HEART FAILURE (HF) Heart failure is the pathophysiological state in which an abnormality of cardiac function is responsible for failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissue, or to do so only from an elevated filling pressure. Clinical syndrome due to different structural and functional disease of the heart leading to abnormality in filling or emptying of the left ventricle.

Myocardial insufficiency – related to impaired contractility Myocardial insufficiency – related to impaired contractility. Not every heart failure is associated with myocardial insufficiency. Circulatory failure – clinical syndrome which is caused by abnormality of the following components of circulation, such as the heart, blood volume, Hb level, vessels.

PATHOPHYSIOLOGY OF HF

Early adaptive mechanisms Frank-Starling mechanism Activation of neurohormonal systems

NEUROHORMONAL MECHANISMS Elevation of norepinephrine leading to increased contractility. Activation of renin-angiotensin-aldosterone system (RAAS). Activation of arginine-vasopressin system. Activation of natriuretic peptides (ANP, BNP, CNP). Elevation of endotheline. Elevation of cytokines (TNF-α, IL-1β). NO (NO synthethase –NOS1-3). Elevation of oxidative stress in the myocardium.

LATE ADAPTIVE MECHANISMS Left ventricular remodeling

Parallel arrangement of sarcomers Pressure overload Volume overload ↑ Systolic strain ↑ Diastolic strain ↑ Activation of extracellular and intracellular signals Left ventricular remodeling Parallel arrangement of sarcomers Serial arrangement of sarcomers Concentric hyperthrophy Excentric hyperthrophy Normal

Framingham criteria for HF Major criteria Paroxyzmal nocturnal dyspnoe Neck-vein distension Rales Cardiomegaly Acute pulmonary edema S3 gallop ↑ venous pressure(16 cm H2O) Hepatojugular reflux Loss of weight > 4,5 kg during 5 days Minor criteria Ankle edema Night cough Dyspnoe on exertion Hepatomegaly Pleural effusion Tachyaardia (>120/min.)

FORMS OF HF Right-sided vs left-sided HF Acute vs chronic HF Low-output vs high-output HF Systolic vs diastolic HF

Causes of HF Pericardial disease (tamponade, constrictive pericarditis) Valvular heart disease Disease of the myocardium (dilated CMP) Coronary heart disease Arrhythmias (tachycardia-induced CMP)

Pharmacological treatment Diuretics Vasodilators Positive inotropic agents (digitalis, beta-blockers, phosphodiesterase inhibitors, Ca-senzitisers) Neurohormonal inhibitors (ACEI, ARB, beta-blockers)

Nonpharmacological treatment Intraaortic balloon contrapulsation Mechanical support CRT Transplantation