Internal illnesses. Heart failure (lecture notes)

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Internal illnesses. Heart failure (lecture notes)

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LECTURE No. 21. Heart failure

Heart failure is a pathological condition in which the cardiovascular system is unable to provide organs and tissues with the necessary amount of blood both at rest and during exercise.

Etiology. The main reasons for the development of insufficiency are infectious-inflammatory and toxic lesions of the myocardium, impaired blood supply to the myocardium, metabolic disorders, heart pressure overload, volume overload, heart defects such as valvular insufficiency, a combination of heart overload and myocardial damage, and heart rhythm disturbance.

Pathogenesis. In the initial period of heart failure, the functioning of cardiac and extracardiac compensation mechanisms is noted:

1) an increase in the strength of heart contractions (under the influence of the amplifying nerve of the heart);

2) an increase in the number of heart contractions (Bainbridge reflex);

3) decrease in diastolic pressure (as a result of the expansion of arterioles and capillaries);

4) increase in oxygen consumption by tissues;

5) compensation mechanisms are capable of maintaining a sufficient level of hemodynamics for a long time.

Congestive heart failure is caused by:

1) activation of the sympathoadrenal system with the development of tachycardia;

2) myocardial hypertrophy (long-term compensation mechanism);

3) tonogenic dilatation of the heart (Starling mechanism - displacement of myocardial layers relative to each other, leads to increased contractile function of the myocardium, hyperfunction and hypertrophy);

4) an increase in the volume of circulating blood (kidney function, an increase in the production of ACTH and aldosterone, an increase in the number of formed elements due to hypoxia);

5) spasm of the arteries (increased afterload) and congestion in the veins (increased preload);

6) myogenic dilatation;

7) the formation of edema (an increase in hydrostatic pressure in the veins, sodium and water retention, hypoxic capillary porosity, impaired protein synthesis);

8) dystrophic changes in the internal organs.

Table 3. Classification of chronic heart failure (New York Heart Association)

(*FK - functional class)

Clinic. Early stages of heart failure characterized by the appearance of shortness of breath during physical exertion, nocturnal dry cough, nocturia. Auscultatory listening to the gallop rhythm, IV tone.

Acute left ventricular failure (cardiac asthma, pulmonary edema) more often observed in myocardial infarction, hypertension, aortic disease, chronic coronary artery disease. An attack of cardiac asthma develops (severe shortness of breath due to stagnation of blood in the lungs, impaired gas exchange). Shortness of breath occurs more often at rest at night, there is suffocation, severe weakness, cold sweat, cough with difficult to separate mucous sputum, the patient takes a sitting position. Diffuse cyanosis is noted against the background of severe pallor of the skin, hard breathing in the lungs, unsound small and medium bubbling rales in the lower sections. The heart sounds at the apex are weakened, the II tone above the pulmonary artery is increased, the pulse is small, frequent.

With the progression of congestion, pulmonary edema develops - there is an increase in suffocation and coughing, bubbling breathing appears, abundant foamy sputum mixed with blood. In the lungs, profuse wet rales of various sizes are heard in all lung fields; gallop rhythm. The pulse is threadlike, sharply accelerated.

Acute left atrial failure develops with mitral stenosis due to a sharp weakening of the contractility of the left atrium. The clinic is similar to manifestations of acute left ventricular failure.

Acute right heart failure develops with embolism of the pulmonary artery trunk or its branches due to the drift of a blood clot from the veins of the large circle or the right parts of the heart, with pneumothorax, total pneumonia, with gas (decompression sickness) and fat embolism (with fractures of tubular bones). Appear: rapid breathing, cyanosis, cold sweat, pain in the region of the heart, the pulse is small, frequent, blood pressure drops, swelling of the cervical veins, the liver enlarges, edema appears.

Acute vascular insufficiency (fainting, collapse, shock) develops with a decrease in blood mass (blood loss and dehydration), a drop in vascular tone (reflex disorders in trauma, irritation of the serous membranes, myocardial infarction, pulmonary embolism; disorders of innervation of central origin: hypercapnia, acute hypoxia of the interstitial brain, overload, psychogenic reactions; with infections and intoxication). The deposition of a significant part of the blood in the vessels of the abdominal cavity leads to a decrease in the volume of circulating blood, a decrease in pressure.

