY? Fluid “backs up” in the lungs SYMPTOMS Coughing that produces white or pink blood-tinged sputum Edema WHY? Decreased blood fl
35、ow out of the weak heart Blood returning to the heart from the veins “backs up” causing fluid to build up in tissues SYMPTOMS Swelling in feet, ankles, legs or abdomen Weight gain41Signs and Symptoms of Heart Failure Tiredness, fatigue WHY? Heart cant pump enough blood to meet needs of metabolizing
36、tissues Body diverts blood away from less vital organs (muscles in limbs) and sends it to the heart and brain SYMPTOMS Constant tired feeling Difficulty with everyday activities42 Lack of appetite/ Nausea WHY? The digestive system receives less blood causing problems with digestion SYMPTOMS Feeling
37、of being full or sick to your stomach Confusion/ Impaired thinking WHY? Changing levels of substances in the blood ( sodium) can cause confusion SYMPTOMS Memory loss or feeling of disorientation Relative or caregiver may notice this firstSigns and Symptoms of Heart Failure43Signs and Symptoms of Hea
38、rt FailureIncreased heart rateWHY? The heart beats faster to “make up for” the loss in pumping functionSYMPTOMSHeart palpitationsMay feel like the heart is racing or throbbing 44Signs and Symptoms of Heart Failure Decreased Exercise Activity Why? pulmonary vessel congestion heart failure to provide
39、sufficient blood to peripheral tissue-exercise muscles Secondary pulmonary hypertension and right ventricle dysfunction Decreased central response to physical activity 45Physical Findings General Appearance: In severe heart failure, reduced pulse pressure (reduced stroke volume) and dusky discolorat
40、ion in skin, and systolic arterial blood pressure may be reduced in acutely developed heart failure. Cardiac findings Cardiomegaly (enlarged heart) Gallop sounds, decreased beat sound (S1) P2 Pulmonary rales46Physical Findings Right-Sided Heart failure Systemic venous hypertension (jugular vein) Hep
41、atojugular reflux Congestive hepatomegaly Edema Renal dysfunction Hydrothorax (pleural effusion) or/and pericardiac effusion Ascites 47Lab. Tests Chest Radiography Echocardiography Plasma B-type natriuretic peptide level Serum electrolytes Renal function Liver function Hematological studies Others:
42、6-minutes walking 484950nt-proBNP is more powerful than BNPPre-Pro-BNP1-13426-氨基信号序列N-末端Pro-BNP1-76BNP77-108Pro-BNP1-108t1/2 = 18 分钟t1/2 = 60-120 分钟BNP与与NT-proBNP的合成与分泌的合成与分泌室壁张力增加室壁张力增加Troughton RW et al. J Am Coll Cardiol Img 2009;2:216-225B-Type Natriuretic Peptide Molecular Forms and Processing5
43、3545556Treatments of Heart Failure Treat the causes of heart failure such as hypertension, valve disease, diabetes, CAD, myocarditis, hyperthyroidism Eliminate predisposing factors: infection is the commonest and important predisposing factor.57Treatments of Heart Failure Treatment Options The more
44、common forms of heart failure cannot be cured, but can be treated Lifestyle changes Medications Surgery58Treatments of Heart Failure Lifestyle changes Stop smoking Loose weight Avoid alcohol Avoid or limit caffeine Eat a low-fat, low-sodium diet Exercise and rest59Treatments of Heart Failure Lifesty
45、le changes Reduce stress Keep track of symptoms and weight and report any changes or concern to the doctor Limit fluid intake See the doctor more frequently60Treatments of Heart Failure Medications used to treat Heart Failure ACE Inhibitors Cornerstone of heart failure therapy Proven to slow the pro
46、gression of heart failure via inhibiting remodeling of heart Vasodilator cause blood vessels to expand lowering blood pressure and the hearts work load ACE Inhibitors raise kinin and bradykinin level, which provide broad protection to heart and kidney61Treatments of Heart Failure Diuretics (water pi
47、lls) Prescribed for fluid build up, swelling or edema Cause kidneys to remove more sodium and water from the bloodstream Decreases workload of the heart and edema Fine balance removing too much fluid can strain kidneys or cause low blood pressure62Treatments of Heart Failure Potassium Most diuretics
48、 remove potassium from the body Potassium pills compensate for the amount lost in the urine Potassium helps control heart rhythm and is essential for the normal work of the nervous system and muscles63Treatments of Heart Failure Vasodilators Cause blood vessel walls to relax Occasionally used if pat
49、ient cannot tolerate ACE Decrease workload of the heart Digitalis preparations Increases the force of the heart contractions Relieves symptoms Slows heart rate and certain irregular heart beats64Treatments of Heart Failure Beta-blockers Lower the heart rate and blood pressure Decrease the workload o
50、f the heart Blood-thinners (coumadin) Used in patients at risk for developing blood clots in the blood vessels, legs, lung and heart Used in irregular heart rhythms due to risk of stroke65Summary of HF Treatments66AR blocker Bers and Harris. Nature 2011;473:36-8. 5 MayHypothesis6768Treatments of Hea
