An Osmosis Video: Congestive Heart Failure (CHF) Explained

By Adem Lewis / in , , , , , , , , , , , , , , , , , , , , , /

Heart failure’s used to describe a point
at which the heart can’t supply enough blood to meet the body’s demands. This can happen
in two ways, either the heart’s ventricles can’t pump blood hard enough during systole,
called systolic heart failure, or not enough blood fills the ventricles during diastole,
called diastolic heart failure. In both cases, blood backs up into the lungs, causing congestion
or fluid buildup, which is why it’s also often known as congestive heart failure, or
just CHF. Congestive heart failure affects millions of people around the world and since
it means that the body’s needs are not being met, it can ultimately lead to death. Part
of the reason why so many people are affected by heart failure, is that there are a wide
variety of heart diseases like ischemia and valvular disease that can impair the heart’s
ability to pump out blood and—over time—can ultimately cause the heart to fail. Alright, first up is systolic heart failure,
kind of a mathematical way to think this one is that the heart needs to squeeze out a certain
volume of blood each minute, called cardiac output, which can be rephrased as the heart
rate (or the number of beats in a minute) multiplied by the stroke volume (the volume
of blood squeezed out with each heart beat). The heart rate is pretty intuitive, but the
stroke volume’s a little tricky. For example, in an adult the heart might beat 70 times
per minute and the the left ventricle might squeeze out 70ml per beat, so 70 x 70 equals
a cardiac output of 4900 ml per minute, which is almost 5 liters per minute. So notice that
not all the blood was pumped out right? And the stroke volume is a fraction of the total
volume. The total volume may be closer to 110 ml, and 70ml is the fraction that got
ejected out with each beat, the other 40ml kind of lingers in the left ventricle until
the next beat, right? In this example, the ejection fraction would be 70ml divided by
110 ml or about 64%, a normal ejection fraction is around 50-70%, between 40-50% would be
borderline, and anything about 40% or less would indicate systolic heart failure because
the heart is only squeezing out a little blood each beat. So in our example, if the total
volume of the left ventricle was 110 ml, but only 44 ml was pumped out with each beat (then
you have 44 ml divided by 110 ml which is 40%), and we would say that this person is
in systolic heart failure. Now in addition to systolic heart failure,
you’ve also got diastolic heart failure, which is where the heart’s squeezing hard
enough but not filling quite enough. In this case again the stroke volume is low, but the
ejection fraction’s normal…how’s that? Well it’s not filling enough so there’s
a low total volume, say about 69 mL, well even though both are low, 44 ml divided by
69 ml is still 64%. In this situation, the failure’s caused by abnormal filling of
the ventricle so that the chamber doesn’t get fully loaded or stretched out in the first
place. Another term for this is having a reduced “preload” which is the volume of blood
that’s in the ventricle right before the ventricular muscle contracts. An important relationship between systolic
and diastolic function is the Frank-Starling mechanism, which basically shows that loading
up the ventricle with blood during diastole and stretching out the cardiac muscle makes
it contract with more force, which increases stroke volume during systole. This is kinda
like how stretching out a rubber band makes it snap back even harder, except that cardiac
muscle is actively contracting whereas the rubber band is passively going back to its
relaxed state. Heart failure can affect the right ventricle,
or the left ventricle, or both ventricles, so someone might have, right-sided heart failure,
left-sided heart failure, or both (which is called biventricular heart failure), each
of which can have systolic or diastolic failure. Having said that, if less blood exits either
ventricle it’ll affect the other since they work in series, so left-sided could cause
right-sided, and vice versa, so these terms really refer to the primary problem affecting
the heart, basically which one was first. Usually left-sided heart failure is caused
by systolic (or pumping) dysfunction. This is typically due to some kind of damage to
the myocardium—or the heart muscle—which means it can’t contract as forcefully and
pump blood as efficiently. Ischemic heart disease caused by coronary artery atherosclerosis,
or plaque buildup, is the most common cause. In this case, less blood and oxygen gets through