With fainting, there is a sudden short-term loss of consciousness due to insufficient blood supply to the brain, appear: pallor of the skin, cold sweat, cold extremities, weak or thready pulse, a sharp decrease in blood pressure.

With collapse, there are: dizziness, darkening of the eyes, ringing in the ears, possible loss of consciousness, cold sweat, cold extremities, rapid shallow breathing, small thready pulse, drop in blood pressure; in contrast to fainting, the duration and severity of manifestations are longer.

In shock, the clinical manifestations are similar to collapse, differ in the mechanism of development (associated with trauma, pain, intoxication).

Chronic left ventricular heart failure develops with aortic defects, mitral insufficiency, arterial hypertension, coronary artery disease, diseases with damage to the left ventricle. Appear: shortness of breath, cyanosis, cough; develops congestive bronchitis with sputum, hemoptysis. Harsh breathing is heard in the lungs, in the lower sections there are moist fine and medium bubbling rales, expansion of the heart to the left, tachycardia, accent of the II tone over the pulmonary artery.

Progressive pulmonary hypertension leads to right ventricular failure.

Chronic right ventricular heart failure develops with mitral defects, emphysema, pneumosclerosis, tricuspid valve insufficiency, congenital malformations. There is stagnation of blood in the veins of the systemic circulation, shortness of breath, palpitations, swelling of the legs, pain and heaviness in the right hypochondrium, small diuresis. Expressed acrocyanosis, swelling of the cervical veins, cardiac impulse, epigastric pulsation, expansion of the heart to the right.

There is an increase in the liver, a positive symptom of Plesh (hepatojugular reflux: pressure on the liver increases the swelling of the cervical veins) and venous pulse, ascites, hydrothorax are noted.

An increase in central venous pressure leads to a slowdown in blood flow.

Additional diagnostic study. The colloid-osmotic state of blood is studied: integral indicators of protein and water-electrolyte metabolism, the content of their main components in plasma (electrolytes, non-electrolytes, colloids, plasma volume).

The following indicators are being studied:

1) determination of the volume of fluid spaces (volume of circulating blood);

2) osmotic indicators (serum sodium content, mean erythrocyte volume, osmolarity);

3) dilution or hemoconcentration in the blood - the concentration of hemoglobin in the blood, the hematocrit value, the number of red blood cells in the blood, the concentration of total protein in the serum.

The electrolyte balance of sodium, potassium, calcium, etc. is examined. The ECG reveals signs of overload of the left or right atrium, etc.

EchoCG study determines an increase in cavities, a decrease in myocardial contractility.

X-ray examination establishes the expansion of the cavities of the heart, central and peripheral venous congestion.

Doppler EchoCG study determines the slowing of blood flow, a decrease in stroke and minute blood volumes, and an increase in the mass of circulating blood.

Treatment. A dietary regimen is prescribed (table No. 10) with restriction of liquid and table salt.

To improve the contractile function of the myocardium, cardiac glycosides are prescribed (digitalis, isolanide, digoxin, corglicon, strophanthin, stimulants of β-adrenergic receptors (dopamine, dobutamine), ACE inhibitors (accupro, captopril, berlipril 5).

Normalization of myocardial metabolism is carried out with potassium preparations, ATP, cocarboxylase, B vitamins, inosine; amino acids, anabolic hormones, cozaar, monizol, monocinque.

Diuretics are prescribed - hypothiazide, furosemide, indapamide, triamterene, spironolactone, aldosterone antagonists (veroshpiron).

To improve peripheral circulation, camphor, caffeine, cordiamine preparations, peripheral vasodilators are used: nitroglycerin (for venous vessels), apressin (for arterial vessels), naniprus (mixed action), phosphodiesterase inhibitors (amrinone, milrinone);

Hypoxia should be eliminated using oxygen therapy.

The elimination of stagnation in the small circle is carried out by bloodletting, the use of fast-acting diuretics - uregit, mannitol.

To increase the tone of the cardiovascular system, exercise therapy, massage, carbon dioxide and hydrogen sulfide baths are prescribed.

Forecast. Depends on the severity of the underlying disease and the functional class of heart failure. At stages I and IIA, the prognosis is relatively favorable, at stage IIB - serious, at stage III - unfavorable.

Author: Myshkina A.A.

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