Major sources of cardiac pain
- Myocardial Ischemia
2. Pericarditis
Circulatory Failure is associated with
an inability to maintain adequate blood flow to the tissues
- Acute Heart Failure
- Chronic Heart Failure
- Compensatory mechanisms
- Decompensation
Contributing factors to circulatory failure
- Insufficient cardiac output (heart failure)
2. Marked reductions in circulating blood volume (hemorrhage, acute dehydration, septic shock)
Acute Heart Failure: Course
Rapidly progressive; associated with medical emergencies
Acute Heart Failure: Causes
infarcts, aortic/ventricular rupture, cardiac arrest, large emboli
Chronic (Congestive) Heart Failure (CHF): onset is preceded by
- Myocardial hypertrophy
2. Compensatory response to increased workload in a compromised heart
CHF: Populations
- 5 million affected each year
2. 2% at 50 => 10% at 80
CHF: Prognosis
- Recurrent with poor prognosis
2. 300,000 deaths due to CHF
CHF: General Features
- Congestion
- Pooling of blood in veins
- Reduced/Low arterial flow
CHF Underlying causes
- Myocardial dysfunction
- Impaired ventricular filling
- Increased cardiac workload
CHF: Myocardial dysfunction: General features
- Most common
- Ischemic and Non-ischemic
- Conduction disturbances
CHF: Impaired ventricular filling: associated with
- Increased cardiac stiffness (diastolic dysfunction
CHF: Impaired ventricular filling: Causes
- L. ventricular hypertrophy
- amyloid
- pericardial fibrosis
- rigidity
CHF: Increased cardiac workload: synonyms
- hypertenstion
- valve lesions
- high output failure
Compensatory mechanisms: definition
Mechanisms that are activated in order to maintain adequate blood flow. They may initially maintain cardiac output at adequate levels, but they also contribute signs of heart failure and other deleterious effects
Compensatory mechanisms: types
- Ventricular dilatation
- Myofiber hypertrophy
- Neurohumoral mechanism activation
Ventricular dilatation: Mechanism
improves contraction by stretching the myofibers according the the Frank Starling mechanism
Myofiber hypertrophy: Mechanism
increased myocardial mass augments contractile forces
The 3 types of Nuerohumoral mechanisms
- Increased sympathetic nerve activity
- Activate the renin-angiotensin-aldosterone system
- Secretion of atrial natriuretic peptide
Neurohumoral mechanism: Sympathetic activity
- serves to increase heart rate
- augment ventricular contraction
- activate vasomotor responses
Neurohumoral mechanism: Renin-Angiotensin-Aldosterone
- Promote retention of Na and Water
2. Expand the circulating blood volume
Decompensation: Definition
associated with a decreased ability to maintain minimum levels of output.
Decompensation: Circulatory disturbances are
- more severe
- progressive
- symptomatic
- supportive therapy is required if patient is to survive
Decompensation: Therapeutic agents
Concerned with improving the unwanted effects of pulmonary congestion and fluid retention to improve Cardiac Output
- Diuretics, nitrates, ACE
- Digitalis to augment myocardial contraction
Decompensation: Contributing factors
- Progressive deterioration
- Increased circulating blood volume
- Hypertrophy of myocardium
Decompensation: Progressive deterioration
Progressive deterioration of the myocardium due to underlying disease
- Fibrosis
- Chronic ischemic atrophy
Decompensation: Increased circulating blood volume
- Places an additional hemodynamic burden on the heart
- ultimately contributes to ventricular dilation and over-stretching
- decreased force of contraction (Frank Starling)
Decompensation: Hypertrophy of Myocardium: Definition
Increased thickness of . ventricle and increased mass
Decompensation: Hypertrophy of Myocardium: Pathologic changes lead to:
Anatomical and Physiological changes that compromise cardiac function
Decompensation: Hypertrophy of myocardium: Pathological hypertrophy include
- Appearance of abnormal myosin
- myocardial fibrosis
- decresed capillary to myocyte ratio
- decreased sequestration of calcium
- diminished sympathetic function
- decreased beta-adrenergic r/c’s and depletion of catecholamines in sympathetic terminals
Features of Heart Failure
- Left side (ventricular)
2. Right ventricular failure
Heart Failure: Left Side: Etiology
- Coronary Heart Disease
- Systemic hypertension and its complications
- Aortic and mitral valve disease - stenosis/insufficiency
- Congenital conditions - septal defects, patent ductus arteriosus, aortic coarctation
- Cardiomyopathy
Heart Failure: Manifestations
- Pulmonary congestion
- Reduced output
- Tachycardia - “weak pulse”
- “Poor circulation” with reduced tolerance to cold temperatures
Heart Failure: Manifestations: Pulmonary Congestion: Cause
Congestion of the left ventricle contributes to elevated pulmonary venous pressure and pulmonary edema.
Heart Failure: Manifestations: Pulmonary Congestion: Symptoms
- Dyspnea after rest or exercise
2. Othopnea
Orthopnea: definition
feeling of being out of breath when lying flat, and improves when sitting up
Heart Failure: Manifestations: Pulmonary Congestion: Paroxysmal nocturnal dyspnea: Cause
when edema fluids from the periphery are redistributed to the lungs wen the patient lies flat at night. Gives rise to rapidly progressive dyspnea which makes the patient sit up or lean out of the window to get “fresh air”
Heart Failure: Manifestations: Pulmonary Congestion: Paroxysmal nocturnal dyspnea: other features
- Dyspnea and increased fatigue with mild exercise
- Pulmonary “Rales”
- Large volumes of frothy white sputum that may be tinged with blood (rusty sputum)
- Pleural effustion - severe may compress lungs
Heart Failure: Manifestations: Reduced Output
Forward Failure
Heart Failure: Manifestations: Reduced Output: Contributes to
low cardiac output contributes to decreased arterial perfusion and systemic hypoxia
Heart Failure: Manifestations: Reduced Output: Renal ischemia activates…
activates vasopressor mechanisms and contributes to increased retention of fluids
- vasopressor mechanisms activated
- severe renal ischemia may cause tubular injury and renal failure
Heart Failure: Manifestations: Reduced Output: Advanced stages
Organs may become hypoxic
CNS - anxiety, reduced attention span, restlessness, irritability, visual dimness
Mitral stenosis contributes to pulmonary hypertension and right ventricular failure, BUT…
this develops in the absence of left ventricular failure.
