hello everybody and today we are gonna talk about heart failure and some of the basics about the heart failure so we're gonna start with the picture one two and then we will go to a higher level we'll talk about the pressure-volume loop which I think we all hate we might have done it in the med school but I will try to come to it once we have a little basic concept so that it is easier to understand and these loops so let's start with this simple concept I have drawn this picture of a donkey which is pulling a cart so the donkey is trying to go uphill so if we think the donkey is the heart trying to push the blood and working against the blood pressure this uphill will be your afterload let's say for example the blood pressure is 160 over 90 so the donkey has to kind of pull hard to go up on a steep cliff so this is in the in terms of the heart is your afterload so the Dinka is carrying this cart full of boxes so these are the in this example to be the preload so more the preload the more the donkey has to work the more the tank is gonna get tired similarly in the heart if the patient is ingested volume up increase venous stasis then you know more preload in the heart and more pressure on the heart and let's had another thing to this let's say for example if the donkey is not going up and you start hitting it with stick so in this case I'll label it as inotropes yes this is gonna make the dunk you work a little more but if this if the donkey is still carrying this amount of preload the after load is the same you are trying to make him go uphill and then just hitting it with this trick in this games we call it the inotropes you're just gonna tie him up and he might just faint or die so this is like a cartoon example of how things work in terms of the heart failure so in picture too if you look at this the tank is very happy so you're taking away the preload now the pinky is going downhill let's say for example the blood pressure is 100 over 60 so it's not working against the high blood pressure and just to add a little spice to the salad or the food if you give the patience if you give the donkey some digoxin in this case this kid you know roller skaters that the 10k is using in the in case of the heart it can be the detox and spottin Alecto on beta-blockers so those are all the good medications that you're trying to make the heart happy so in this example as I said we take on away the preload which is the card that it was pulling we taken away the uphill which is in case of the heart we'll with after Lord we have taken away or we might not even know need the inotropes if we decrease the blood crush or rather afterload so with this we move on to to the heart failure basics the pressure-volume loop so as we all see this is your pressure access this is your volume and one thing that is very important is what we call in heart failure terminology ESP VR which is end-systolic pressure-volume relation so this is a line that we draw when we look at a lot of patient's and we put their you know normal hemodynamics or the pressure-volume loops on a chart and then we cross the one point with one line with these dots that you get what we call like an ESP VR or end systolic pressure volume relation we'll break it down to see what exactly does that mean so let's look at the loop here so what's happening here is you're isovolumetric contraction so you see that the pressure is going up the pressure is on this axis the pressure is going up but the volume remains the same so this is isovolumetric contraction then the aortic valve opens and then you have the ejection of the blood here the aortic valve closes so this is your systolic blood pressure in this case we'll kate take it as 120 and then as you go down you again see then here the volume is not changing remaining the same the pressure is going down so it's got a isovolumetric relaxation then comes a phase where the mitral valve opens and you have this active filling so this is the kind of the cardiac cycle that we see on the pressure-volume loop but what's more important here is I'm just gonna label it with blue this line here so this is your stroke volume with each beat the amount of blood that is being pumped out of the heart so let's see what happens if you have a normal patient normal healthy individual no heart failure or anything like that you give them lisinopril or hydralazine or amlodipine and you lower their blood pressure so let's say for example in this case we lower the blood pressure of the patient 200 so we lower the blood pressure to 100 now we're going to draw the pressure volume loop for this patient the volume and systolic volume will go down as well let's delete that here so the the loop will be something like this so this is the loop that you will get so what I want you to focus is what happens when you lower the blood pressure in a normal person and what happens to the stroke volume so I'm just gonna draw it with orange so now you see the stroke volume goes up but what you have to understand is how much of the stroke volume has gone up I just shared this area this is only the amount of stroke volume or the benefit that will you will get if you lower the blood pressure from twenty one twenty two hundred in a patient who's got a normal heart so now come we come to the main theme of this talk and what you can take away from this talk is one line or these few min last minutes of this talk basically what happens in patients who are in heart failure they are working their heart is working on a flatter es PVR or pressure volume loop so if I have to draw a line for their es PVR it looks like like that is more tilted towards the volume axis so if this is normal this is somebody with a heart failure so again this is es PVR for a patient as quite a heart failure so now let's draw the pressure-volume loop for this patient so for example if this blood if the patient has for example a blood pressure of 120 here or let's say android systolic hundred their volumes will be high and systolic volume will be high be high so they are working more on the right side so in these patients lowering a little bit of blood pressure will give you a lot of benefit in terms of the stroke volume so in these patients the systolic blood pressure was hundred if you lower their blood pressure to let's say from example one from 100 to 80 as they are on a flatter curve you'll cross the line here and it's going to draw here so this is the amount of blood pressure drop but see how much of the stroke volume you get when you just lower the blood pressure a little bit so this is the key when we are doing a right heart cath and when we are managing patients with a heart failure we always say target the after low target the after load that is to decrease the after a load we know that once you decrease the after load the stroke volume goes remarkably up of course there will be a situation where the patients are on the extreme right of this axis these patients when they are at extreme right let's say for example here their blood pressures are also low and they are working on a very very flat curve and these patients are truly these are the patient who are in trouble because now what you see is they have low blood pressure to begin with you don't have any room to lower their blood pressure and then the other stroke volume is low as well the rejection is low the only way you can move the patience towards the left or make their ESP VR go up either in this zone or all the way to the normal is by adding some inotropes so bottom line when you have a patient with heart failure the key is afterload reduction afterload reduction after low reduction yes you can diurese them you can decrease their preload you can decrease it and systolic and diastolic volume elvis left 20 grand historical volumes and you know all those things but when it comes to the management key the afterload reduction is the key in this baby I hope this will was helpful you all have a very good thing