Chapter 12 Heart failure

Zhao Mingyao
BMC.ZZU.
2006-3-22
the concept of heart failure
heart pump failure
myocardial failure
chronic congestive heart failure
 • Heart pump function

myocardial contractility
myocardial relaxility
SV preload (VR)
afterload
CO (ejection impedance)

Prolonged overload
HR metabolism structure change
Section 1 etiology and
classification
 1.underling causes
(1) myocardium impaired
???
(2) myocardium overload
over preload
overafterload
 2. Precipitating factors
• O2 supply of myocardia
• O2 consumption and myocardial work

• Infection
• Arrhythmia
• Pregnancy
• Disorder of water, electrolytes and acid-base
• Over fatigue
 3.Classification
• Degree: symptomatic heart failure
• Progress velocity
• Cardiac output
• Site
• Function impaired
Section 2 pathogenesis
1. myocardial contractility↓

(1) Damaged cardiomyocyte

(2) Metabolic disorder of energy

production
utilization
 insufficiency of vitamin B1
lead to heart failure

~ decarboxylase
Pyruvic acid acetyl Co A

Krebs citric
ATP acid cycle
 (3)Dysfunction of excitation-
contraction coupling( Ca2+ delivery
disorder )
1)reduced Ca2+ intake, reserve and release
of SR (Ry-R)
2) reduced influx of extracellular Ca2+
3)dystunction of Ca2+ binding to troponin

Ca2+ waves and oscillations

 2. diastolic dysfunction ↓
• (1) delayed reposition of Ca2+
• (2)blocked dissociation of the actin-myosin
complex
• (3)decresed ventricular diastolic potential
• (4)Reduced ventricular compliance
Diastolic properties ↓

Diastolic process = Relaxility

compliance
diastolic load
3. Asynergic myocardial contract
ion and relaxation

asymmetry and asynchronism

 4. Endothelial dysfunction
• Vascular contraction and dilation
• Vascular remodeling
• Adhesive properties
• Apoptotic process
Section 3 Compensatory
responses
 1.cardiac compensation
• (1) heart rate
• (2) Frank-Starling
mechanism
• (3) myocardial hypertrophy
(1) increased in HF
CO = SV X HR
(2)Frank-Starling law

Contractile power
Contractility
 Frank-Starling Curve
Body Intra-Thoracic
Total Blood Pressure
Volume Position

Atrial
Contribution
Stretch of Pericardial Pressure,
Compliance
Myocardium
Pumping Action of Venous
Skeletal Muscle Tone
Performance
Ventricular

End-Diastolic Volume
(3)Myocardial hypertrophy

concentric
eccentric

sarcomeres in parallel or in series

concentric eccentric
 2. Systemic compensation
(1)blood volume
(2) redistribution of blood flow
(3)erythrocyte
(4)ability of tissue to utilize O2
3. Neurohormonal compensation
(1)sympathetic nervous system
(2)RAAS
(3)atrial natriuretic peptide
(4)endothelin
two side effects of heart hypertrophy
(myocardial remodeling )

fibril, mit, vol↑ but

collagen(~ I, thick ,stiff; ~III ) ↑
phenotype change α- MHC ↓,β- MHC↑

MHC: Myosin heavy chain

                                           

myocyte hypertrophy and widening of interstitial spaces due to de

postion of collagen, inflammatory cells and amyloid.
 Section 4 effects on body

myocardial contractility↓
heart pump↓
diastolic properties↓
VR↓
CO ↓
pulmonary systemic
congestion congestion
? ?
?
1.Congestion of pulmonary circu
lation
(1) dyspnea
• mechanism:
 Types of dyspnea
1) exertional ~:
2) orthopnea
3) paroxysmal nocturnal ~
 Orthopnea means shortness of br
eath while lying down.

                                                      
                                               
Orthopnea means shortness of breath while lying down
(2)Pulmonary edema
 2. congestion of systemic
circulation
(1)systemic venous congestion and
hypertension
(2)edema
(3)hepatomegaly and hepatic dysfunction
 3. Low cardiac output
• Fatigue and limb weakness
• Mental confusion and disturbed behavior
• Cyanosis
• Nocturia
• Anasarca
• Cardiogenic shock
 Section 5 Principle of
prevention and treatment
removal cause
prevent predisposing factor
improving cardiac function:
inotropic agent digitalis
Ca 2+ channel antagonist or Ca 2+ rece
ptor blocker
vasodilator agents
stem cell and heart transplantation
• Brief history about treating
heart failure:
1940 times heart + kidney mode
1970 times heart + circulation mode
1990 times heart + endocrine mode
ACEI, β-receptor blocker ,α- receptor
blocker