AssessmentsHeart failure: Pathology review
USMLE® Step 1 style questions USMLE
A 76-year-old man comes to the clinic due to insomnia. He reports he has been unable to sleep at night due to a persistent cough every time he lies flat, which has been ongoing for months. Additionally, he notes new exercise intolerance, reporting he can only walk two to three city blocks before catching his breath. His medical history is significant for hypertension, type 2 diabetes mellitus, and osteoarthritis. His temperature is 37.2°C (98.9° F), pulse is 75/min, respirations are 18/min, and blood pressure is 142/82 mmHg. Physical examination shows 1+ pitting edema of the lower extremities, and prominent jugular veins. Faint bibasilar crackles are heard on auscultation of the lungs. Which of the following medications is associated with an increased survival benefit for patients with this disease process?
On the cardiology ward, there were two people who had been admitted to the hospital repeatedly.
The first one is 70 year old Lidia, who had a myocardial infarction about 3 years ago.
She presents with fatigue, and dyspnea.
She says that she usually wakes up at night because of shortness of breath, but using more pillows when sleeping helps relieve it somewhat.
On examination, she has pitting edema in her legs and on auscultation, an S3 sound is heard.
The other person is 81 year old Richard who has been a smoker for the past 50 years.
He is also experiencing fatigue, and has pitting edema, but on further examination, there’s also jugular venous distention and hepatomegaly.
Okay, so, both these individuals suffer from heart failure.
Heart failure is a clinical syndrome used to describe the inability of the heart to pump enough blood or a point at which the heart can’t supply enough blood to meet the body’s demands.
This can happen in two ways, either the heart’s ventricles can’t pump blood hard enough during systole, called systolic heart failure, or not enough blood fills into the ventricles during diastole, called diastolic heart failure.
In both cases, blood backs up into the lungs, causing congestion or fluid buildup, which is why it’s also often known as congestive heart failure, or just CHF.
Alright, first up is systolic heart failure.
One way to think about this is that the heart needs to squeeze out a certain volume of blood each minute, called cardiac output, which can be calculated as the heart rate multiplied by the stroke volume.
The heart rate is pretty intuitive, but the stroke volume is a little tricky.
For example, an adult heart might beat 70 times per minute and the left ventricle might squeeze out 70ml per beat, so 70 x 70 equals a cardiac output of 4900 ml per minute, which is almost 5 liters per minute.
Now, the stroke volume is only a fraction of the total volume.
The total volume might be closer to 110 ml, and 70ml is the fraction that got ejected out with each beat, the other 40ml kind of lingers in the left ventricle until the next beat.
In this example, the ejection fraction would be 70ml divided by 110 ml or about 64%, a normal ejection fraction is around 50-70%.
Now, in systolic heart failure, there’s decreased contractility of the left ventricle, which causes a decreased cardiac output because the stroke volume is low.
This means there’s also a decreased ejection fraction.
During diastole blood returns to the ventricles and combines with the leftover blood that didn’t get pumped out during systole, and this is called the EDV or end diastolic pressure volume.
With systolic heart failure, don’t forget that EDV is high, because there’s more blood leftover after each heartbeat.
Regarding the end diastolic pressure or EDP, which is the pressure that’s found in the ventricle at the end of diastole, this will also be high, because the volume at the end of diastole is high as well.
Systolic heart failure is mainly caused by low contractility which can happen with ischemia caused by myocardial infarction, where a part of the cardiac tissue is damaged so it won’t contract properly anymore.
Another cause is dilated cardiomyopathy, where the ventricle is dilated and weakened.
Now in addition to systolic heart failure, you’ve also got diastolic heart failure, which is where the cardiac contractility is sufficient but not enough blood is returning to the ventricles.
In this case, again, the stroke volume is low, but the ejection fraction is normal.
So for example, the total volume might be lower than normal, say about 69 mL, and we pump out 44 mL, so if we divided 44 by 69, we get 64%, which is in the normal range.
With diastolic heart failure, we need to look at the end diastolic pressure, or the EDP, as well.
The problem is that the left ventricle isn’t compliant enough, so when the ventricle is filling during diastole, the pressure within will rise, so keep in mind that EDP is elevated during diastolic heart failure.
Also remember that with diastolic heart failure, EDV is normal, at least in the beginning, because the atria are capable of squeezing more blood into the ventricle.
One cause of diastolic heart failure is ventricular hypertrophy, where the ventricular myocardium gets thicker, and this decreases the ability of the chamber to stretch when filling.
Alright, so heart failure can be systolic or diastolic and can affect the right ventricle, or the left ventricle, or both ventricles, which is called biventricular heart failure.
Having said that, if less blood exits either ventricle it’ll affect the other since they work in series. So these terms really refer to the primary problem affecting the heart, basically which one was first.
When right heart failure isn’t caused by left heart failure, but by a pulmonary cause, we refer to this as cor pulmonale.
In terms of symptoms, in left heart failure the blood starts to back up into the lungs, specifically in the pulmonary veins and capillary beds which can increase the pressure in these vessels.
This leads to fluid moving from the blood vessels to the interstitial space causing pulmonary edema, or congestion.
This is a very important sign and must be remembered!
In the alveoli of the lungs, all the extra fluid makes oxygen and carbon dioxide exchange a lot harder, and therefore patients have dyspnea or trouble breathing.
Another symptom is orthopnea, which is difficulty breathing when lying down flat.
This is because there’s more venous return from the legs and the gut to the heart, which increases the amount of blood backing up into the pulmonary circulation.
This also explains why these people experience paroxysmal nocturnal dyspnea, which is when the sensation of not being able to breathe wakes a person at night.
Such individuals often sleep using more pillows in order to keep their upper body a bit elevated. This will lower the venous return and ease lung congestion.
The extra fluid in the lungs causes crackles or rales on auscultation.
If enough fluid fills the capillaries in the lungs, they can rupture, causing blood to leak into the alveoli.
Alveolar macrophages then eat up these red blood cells, which causes them to take on this brownish color from iron build-up.
And then they’re called “hemosiderin-laden macrophages”, also known as “heart failure cells”.
Next, since there’s decreased cardiac output, not enough blood is reaching vital organs. As a result, an individual with heart failure may also present with fatigue.
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