Chapter 4 Cardiovascular System

Questions Alerts!
Common questions in pharmacy exam is to ask!

 What arteries supply blood to eyes? external carotid artery and internal carotid artery.
 Carotid artery supply blood to? Brain
 Pathophysiology of atherosclerosis, plaques leading to ischemia, thrombus, embolus,
aneurism, and edema.
 Electrode potential curve drug that affect on depolarization and repolarization
 ECG or EKG; P wave is atrial depolarization, QRS is ventricular depolarisation,
 QT wave is mechanical contractions of ventricles).
 Investigations: Electrocardiography, and Echocardiography and biological markers.

 
 
Blood flow sequence: Vena cava → right atrium → right ventricle → left pulmonary artery→ LUNGS →
left pulmonary vein → left atrium → left ventricle → aorta → systemic circulation.

Q.) Septal defect: Ventricular septal defect is a hole in the wall separating the two lower chambers of the
heart.

Conduction (automaticity)
There are four pace maker; Natural (main) pacemaker of heart is SA node. Latent pacemaker of heart is
AV node, bundles of His and purkinje fibres.AV node determines heart rate.

                                                

 
Q.) Pulse direction’s SA node → AV node → Bundles His → Purkinje fibres.

 
Depolarization
Q.) Depolarization (inward current):Carrying +ve charge into cell or increased positive charge.
Increase Na+ influx into cell (Na+ is extracellular ion means present outside of cell).
Decrease K+ efflux out to cell (K+ is intracellular ion means present inside of cell).
The increased +ve charge within cell causes potassium channels to open and leads to repolarization.
 
Q.) Repolarization (outward current or hyper polarization). Take +ve charge out of cell.
Increase K+ efflux out to cell
Increase Cl- influx into cell.

Myocardial Action Potential Curve

Myocardial action potential curve reflects action potential, which
describes electrical 
activity of five phases. This occurs in atrial and ventricular
myocytes
and purkinje fibers.

 Phase 0: Rapid depolarization: Na+ enters the cell.

 Phase 1: Early rapid repolarisation: K+ leaves the
cell.
 Phase 2: Plateau: Ca2+ enters the cell.
 Phase 3: Final rapid repolarisation: K+ pumped out of
the cell.
 Phase 4: Slow depolarization: K+ inside the cell and
Na+, Ca2+outside the cell.

 Q.) Phase 1 to starting phase 3 is absolute refractor period or effective refractory period. The cell cannot
respond to any stimuli (NO action potential can be initiated).
During Phase 3 is relative refractory period. The cell ability to respond stimuli increases or cell can
respond to strong stimuli.

Electrocardiograph Wave
Forms
The electrical activity occurred during
depolarization and repolarization transmitted
through electrodes attached to the body and
transformed by an electrocardiograph(ECG) in to
series of waveforms.

 Q.) P wave indicates atrial

depolarization.
  PR interval indicates the spread of the
impulse from the atria through purkinje
fibres (beginning of initial
depolarisation of ventricle).
 Q.) QRS complex indicates ventricular
depolarization.
 ST segment indicates phase 2 of the
action potential the absolute refractory
period.
 T wave shows phase 3 of the action
potential ventricular repolarization.
 Q.) Q-T interval. Mechanical
contraction of the ventricles (Torsade’s
de pointes).
 U wave caused by hypokalemia.

Q.) QT Interval prolongation

 
Q.) QT prolongation is measure of delayed ventricular repolarization and it is polymorphic ventricular
tachycardia. Excessive QT prolongation can predispose myocardium to the development of early after
depolarizations which in turn can trigger re-entrant tachycardia such as Torsades de pointes.

 
Drug-Induced QT Interval prolongation
Medications that cause QT prolongation:
Q.) Macrolide (clarithromycin, erythromycin),
Q.) Fluoroquinolone, (gatifloxacin, gemifloxacin, moxifloxacin, levofloxacin). Ziprasidone, citalopram,
escitalopram, quinidine, procainamide, amiodarone, methadone, ondansetron, domperidone and
amitriptyline.
Class 1 drugs: Quinidine, procainamide, Lidocaine
Class 2 drugs: metoprolol
Class 3 drugs: Amiodarone, dofetilide Sotalol.
 

Cardiovascular Disease
        Thrombus is blood clot.  

 Embolus is moving blood clot.

 Q.) Aneurysm is abnormal dilatation of arteries. Can cause stroke. 
 Stenosis is constriction or narrowing of opening.

Atherosclerosis
Q.) The most common cause of atherosclerosis is due to increased in LDL, which progressively hardens
the arteries and veins. Atherosclerosis is characterized by a build-up in the artery walls. Site of injuries in
arteries results formation of plaques which causes decreased blood flow. Plaques are progressive
accumulation of lipids and inflammatory cells. Sheer stress may result in plaque rupture, collagen
exposure, platelet aggregation, and clot formation.