the coronary artery to the heart tissue, which damages the myocardium. Sometimes, if the
coronary’s blocked completely and the person has a heart attack, they might be left with
scar tissue that doesn’t contract at all, which again means the heart can’t contract
as forcefully. Longstanding hypertension is another common cause of heart failure. This
is because as arterial pressure increases in the systemic circulation, it gets harder
for the left ventricle to pump blood out into that hypertensive systemic circulation. To
compensate, the left ventricle actually bulks up, and its muscles hypertrophy, or grow so
that the ventricle can contract with more force. The increase in muscle mass also means
that there is a greater demand for oxygen, and, to make things even worse, the coronaries
get squeezed down by the this extra muscle so that even less blood’s delivered to the
tissue. More demand and reduced supply means that some of the ventricular muscle starts
have weaker contractions—leading to systolic failure. Another potential cause would be
dilated cardiomyopathy, where the heart chamber dilates, or grows in size in an attempt to
fill up the ventricle with larger and larger volumes of blood, or preload, and stretch
out the muscle walls and increase contraction strength, via the Frank-Starling mechanism.
Even though this can work for a little while, over time, the muscle walls get thinner and
weaker, eventually leading to muscles that are so thinned out that it causes systolic
left-sided heart failure. Ultimately the ventricle walls need to be the right size relative to
the size of the chamber in order for the heart to work effectively. Any major deviation from
that can lead to heart failure. Even though systolic failure is most common
in left-sided heart failure, diastolic heart failure or filling dysfunction can also happen.
In hypertension, remember how the left ventricular hypertrophied? Well that hypertrophy is concentric,
which means that the new sarcomeres are generated in parallel with existing ones. This means
that as the heart muscle wall enlarges, it crowds into the ventricular chamber space,
resulting in less room for blood, meaning that in addition to contributing to systolic
dysfunction, hypertension also can cause diastolic heart failure. Concentric hypertrophy leading
to diastolic failure can also be caused by aortic stenosis, which is a narrowing of the
aortic valve opening, as well by hypertrophic cardiomyopathy, an abnormal ventricular wall
thickening often from a genetic cause. Restrictive cardiomyopathies are yet another cause. In
this case the heart muscle gets stiffer and less compliant, and therefore the left ventricle
can’t easily stretch out and fill with as much blood, which leads to diastolic heart
failure. When the heart doesn’t pump out as much
blood, there’s decreased blood flow to the kidneys, which activates the renin-angiotensin-aldosterone
system, ultimately causing fluid retention. Which fills the heart a bit more during diastole
and increases preload, which increases contraction strength again by the Frank Starling mechanism.
Unfortunately, just like the other strategies, in the long term, retaining fluid so that
more fluid remains in the blood vessels typically leads to a large portion of it leaking into
the tissues and can contribute to fluid buildup in the lungs and other parts of the body,
which can worsen the symptoms of heart failure. Aright so a major, major clinical sign of
the heart not being able to pump enough blood forward to the body, is that blood starts
to back up into the lungs. A backup of blood in the pulmonary veins and capillary beds
can increase the pressure in the pulmonary artery and can also result in fluid moving
from the blood vessels to the interstitial space causing pulmonary edema, or congestion.
In the alveoli of the lungs, all this extra fluid makes oxygen and carbon dioxide exchange
a lot harder, since a wider layer of fluid takes more time for oxygen and carbon dioxide
to diffuse through, and therefore patients have dyspnea—trouble breathing, as well
as orthopnea – which is difficulty breathing when lying down flat since that allows venous
blood to more easily flow back from the legs and the gut to the heart and eventually into
the pulmonary circulation. This extra fluid in the lungs causes crackles or rales to be
heard on auscultation while the patient breathes. If enough fluid fills some of these capillaries
in the lungs, they can rupture, leaking blood into the alveoli. Alveolar macrophages then
eat up these red blood cells, which causes them to take on this brownish color from iron
