Table of Contents
Foreword
1 Cardiac physiology of acute heart failure syndromes
1.1 Cardiac performance
1.2 The fundamental equation of the circulation
1.3 Preload
a) Definition
b) Frank–Starling mechanism
c) Venous return and CVP in daily practice
1.4 Haemodynamic monitoring
a) Assessment and monitoring of fluid status
b) Prediction of fluid responsiveness
i) Pressure measurements
ii) Volumetric measurements
iii) Dynamic parameters
iv) Fluid challenge
v) PiCCO-monitoring
vi) Echocardiography
c) Arterial blood pressure
i) BP and autoregulation
ii) Assessment of tissue perfusion
1.5 Afterload
a) Definition
b) Vascular properties, effective arterial elastance, wall stress and the law of LaPlace
c) Afterload mismatch and acute heart failure syndromes
1.6 Contractility
a) Definition
b) Ventricular elastance and other measurements and indicators of contractility
c) Inotropic medications
1.7 Heart rate and contractility
1.8 Diastolic ventricular interaction/interdependance (DVI)
a) Definition
b) Septum and trans-septal pressure
c) Pericardium
d) Pulmonary hypertension and the risk of DVI
e) Acutely exacerbated chronic congestive (left-sided or biventricular) HF
f) Conclusions
1.9 Ventriculo-arterial coupling
a) Definition
b) Arterial elastance
c) Ventricular elastance
e) Deranged coupling
1.10 Myocardial and chamber stiffness
1.11 Evaluation and assessment of cardiac performance
1.12 Summary
a) Key physiology
b) Afterload
c) Systolic function
d) Volume status
e) Ventriculo-arterial coupling
f) Diastolic ventricular interaction
g) Myocardial and chamber stiffness
h) Cardiac power output / index
i) Echocardiography
2 Acute heart failure syndromes
2.1 Definition
2.2 Classification of acute heart failure syndromes (AHFS)
2.3 Etiology and epidemiology
2.4 Pathophysiology
a) General pathophysiological remarks
b) Special pathophysiological issues
i) LVEDP and congestion
ii) Neurohormonal systems, endothelial dysfunction and inflammation
iii) Vascular properties, AV-coupling, afterload mismatch and Cotter's dual pathway concept
iv) Fluid redistribution, splanchnic veins and the venocentric input
v) Fluid accumulation, venous congestion and the link between cardiac and vascular pathway
vi) (Self)-amplification and vicious cycles
c) Summary
2.5 Diagnosis, symptoms, presentation, important clinical and prognostic data
a) Typical symptoms and diagnosis
b) Prognostic indicators
c) Initial clinical assessment, diagnostic measures and considerations
i) Hemodynamic profiles on admission
ii) Identification of precipitants
iii) Other diagnostic measures
2.6 Therapy
a) Therapeutic principles and goals
b) Initial therapeutic approach
i) Treatment of underlying diseases
ii) Common basic measures
iii) Typical and specific measures
- Diuretics and ultrafiltration
- Vasodilators
- Inotropic drugs
iv) Essential, permanent medication in the acute phase
v) Arrhythmias and heart failure
vi) Continuous positive airway pressure (CPAP) and other non-invasive positive pressure
ventilatory support (NIPPV)
vii) Anticoagulation
2.7 Valvular heart disease presenting as heart failure
a) Mitral regurgitation
b) Mitral stenosis
c) Aortic regurgitation
d) Aortic stenosis
2.8 Summary
3 Cardiogenic shock
3.1 Definition
3.2 Epidemiology
3.3 Etiology
3.4 Pathophysiological aspects and special pathobiological features
a) Classical pathophysiology and new cardiogenic shock paradigm
b) The role and impact of hypotension in cardiogenic
c) Myocardial ischemia and LV- compliance
d) The right ventricle and cardiogenic shock
e) Other acute causes of a substantial impairment in contractility
3.5 Clinical features and diagnostic remarks
a) Hypoperfusion
b) Right ventricular infarction
c) The LVEDP in cardiogenic shock
d) Differential diagnosis of cardiogenic shock
3.6 Therapy
a) Main therapeutic strategies
b) Adjunctive treatment
i) Re-establishing and maintaining appropriate coronary and systemic perfusion
ii) Fluid administration
iii) Vasopressor administration
iv) Inotropic medication
v) Intra-aortic balloon counter pulsation (IABP)
vi) Renal function
vii) Compensation of acidosis
viii) Anticoagulation therapy
3.7 Summary
4 Acute right heart failure
4.1 Definitions
4.2 Epidemiology and etiology
4.3 Physiological and pathophysiological aspects
a) General physiology and pathophysiology
b) Special pathophysiological issues
i) Diastolic ventricular interactions
ii) The role of the pericardium in diastolic-ventricular interaction
iii) Auto-aggravation
iv) Series effect
v) Pulmonary hypertension and ischemia
vi) The interventricular septum and the apex
vii) The left ventricle
viii) Mechanical ventilation
4.4 Diagnostic aspects
a) Clinical features
b) Serum biomarkers
c) Electrocardiography
d) Echocardiography
e) Invasive hemodynamic assessments
4.5 Therapy
a) Specific measures
b) Adjunctive therapy
i) Fluid management and optimization of preload, diuretics
ii) Vasopressors: Treatment and avoidance of ischemia
iii) Critical RV-afterload reduction
iv) Improvement of RV systolic function / contractility
v) Intra-aortic balloon pump
vi) Hypercapnia and acidosis
vii) Oxygen therapy
viii) AV sequential stimulation
ix) Mechanical ventilation
x) Anticoagulation
xi) Digoxin
c) Therapeutic conclusions
4.6 Summary
a) Pathophysiological and clinical issues
b) Overview of treatment options, figure by Naeije and and Manes
5 Heart failure with normal left ventricular ejection fraction (HFNEF)
5.1 Definition and general remarks
5.2 Epidemiology and etiology
5.3 Etiopathogenesis and basic pathophysiological issues and considerations
5.4 Special pathophysiology
a) The pressure-volume relation and the filling pressure (LVEDP) in HFpEF
b) Pathomechanisms
i) Diastolic dysfunction
ii) Vascular stiffening and av-coupling
iii) Systolic function and cardiac reserve
iv) Pulmonary hypertension and RV dysfunction, DVI
v) Ventricular dys-synchrony
vi) Left atrial dysfunction
vii) Peripheral factors
5.5 Diagnosis and clinical issues
a) Symptoms and signs of heart failure
b) Ejection fraction
c) Diastolic dysfunction, structural changes and bio-markers
i) Natriuretic peptides
ii) Functional and structural alterations
iii) E/e'ratio
iv) Inconclusive E/e'ratio - surrogate markers
v) Invasively derived parameters
vi) Diastolic stress test
5.6 Therapy
6 Pulmonary hypertension (PH) in left heart disease (LHD - PH)
1. Definition
2. Classification of pulmonary hypertension
3. Epidemiology of PH due to LHD
4. Pathophysiology
5. Clinical issues and diagnosis
6. Therapeutic considerations
7 Cardiorenal syndrome (CRS)
1. Definition
2. Epidemiology and prognostic issues
3. Clinical issues and diagnosis
4. Pathophysiology
5. Management
a) Diuretics
b) Blood pressure /renal perfusion pressure
c) Further measures
Index
Abbreviations