                                                             
          
Most commonly affected arteries are coronary arteries, carotid arteries and peripheral arteries which can
cause 3 major types of complications;
  Coronary arteries Carotid arteries Peripheral
(cerebrovascular) arteries/veins

Site Heart Brain Thighs, lungs

Diseases Angina, Myocardial infarction or Acute Transient ischemic attack Intermittent

Coronary artery syndrome (STEMI, (TIA)Acute Stroke claudication
NSTEMI). Venous
thromboembolism
Pulmonary embolism

Symptoms Chest pain FAST  

 

Cardiogenic shock
The causes of cardiac shock include acute MI, CHF, valvular dysfunction, arrhythmias (ventricular
fibrillation).
 

Q.) Laplace's Law

Laplace's law describes how tension in the vessel wall increases with trans mural pressure. According to
Laplace’s law, tension is proportional to the radius of a sphere.
 

Inotropic
Inotropic is force of contraction. The ability of the cardiac muscle to develop force at given muscle length.
Positive (+ve) inotropic: Digoxin, ACEI, and dihydropyridine (DHP)-CCB.
Negative (-ve) inotropic: BBs, verapamil, diltiazem.
 

Chronotropic
Chronotropy is heart rate.The number of action potential that occurs per unit time.
Positive (+ve) chronotropic; DHP-CCB
Negative (-ve) chronotropic; Amiodarone, BBs, NDHP-CCBs, digoxin, "(ABCD)".
 

Dromotropic
Autonomic effects on heart rate and conduction velocity.
Positive (+ve) dromotropic: Q.Amitriptyline (AV conduction)
Negative (-ve) dromotropic: Na+& K+ channel blockers.
 

Stroke Volume
The volume of blood ejected from the ventricle on each heartbeat (pulse rate).
 

Ejection Fraction
The fraction of end-diastolic volume ejected in each stroke volume.
Ejection fraction: Stroke volume/end diastolic volume
Normal ejection fraction = 55-70%
Low function = 40-55%
If ejection fraction is <40%likely diagnosis of heart failure with reduced ejection fraction (HFrEF).
If ejection fraction is >40% likely diagnosis of heart failure with preserved (HFpEF) ejection fraction.
 

Cardiac Output
Cardiac output (CO) = Stroke volume x heart rate
Pre-load = Volume of blood fills in ventricles in diastolic state
After load= Force to overcome peripheral resistance.
Example: Vasodilators (hydralazine, nitrates, CCBs), ACEi, ARBs, decrease preload and after load.
 

Cardiovascular Investigations
Q.) Blood pressure: Sphygmomanometer.
Q.) Normal 120/80
Q.) BP is diagnosed in 2 office visits if BP average >140/90 mm Hg, in presence of DM, renal,
atherosclerosis, and cerebrovascular.
Q.) Target blood pressure for diabetic and renal disease is <130/80. If the average SBP/DBP is 140-
159/90-99 mmHg, treatment is recommended in the presence of risk factors smoking, family history,
truncal obesity, sedentary lifestyle, male >55 year-old and female >60-year old.
Biological marker
(Q.) Troponin and Creatine kinase CK-MB)
Q.) Electrocardiogram (ECG or EKG) and measures cardiac rhythms. ECG used for excluding atrial
fibrillation.
Q.) Echocardiogram: Shows the presence of regional valve motion abnormalities, size of heart chambers.
Echocardiogram allows for identification of valvular abnormalities and other MI problems. Blockade in
coronary arteries and veins can be diagnosed by echocardiogram. The presence of regional wall motion
abnormalities with chest pain is suggestive of underlying ischemia.
 

Lymphatic System
Lymphatic system consists of tonsils and adenoid gland, thymus, lymph nodes, spleen, bone marrow and
lymphatic vessels. Functions of lymphatic system includes transports mainly lipid soluble substance.

Lymp Interstitia
Q.) Blood
h l fluid

Plasma
Lots Absent Absent
Proteins

Fatty acids yes yes yes

Hormones yes yes yes

Nutrients yes yes yes

Waste yes yes yes

Erythrocyte
yes No No
s

Platelets yes No No

Has
WBC yes the Least
most

Q.)
Provid
mainly e Mainly
water nutrien lipid
Transports soluble t to soluble  
substance cell & substance
s remov s
e
waste

TIPS
Find answers from the table.

Absolute refractory
1. 2. Repolarization 3. Arrhythmia
period

4. Phase 0 5. Phase 1 to starting phase 3 6. Relative refractory period

7. Phase 3 8. + ve inotropic 9. –ve inotropic

10 12
Digoxin 11. ACEI Dihydropyridine CCBs
. .

13 15
Beta blockers 14. Stroke Brain attack
. .
 16
Cerebral embolism        
.
 

 Absence of rhythm (         )

 Drugs that cause +ve inotropic effect (        )
 Rapid depolarization (         )
 Increase in force of contraction (        )
 The cell cannot respond to any stimuli (         )
 The cell ability to respond stimuli increases or cell can respond to strong stimuli (        )
 Decrease in force of contraction   (        )
 Excessive negative charge in cell occurs(          )

 
Select True/False Statements
 

 A brain attack that occurs when an emboli or some other particle forms in a blood vessel
usually in the heart and flow into in the brain cerebral vessel is cardiogenic cerebral
embolism. True/False
 Drugs that cause –ve chronotropic effect (digoxin, beta blockers) True/False

Stroke or brain attack happens when brain cells die because of inadequate blood flow to the brain
(True/False)