HEART FAILURE

Heart Failure
• Heart is unable to provide adequate perfusion to meet the metabolic
needs of the body.
• is the common end point for many forms of cardiac disease.
• a progressive condition with a poor prognosis.
Etiology
• Heart failure may be caused by one of the following factors;
1. INTRINSIC PUMP FAILURE: Weakening of the ventricular
muscle due to disease so that the heart fails to act as an efficient
pump.
• Ischemic heart disease
• Myocarditis
• Cardiomyopathies
• Disorders of the rhythm e.g. atrial fibrillation and flutter
2. INCREASED WORKLOAD ON THE HEART
• Increased load on the heart may be in the form of pressure load or
volume load:
• i) Increased pressure load may occur in the following states:
• a) Systemic and pulmonary arterial hypertension.
• b) Valvular disease e.g. mitral stenosis, aortic stenosis, pulmonary stenosis.
• c) Chronic lung diseases.
• ii) Increased volume load is seen in the following conditions:
• a) Valvular insufficiency
• b) Severe anaemia
• c) Thyrotoxicosis
• d) Arteriovenous shunts
• e) Hypoxia due to lung diseases
3. IMPAIRED FILLING OF CARDIAC CHAMBERS
• Decreased cardiac output and cardiac failure may result from
extracardiac causes or defect in filling of the heart:
• a) Cardiac tamponade e.g. hemopericardium, hydropericardium
• b) Constrictive pericarditis
TYPES OF HEART FAILURE
• Can be classified as
• Acute or chronic
• Systolic vs diastolic
• Right-sided or Left-sided
Acute vs Chronic
• Depends whether the heart failure develops rapidly or slowly.
• Acute heart failure : Sudden and rapid development of heart failure
occurs in the following conditions:
• i) Larger myocardial infarction
• ii) Valve rupture
• iii) Cardiac tamponade
• iv) Massive pulmonary embolism
• v) Acute viral myocarditis
Chronic heart failure
• heart failure develops slowly as observed in the following states:
• i) Myocardial ischemia from atherosclerotic coronary artery disease
• ii) Multivalvular heart disease
• iii) Systemic arterial hypertension
• iv) Chronic lung diseases resulting in hypoxia and pulmonary arterial
hypertension
• v) Progression of acute into chronic failure.
LEFT-SIDED AND RIGHT-SIDED HEART
FAILURE
• Heart is a single organ, but functionally the left and right heart act
as independent units.
• Heart failure can affect the left or the right side of the heart or may
involve both sides.
Left-Sided Heart Failure
• The major causes are as follows:
• i) Systemic hypertension
• ii) Mitral or aortic valve disease (stenosis)
• iii) Ischaemic heart disease
• iv) Myocardial diseases e.g. cardiomyopathies, myocarditis.
• v) Restrictive pericarditis.
• The morphologic and clinical effects results from diminished
systemic perfusion and elevated back-pressures within the pulmonary
circulation
Morphology
• The gross cardiac findings depend on the underlying disease process;
• Signs of myocardial infarction or valvular deformities may be
present.
• Left ventricle usually is hypertrophied and can be dilated, sometimes
massively.
Morphology
• The microscopic changes are nonspecific,
• consisting primarily of myocyte hypertrophy with interstitial
fibrosis of variable severity.
Lungs
• Rising pressure in the pulmonary veins back to the capillaries and
arteries of the lungs
• Results in congestion and edema.
• Grossly lungs are heavy and boggy
Microscopic
• Perivascular and interstitial transudates, alveolar septal edema,
and accumulation of edema fluid in the alveolar spaces.
• In CHF, variable numbers of red cells leak into alveolar spaces,
where they are phagocytosed by macrophages.
• (hemosiderin-laden alveolar macrophages—so-called heart failure
cells)
Clinical Features
• The clinical manifestations of left-sided heart failure result from
decreased left ventricular output and hence there is accumulation of
fluid upstream in the lungs.
• Exertional dyspnea and orthopnea
• Cardiomegaly, tachycardia
• ischaemic acute tubular necrosis
• hypoxic encephalopathy
• muscular weakness and fatigue
Right-Sided Heart Failure
• Usually the consequence of left-sided heart failure.
• However, some conditions affect the right ventricle primarily,
producing right-sided heart failure. These are as follows:
• i) Cor pulmonale (due to intrinsic lung diseases).
• ii) Pulmonary or tricuspid valvular disease.
• iii) Pulmonary hypertension secondary to pulmonary
thromboembolism.
• iv) Myocardial disease affecting right heart.
• v) Congenital heart disease with left-to-right shunt.
MORPHOLOGY
• Rt ventricular hypertrophy and dilation.
• Microscopically: myocyte hypertrophy with interstitial fibrosis.
• Liver and Portal System: liver usually is increased in size and
weight (congestive hepatomegaly)
• cut section: congested centrilobular areas are surrounded by
peripheral paler, noncongested parenchyma (nutmeg liver)
• long-standing severe right-sided heart failure, the central areas can
become fibrotic, creating so-called cardiac cirrhosis.
MORPHOLOGY
• can also lead to elevated pressure in the portal vein and its
tributaries (portal hypertension),
• with vascular congestion producing a tense, enlarged spleen
(congestive splenomegaly).
• Systemic venous congestion due to right-sided heart failure can lead to
transudates of Pleural, Pericardial, and Peritoneal Spaces.
• Subcutaneous Tissues. Edema of dependent portions of the body,
especially the feet and lower legs, is a hallmark of right sided heart
failure.
Clinical Features
• pure right-sided heart failure clinical manifestations are related to
systemic and portal venous congestion and include
• hepatic and splenic enlargement
• peripheral edema,
• pleural effusion, and ascites.
• Venous congestion and hypoxia of the kidneys and brain due to right-
sided heart failure can produce deficits comparable to those caused by
the hypoperfusion of left-sided heart failure