Circulation Review

PreloadPreloadPressure filling the left ventriclePressure filling the left ventricle

AfterloadAfterloadPressure the heart has to pump againstPressure the heart has to pump against

Low Low pressurepressure

High High pressurepressure

Heart Failure

•The heart cannot pump enough blood to meet the need.

•This is not the same as a heart attack

•This is not the same as coronary artery disease

•Those things are just one of many causes of heart failure

Systolic vs Diastolic Heart Failure Systole: When the heart is pumpingCorresponds to Systolic blood pressure

160 ml140 / 90

Systolic Heart Failure is failure of the heart to Pump

Pump

Systolic vs Diastolic Heart Failure Diastole: When the heart is relaxing / filling

Corresponds to Diastolic blood pressure

160 ml140 / 90

Diastolic Heart Failure is failure of the heart to Relax

Relax

Systolic vs. Diastolic Dysfunction (round 2)

Normal Amount of

blood at the end of diastole

Normal HeartNormal MuscleThickness

Normal MuscleThickness

Normal amount ejected

EF 70/120

Ejection Fraction

55 -65%

Normal Cardiac Output (around 5 L/min)Normal Cardiac Output (around 5 L/min)

Normal Heart

Systolic Dysfunction

Thin Heart Muscle

Thin Heart Muscle

Normal Amount of

blood at the end of diastole

Much larger amount at the end of diastole

in Systolic Dysfunction

Big, floppy heart , more than

50% of the chest cavity

Systolic Dysfunction

Systolic DysfunctionEF 70/120

58 %Ejection Fraction

25 %

Small amount ejected

Reduced Cardiac OutputReduced Cardiac Output

Diastolic

DysfunctionThickened (hypertrophi

ed)Heart Muscle

Thickened (hypertrophi

ed)Heart Muscle

Normal Amount of

blood at the end of diastole

Smaller amount at the end of diastole

in Diastolic Dysfunction

Diastolic

Dysfunction

Normal CardiacSilhoutte

Diastolic

Dysfunction

Diastolic DysfunctionEF 70/120

58 %EF

70%

Similar Cardiac Output to Systolic DysfunctionSimilar Cardiac Output to Systolic Dysfunction

Small amount ejected

OUTLINE DIPIRO USE DIPIRO SLIDES Other Neuroendocrine mediators

Arginine Vasopressin (ADH)

Stimulated by extreme low kidney perfusion, just like Aldosterone. Causes free water retention and hyponatremia

Receptor Site Effect

V1a Vascular smooth musclePlateletsCardiac muscle

VasoconstrictionPlatelet aggregationPositive intropism

V1b Anterior pituitary Release of ACTH and Beta endorphins

V2 Renal collecting dugs

Increased water absorption

Tolvaptan, (V2 antagonist), Conivaptan (V1a and V2 antagonist)

Other Neuroendocrine mediators

Endothelin

One of the absolute most potent vasoconstrictors. Endothelin antagonists in the works

Atrial and B-type Natriuretic peptide

Stimulated by stretch of the atria and the ventricles and cause sodium and water excretion. Sort like a counter-regulatory hormone to aldosterone

CHF: CompensationCardiac Output

Kidney Perfusion

ReninAngiotensinAldosterone

Na+ & H2O

retention

Preload

SNS

Cardiac Output

((Compensated)

CHF: CompensationCardiac Output

CHF: Compensation

Kidney Kidney PerfusionPerfusion

Cardiac Output

CHF: Compensation

Kidney Perfusion

ReninReninAngiotensinAngiotensinAldosteroneAldosterone

Cardiac Output

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Na+Na+ andand H2OH2O

retentionretention

Cardiac Output

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload

CardiacCardiacOutputOutput

(CompensatedCompensated))

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

CHF: Compensation

Kidney Kidney PerfusionPerfusion

ReninAngiotensinAldosterone

Na+ and H2O

retention

Preload

Cardiac Output CardiacCardiacOutputOutput

(Compensated)Compensated)

CHF: Compensation

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

Na+ and H2O

retention

SNSSNS

Cardiac Output CardiacCardiacOutputOutput

(CompensatedCompensated))

Preload

CHF:Cardiac Output

WHY?

CHF:Cardiac Output

WHY?

SystolicSystolic DilatedDilated CardiomyopathyCardiomyopathy CADCAD HTNHTN

CHFCardiac Output

WHY?

SystolicSystolic DilatedDilated CardiomyopathyCardiomyopathy CADCAD HTNHTN

Diastolic

Hypertension

CAD

Hypertrophic Cardiomyopathy

CHF: The Viscious CycleThe Viscious Cycle

Kidney Perfusion

ReninAngiotensinAldosterone

Cardiac Output

CHF: The Viscious Cycle

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

VasoconstrictionVasoconstriction

SNS

Cardiac Output

CHF: The Viscious CycleCardiacCardiac OutputOutput

Kidney Perfusion

ReninAngiotensinAngiotensinAldosterone

VasoconstrictionVasoconstriction

SNS

AfterloadAfterload

CHF: The Viscious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Cardiac Output

CHF: The Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

Na+Na+ andand H2OH2O

retentionretention

Cardiac Output

CHF: Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

CHF: Vicious Cycle

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

StrainStrain

Improve

d

However

CHF: Symptoms

Kidney Perfusion

ReninAngiotensinAldosteroneAldosterone

PreloadPreload and and Pulmonary EdemaPulmonary Edema

Cardiac Output

Na+Na+ andand H2OH2O

retentionretention

StrainStrainLow PerfusionLow PerfusionLow PerfusionLow Perfusion

Fluid OverloadFluid OverloadFluid OverloadFluid Overload