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ANATOMY AND PHYSIOLOGY

The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a whole. Structure and Function of the Heart Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allow them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessels are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium.

Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic valve is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. What is the Cardiovascular System? The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drains into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are: Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues. What is the Cardiac Cycle? The cardiac cycle is the sequence of events that occurs in one complete beat of the heart. The pumping phase of the cycle, also known as systole, occurs when heart muscle contracts. The filling phase, which is known as diastole, occurs when heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles are in diastole. During

this time, all the chambers of the heart are relaxed and receive blood. The atrioventricular valves are open. Atrial systole follows this phase. During atrial systole, the left and right atria contract at the same time and push blood into the left and right ventricles, respectively. The next phase is ventricular systole. During ventricular systole, the left and right ventricles contract at the same time and pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the blood to flow into the aorta and pulmonary trunk. Following this phase, Â the ventricles relax that is ventricular diastole occurs. The semilunar valves close to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and the cycle begins again. Components of the Heartbeat The adult heart beats around 70 to 80 times a minute at rest. When you listen to your heart with a stethoscope you can hear your heart beat. The sound is usually described as "lubb-dupp". The "lubb" also known as the first heart sound, is caused by the closure of the atrioventricular valves. The "dupp" sound is due to the closure of the semilunar valves when the ventricles relax (at the beginning of ventricular diastole). Abnormal heart sounds are known as murmurs. Murmurs may indicate a problem with the heart valves, but many types of murmur are no cause for concern. The heart has an inbuilt rhythm of contraction and relaxation. A small group of heart muscle cells called the pacemaker help achieve this. The pacemaker generates an electrical impulse which spreads over the atria, making them contract. This impulse then spreads to the ventricles, causing them to contract. The electrical changes that spread through the heart can be detected at the surface of the body by an instrument called the electrocardiograph. Electrodes are placed in a number of positions over the chest and the electrical changes are recorded on moving graph paper as an electrocardiogram (ECG). Effects of Aging on the Heart in Men and Women As a part of the normal aging process a number of changes occur to the cardiovascular system. Our heart rate slows down because the time between heartbeats increases as we age. This is one of the main reasons why the heart is unable to pump out more blood during exercise when we become old. The amount of blood the heart pumps each minute can change as we age. It decreases slightly in older women. However, it does not change in healthy older men who have no heart disease. The reason for the difference between the sexes is not fully understood. As we age, our blood pressure falls much more on standing from the sitting position compared to when we are younger. This phenomenon is known as postural hypotension. This explains why elderly people are more likely to feel dizzy or to fall when they stand up quickly from a resting position.

LABORATORY DIAGNOSIS
A number of laboratory biomarkers for myocardial injury are available. None is completely sensitive and specific for myocardial infarction, particularly in the hours following onset of symptoms. Timing is important, as are correlation with patient symptoms, electrocardiograms, and angiographic studies. The following biomarkers have been described in association with acute myocardial infarction: 1. Creatine kinase (total) Creatine kinase (CK) is an enzyme present in cardiac and skeletal muscle that is released into the blood when cells are injured. An elevation in total CK means you either have skeletal muscle or cardiac muscle injury (in other words, it’s not specific for MI). This is a easy, cheap, widely-available test. 2. Creatine kinase (MB fraction) CK has three isoenzymes: MM, MB, and BB. CK-MM and CK-MB are both found in cardiac and skeletal muscle, but CK-MB is much more specific for cardiac muscle. CK-BB is found in brain, bowel, and bladder. CK-MB is a very good test for acute myocardial injury. It’s very specific (you don’t see elevations in CKMB in other conditions very often), and it goes up very quickly and dramatically after MI (within 2-8 hours). It returns to normal within 1-3 days, which makes it a good test to use in diagnosing re-infarction. Sometimes the CK total and CK-MB are reported in the form of a “cardiac index”, which is the ratio of total CK to CK-MB. This is a sensitive indicator of early MI. Just to make things more complicated, it turns out there are two isoforms of CK-MB, conveniently called 1 and 2. CK-MB isoform 2 goes up even before the regular old CK-MB does. The results are usually reported as a ratio of isoform 2 to isoform 1; a ratio of 1.5 or more is a great indicator for early MI. However, to detect these isoforms, you have to do electrophoresis (which is a time-intensive test that has to be performed by skilled people), so the results take a while to get back. 3. Troponin I and T Troponins are components of cardiac muscle that are released into the blood when myocardial cells are injured. They are very, very specific for myocardial muscle – even more specific than CK-MB. Troponins go up within 3-12 hours after the onset of MI (though the rise is more gradual than the steep bump you see with CK-MB). They remain elevated for a long time (5-9 days for troponin I and up to a couple weeks for troponin T), which means they’re great for diagnosing MI in the recent past (even up to a couple weeks previous to the test) but not so great for diagnosing re-infarction (unless the first infarction was

over a few weeks ago). Troponin I is more specific than troponin T (which can be elevated rarely in skeletal muscle injury or renal failure). 4. Myoglobin Myoglobin is a protein present in both skeletal and cardiac muscle that is released when cells are damaged. It’s a very sensitive indicator of muscle injury, and it’s also the first marker to go up in a myocardial infarction (even before CK-MB). It’s not specific for cardiac muscle, so you wouldn’t want to do this test as your only marker for ruling in an MI (because if the myoglobin is elevated, you wouldn’t know if it was due to an MI or a skeletal muscle injury). It is a good marker, though, for ruling out an MI (if the myoglobin is not elevated, you can be quite sure your patient hasn’t had an MI). 5. Lactate dehydrogenase Lactate dehydrogenase (LDH) is an enzyme present in many different cells. There are 5 isoenzymes (15), each with different specificities for different types of tissue. In the case of cardiac injury, LDH isoenzyme 1 will go up, and usually you’ll see that isoenzyme 1 is higher than isoenzyme 2 (this is called a “flipped” pattern, because under normal circumstances, isoenzyme 2 is present in greater amounts than isoenzyme 1). The LDH starts going up in 12-24 hours following an MI, and it dissipates within a week or two. This test has been supplanted by the other markers discussed above – but you might still see older texts (or board questions, heaven forbid) that discuss this test as a marker for cardiac injury.