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Pathophysiology of
CHF
CHF
• What is CHF?
• Fix the underlying problem
• Heart is a 2 sided pump
• Both sides can fail independent of each
other.
CHF
• What different types of pathophysiology
cause it?
• Systolic Dysfunction
• Diastolic Dysfunction
• High Output States
CHF
• Systolic Dysfunction – What is it? Is it only related to
events that occur in Systole?
-1. Decreased Contractility
- a. Loss of Myocytes
- b. Over-stretched Heart
-2. Increased Afterload
- a. Increased BP
- b. Stenotic Valve
- Pulmonic Valve and carcinoid
syndrome – 5HIAA
CHF
• Diastolic Dysfunction – What is it?
– 1. Impaired Relaxation
– 2. Obstruction to filling
• Can systolic and diastolic functions
coexist?
CHF
• Pressure volume loops are used to distinguish between
systolic vs. diastolic dysfunction
CHF
• High Output States – What is it?
– Paget’s Disease
– Anemia
– Thiamine Deficiency
– Hyperthyroidism
CHF
• The failing heart and how it compensates
– What does a failing heart mean, and what is
decompensation? What does a failing heart
look like?
– Compensations made by a failing heart
• Frank Starling Forces
• Neuro-Hormonal Changes
• Ventricular Remodeling
CHF
What is looks like:
CHF Compensations
• Frank Starling
– Length Tension Mechanism
CHF Compensations
• L sided failure and Frank
– Blood is not going to go forward
– Blood is going to back up into L atrium and
pulmonary venous circulation
• L Atrium, what happens when it distends?
CHF Compensations
• Hoarseness:
CHF Compensations
• L sided Failure and Frank
– Blood eventually backs up into the pulmonary
circulation
• What happens there?
• What’s the deal with Frank Starling Forces?
CHF Compensation
• L sided failure and the lungs continued…
– Pulmonary congestion
CHF Compensation
• L sided failure and lungs continued…
– Pulmonary Hypertension
– Does pulmonary hypertension happen
immediately?
L sided Compensation
• L sided failure and CXR
– Cephalization
– Indistinct vessels, Kerly B-Lines
– Whited Out lungs fields
CHF Compensations
• L sided failure symptoms related to congestion
– Blood not going forward:
• Muscle fatigue
• Confusion
– Blood going backwards:
• Atrial Distension
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–
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–
–
Arrhythmias
Thrombus formation
Hoarseness
Mitral Regurgitation
S3
CHF Compensations
• L sided failure symptoms continued…
– Blood going backwards continued…
• Pulmonary congestion
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–
–
–
–
–
–
Pulmonary edema
Pulmonary hypertension – R sided failure
Dyspnea, Dyspnea at night
Nocturnal enuresis
Orthopnea
Cardiac Asthma
Hypoxia, cyanosis
CHF Compensations
• R sided failure and Frank:
–
–
–
Most Common Cause is?
Cor pulmonale?
Blood is going to eventually back up into the R atrium and systemic and portal venous
circulation.
CHF Compensations
• What happens when this blood backs up?
– Liver Congestion

– Gastrointestinal Tract
Nutmeg Liver
CHF Compensations
• What happens when this blood backs up
continued…
– Pitting Edema
• Frank Starling Forces
• Stasis Dermatitis
• P02?
CHF Compensations
• JVD – jugular venous pressure chart
CHF Compensations
• Acute R sided failure
– Causes?
– Would you expect to see any change to the R
ventricle?
CHF Compensations
• R sided failure symptoms from the backing
up of blood:
– Pitting Edema
– JVD
– GI discomfort
– Liver congestion
• RUQ pain
• Hepatojugular Reflex
• Ascites – Puddle sign
CHF complications
• Would you expect someone with R sided
failure only, that is, no L sided failure, to
have pulmonary hypertension or
pulmonary edema?
CHF Compensations
• Neurohormonal changes:
– Renin-Angiotensin System
– Adrenergic System
– ADH
CHF Compensations
• Renin-Angiotensin System – raise EABV,
and lower plasma oncotic p.
CHF Compensations
• Does the Renin-Angiotensin System
restore EABV back to normal?
• Why is this harmful in the end?
CHF Compensations
• Adrenergic System:
– Increased Sympathetic
outflow
– Increased effects of
epinephrine on adrenergic
receptors throughout your
body
– What pathological
process could keep the
adrenergic system on
even if the EABV is
restored?
CHF Compensations
• Does the adrenergic system restore the
EABV?
• Why is this harmful in the end?
CHF Compensations
• ADH secretion
– Why do its effects become blunted in long
run?
CHF Compensations
• Ventricular Remodeling