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Starling’s Riddle of the Broken Heart 

Starling’s Riddle of the Broken Heart
Starling’s Riddle of the Broken Heart

James R. Munis

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date: 08 May 2021

In 1897, Ernest Starling lectured on heart failure by inducing cardiac tamponade in an anesthetized dog. When the tamponade began to have an effect, the arterial pressure began to fall, but the venous pressures began to rise. In other words, heart failure didn't just decrease one type of pressure, it simultaneously increased another type of pressure. By the end of the experiment, all pressures had converged to the same value. The heart, like any pump, doesn't just raise fluid pressure on one side, it simultaneously lowers fluid pressure on the opposite side. The heart has a peculiar architecture that prefers a slightly filled resting state. Any smaller volume actually requires active contraction—it passively springs open during a part of diastole, suctioning blood into itself. Why then does heart failure cause capillary edema? We understand that the pressure in large veins will rise with heart failure, but capillary pressure is on the left side of the intersection of the curve and the Pms line. As such, capillary pressure should decrease with heart failure, and the tendency toward edema similarly should decrease.

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