build-up. And then they’re then called “hemosiderin-laden macrophages”, also known as “heart failure
cells”. For left-sided heart failure, certain medications
can be prescribed to help improve blood flow, like ACE inhibitors which help dilate blood
vessels, as well as diuretics to help reduce the overall fluid buildup in the body which
helps prevent hypertension from worsening the heart failure. Now let’s switch gears and think about right-sided
heart failure, which is actually often caused by left-sided heart failure. K remember how
fluid buildup increased pressure in the pulmonary artery? Well this increased pulmonary blood
pressure makes it harder for the right side to pump blood into. In this case the heart
failure would be biventricular, since both ventricles are affected. Someone can also
have isolated right-sided heart failure, though, and an example of this would be a left-to-right
cardiac shunt. In these cases, there might be a cardiac shunt like an atrial septal defect
or a ventricular septal defect, that allows blood to flow from the higher-pressure left
side to the lower-pressure right side, which increases fluid volume on the right side and
can eventually lead to concentric hypertrophy of the right ventricle, making it more prone
to ischemia—which is a systolic dysfunction, and have a smaller volume and become less
compliant—which is a diastolic dysfunction. Another potential cause of isolated right-sided
failure is chronic lung disease. Lung diseases often make it harder to exchange oxygen, right?
Well in response to low oxygen levels, or hypoxia, the pulmonary arterioles constrict,
which raises the pulmonary blood pressure. This, just like before, makes it harder for
the right side of the heart to pump against and can lead to right-sided hypertrophy and
heart failure. When chronic lung disease leads to right-sided hypertrophy and failure, it’s
known as cor pulmonale. With left-sided failure, blood gets backed
up into the lungs. With right-sided failure, blood gets backed up to the body, and so patients
have congestion in the veins of the systemic circulation. One common manifestation of this
is jugular venous distention, where the jugular vein that brings blood back to the heart takes
on more blood and becomes enlarged and distended in the neck. Also in the body, when blood
backs up to the liver and spleen, fluid can move into the interstitial spaces within those
organs and they can both become enlarged, called hepatosplenomegaly, which can be painful,
and if the liver is congested for long periods of time, patients can eventually develop cirrhosis
and liver failure, which would be called cardiac cirrhosis. Excess interstitial fluid near
the surface of the liver and spleen can also move right out into the peritoneal space as
well, and since that cavity can take a lot of fluid before there is any increase in pressure,
a lot of fluid can build up in the peritoneal space which is called ascites. Finally, fluid
that backs up into the interstitial space in the soft tissues in the legs causes pitting
edema, where the tissue is visibly swollen and when you apply pressure to it it leaves
a “pit” and takes awhile to come back to its original place. This generally affects
the legs in most people, because gravity generally causes the majority of fluid to “pool”
in the dependent parts of the body, which is the legs when you’re standing and the
sacrum, essentially the lower back, when you’re lying down. Right-sided heart failure will be treated
similarly to left-sided heart failure, especially because it’s often a result of left-sided
heart failure. Therefore, medications like ACE inhibitors and diuretics may be prescribed. With heart failure, we saw that sometimes
the muscle wall can stretch and thin out, or sometimes it can sometimes thicken and
become ischemic. In either case, those heart cells get irritated, in both scenarios the
cells get irritated, and this can lead to heart arrhythmias. With an arrhythmia, the
ventricles don’t contract in sync anymore making them less able to pump out blood and
worsening the whole situation. In some cases, patients might be treated with cardiac resynchronization
therapy pacemakers, which can stimulate the ventricles to contract at the same time and
potentially improve the blood pumped out. Alternatively, for heart failure in general,
some people might have ventricular assist devices implanted, or VADs, which literally
assist or help the heart pump blood may also be implanted. In end-stage situations where
other forms of treatment have failed, patients might have a heart transplant.

