Beruflich Dokumente
Kultur Dokumente
to cover metabolic needs of body tissue (oxygen, substrates) by adequate blood supply to receive all blood comming back from the tissue to the heart
Essential conditions for fulfilling these functions normal structure and functions of the heart adequate filling of the heart by blood
Essential functions of the heart are secured by integration of electrical and mechanical functions of the heart
Cardiac output (CO) = heart rate (HR) x stroke vol.(SV) - changes of the heart rate - changes of stroke volume
Control of HR:
- autonomic nervous system
Preload
Stretching the myocardial fibers during diastole by increasing endenddiastolic volume p oforce of contraction during systole = Starling Starlings law
Myocardial contractility
Contractility of myocardium Changes in ability of myocardium to develop the force by contraction that occur independently on the changes in myocardial fibre length fibr
The pressure
volume loop
It is the relation between ventricular volume and pressure This loop provides a convenient framework for understanding the response of individual left ventricular contractions to alterations in preload, afterload, and contractility It is composed of 4 phases: - filling of the ventricle - isovolumic contraction of ventricle - isotonic contraction of ventricle(ejection of blood) - isovolumic relaxation of ventricle
Pressure
Afterload
It is expressed as tension which must be developed in the wall of ventricles during systole to open the semilunar valves and valves eject blood to aorta/pulmunary artery Laplace law: intraventricular pressure x radius of ventricle wall tension = -------------------------------------------------------2 x ventricular wall thickness o afterload: due to - elevation of arterial resistance afterload: - o ventricular size - myocardial hypotrophy q afterload: due to - q arterial resistance afterload: - myocardial hypertrophy - q ventricular size
Circulatory failure = any abnormality of the circulation responsible for the inadequacy in body tissue perfusion, e.g. decreased blood volume, changes of vascular tone, heart functiones disorders
Congestive heart failure = clinical syndrome which is developed due to accumulation of the blood in front of the left or right parts of the heart
Cardiac mechanical dysfunction can develop as a consequence in preload, contractility and afterload disorders Disorders of preload
oo preload p length of sarcomere is more than optimal p p q strength of contraction optimal qq preload p length of sarcomere is well below the optimal p p q strength of contraction
Important: failing ventricle requires higher end-diastolic volume endto achieve the same improvement of CO that normal ventricle achieves with lower ventricular volumes
Disorders of contractility
In the most forms of heart failure the contractility of myocardium is decreased (ischemia, hypoxia, acidosis, inflammation, toxins, hypoxia, metabolic disorders... ) disorders...
in failing hearts, the LV end-diastolic volume (or pressure) may increse as the stroke volume (or CO) decreases
2. Secondary
a) oxygen deprivation (e.g. coronary heart disease) (e.g. b) inflammation (e.g. increased metabolic demands) (e.g. c) chronic obstructive lung disease
3. extreme bradycardias
Consequences:
y defect in ATP production and utilisation y changes in contractile proteins y uncoupling of excitation contraction process
y impaired of sympato-adrenal system (SAS) p q number of sympatoF1-adrenergic receptors on the surface of cardiomycytes
Mechanism: y o sympathetic activity po cAMP p po?Ca po?Ca ++Ai p ocontractility y o sympathetic activity p qinfluence of parasympathetic system on the heart Pathophysiology: normal neurohumoral control is changed and creation of pathologic neurohumoral mechanisms are present
Chronic heart failure (CHF) is characterized by an imbalance of neurohumoral adaptive mechanisms with a net results of excessive vasoconstriction and salt and water retention
Catecholamines : - concentration in blood : - norepinephrin 2-3x higher at the rest than in healthy subjects
- circulating norepinephrin is increased much more during equal load in patients suffering from CHF than in healthy subject
- q number of beta 1
System rennin
angiotensin
aldosteron
Important:
Catecholamines and system RAA = compensatory mechanisms
y o sensation of thirst
y o secretion of aldosteron from adrenal gland
y systolic heart failure = failure of ejecting function of the heart y diastolic heart failure = failure of filling the ventricles,
o resistance to filling of ventricles
Primary diastolic heart failure - no signs and symptoms of systolic dysfunction is present
- ! up to 40% of patients suffering from heart failure!
Main causes and pathomechanisms of diastolic heart failure 1. structural disorders popassive chamber stiffness popassive
a) intramyocardial e.g. myocardial fibrosis, amyloidosis, hypertrophy, myocardial ischemia... ischemia... b) extramyocardial e.g. constrictive pericarditis
2. functional disorders p q relaxation of chambers e. g. myocardial ischemia, advanced hypertrophy of ventricles, failing myocardium, asynchrony in heart functions
b) pathological changes in chamber relaxation due to: to: Impaired relaxation process y delayed relaxation (retarded) y incomplete (slowed) relaxation
q Ventricular compliance is caused by structural abnormalities localized in myocardium and in extramyocardial tissue
a) Intramyocardial causes : myocardial fibrosis, hypertrophy of ventricular wall,restrictive cardiomyopathy b. Extramyocardial causes : constrictive pericarditis
2. backward failure: symptoms result from inability of the heart to accept the blood comming from periphery and from lungs comm
a. backward failure of left heart: increased pulmonary capillary pressure p dyspnoea and tachypnoea, pulmonary edema (cardiac asthma) p p arterial hypoxemia and hypercapnia.... hypoxemia hypercapnia....
b. backward failure of right heart: increased pressure in systemic venous system p p peripheral edemas, hepatomegaly, ascites ponocturnal diuresis.... ponocturnal diuresis....