100 thoughts on “An Osmosis Video: Congestive Heart Failure (CHF) Explained

  1. Please create playlist…Then it will be easier to find the contents needed..Tq so much for all those great videos..

  2. Isn't it a pressure build-up and not a volume build up that leads to the concentric hypertrophy in the rightsided heartfailure? @10:45

  3. impressed. a complex and important topic explained in an organized, intelligible and delightful way. this is why I really don't wanna go to the classroom anymore.

  4. Excellent way to teach but too fast when it comes to giving explanations. It would be good to go more slowly, when the narrator speaks, to understand better. It's a suggestion, thank you.

  5. i wouldnt say aortic stenosis causes diastolic heart failure. it doesnt make sense. it actually leads to reduced ejection fraction. aortic stenosis alone is not correct @7:31.
    hypertrophic cardiomyopathy yes, it does cause diastolic heart failure. in hypertrophic cardimyopathy does have thickening of the heart and narrowing of the aortic valve which then causes the unchanged EF. this however doesnt mean that narrowing of the aortic valve by stenosis will also cause diastolic failure.

  6. My professor refuses to post anything online after class.
    I love how I’m able to watch this as many times as I want! It hit all the points my professor taught in class. Thank you!!

  7. Bro,you have nailed it completely!!! U take care of little details and assume that the viewer does not know anything. This is the best part of your videos. I support you and your channel. Wish you all the very best in your endeavours!

  8. question: at 11:00, why would hypoxia cause pulmonary arterioles to constrict? i thought low o2 levels cause vasodilation?

  9. Its jst take only 10 minutes to understand whole scenario of disease….i think this is the best way of smart, and conceptual study..!! First i see osmosis video thn start reading topics in books ….i feel like revision in first attempts…hope for more videos…!! Thanks a lot sir..! 😃 Keep it up ..!

  10. I have calcified left valve, CAD type2 diabetes, bra right foot normalized blood pressure without drugs. Can't tolerate blood pressure or cholesterol meds. Atorvastatin worst drug ever. Ace inhibitors make me to dizzy and tired as well. Just try diet and lots of walking. Heart doc doesn't listen. Now cataracts may be blind in one eye. Why bother to take care of myself. Just keep losing more and more function. Thanks for health information.

  11. Excellent video. very well explained. osmosis was one of the reasons y i understood and passed my medicine paper in 3rd year.

  12. Very great videos from you guys, but i will advice you reduce the speed at which you talk and move, its going to help a lot, we wouldn't have to keep moving back all the time

  13. A new subscriber!
    Slow down the pace a little bit please.
    It’s very hard for people who are studying at midnight for their exams next day 🥵

  14. They said that a right to left shunt would cause concentric hypertrophy and this really confused me because i thought that concentric hypertrophy is usually due to pressure overload… and a shunt would be a volume overload, causing eccentric hypertrophy… would you mind being a pal and helping out a medical student with exams in a few days

  15. The queen of England got all her total idiots and shipped them off to the Americas. Slavery Indian reservations and the rest of all that bullshit. I dont give a fuck who you are .my scale is located in my PRISON so you dont have to make 2 trips.

  16. Thank you for this easy to understand video to cover such a complected topic. Judging by the sheer volume of information in this video I know a lot of time and work went into preparing this 14 minutes video.

  17. I work as a medical assistant at a cardiology clinic and this is by far the most clear and thorough explanation of heart failure I've ever seen/heard! This will help me better explain it to my patients. Thank you guys!

  18. This is a masterpiece thank you thank you thank you thank you thank you !!!! You summarized hundreds of slides in multiple courses in very precise detailed explanation thank you again thank you

  19. I want to let you all know that this is an absolutely extraordinary explanation of congestive heart failure! Thank y'all so much!

  20. Thank you so much!  I needed the visual aid to help me understand what is going on inside me. And THANK YOU for the "crackling" sound effects. I made mention of the sound of gurgling to my cardiologist and he just sat and stared at me and didn't say a word. I felt so stupid and figured it was another one of those things that happens and no one believes you when you tell them about it. But now I know I'm not stupid!  It really is happening and more importantly can be explained! Thank you ever so much for your explanation!

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