Anatomy of CVS

2. The Heart
DR. MOHAMAD BAKER ABU-SNAINA
GENERAL SURGEON
 Cardiovascular System
• The heart & circulatory system
make up cardiovascular system.
• The heart works as a pump that
pushes blood to the organs, tissues
& cells.
• Blood delivers oxygen & nutrients to
every cell & removes the CO2 &
waste products made by those cells.
• Blood is carried from the heart to
the rest of the body through
arteries, arterioles & capillaries & is
returned to the heart through
venules & veins.
 The Heart
• The heart is a hollow muscular
organ.
• Weighs between 250-400g.
• By the end of a long life, a person's
heart may have beat more than 3.5
billion times.
• In fact, each day, the average heart
beats 100,000 times, pumping about
2,000 gallons (7,571 liters) of blood.
• If all our the vessels were laid end to
end, they would extend for about
96,500 km, which is enough to
circle our planet more than twice!
 The Heart
 Size: a little larger than the size of
your fist.
 Shape: somewhat pyramid shaped.
 Location:
• Within the pericardium in the
mediastinum between the lungs.
• Behind the sternum; (2/3 of heart
lies to the left of midsternal line).
• Anterior to vertebral column.
• Above the diaphragm.
• Connected at its base to the great
blood vessels but otherwise lies free
within the pericardium.
 Surfaces of the Heart
The sternocostal (anterior) surface
• Formed mainly by: the right atrium &
the right ventricle, which are
separated from each other by the
vertical atrioventricular groove
• The right border is formed by the
right atrium.
• The left border by the left ventricle &
part of the left auricle.
• The right ventricle is separated from
the left ventricle by the anterior
interventricular groove.
 Surfaces of the Heart
The diaphragmatic (inferior)
surface
• Formed mainly by the right &
left ventricles separated by the
posterior interventricular
groove.
• The inferior surface of the right
atrium, into which the inferior
vena cava opens, also forms
part of this surface.
 Surfaces of the Heart
The base of the heart, or the
posterior surface
• Formed mainly by the left
atrium, into which open the
four pulmonary veins.
• The base of the heart lies
opposite the apex.
 Apex & Base of the Heart
 The apex of the heart, formed
by the left ventricle.
• It is directed downward,
forward & to the left.
• It lies at the level of the 5th left
intercostal space (9 cm) from the
midline.
 The base of the heart lies
opposite the apex.
• The heart does not rest on its
base; it rests on its
diaphragmatic (inferior) surface.
 Borders of the Heart
• The right border is formed by the
right atrium. extends from a point
on 3rd right costal cartilage (1.3 cm)
from the edge of the sternum
downward to a point on the 6th
right costal cartilage (1.3 cm) from
the edge of the sternum .
• The left border by the left auricle
& below by the left ventricle.
extends from 2nd left costal
cartilage (1.3 cm) from the edge of
the sternum to the apex beat of
the heart .
 Borders of the Heart
• The lower border is formed mainly
by the right ventricle & the right
atrium & the apical part of the left
ventricle, extends from 6th right
costal cartilage (1.3 cm) from the
sternum to the apex beat.
• The apex is formed by the left
ventricle, 5th left intercostal space
(9 cm) from the midline
• The superior border, formed by
the roots of the great blood
vessels, extends from 2nd left costal
cartilage.
 Structure of the Heart
• The walls of the heart consist of:
 Epicardium is the serous pericardium
covers the heart externally.
 Myocardium the cardiac muscle.
 Endocardium a layer of endothelium
that lines internally.
• Specialized electrical conduction
system is located within myocardium:
 Sinoatrial SA node.
 Atrioventricular AV node.
 The bundle of HIS
 Purkinje fibers.
 Structure of the Heart
• The heart is divided by vertical
septa into four chambers:
 The right & left atria.
 The right & left ventricles.
 The atrial portion of the heart
has relatively thin walls.
• It is divided by the atrial
(interatrial) septum into the right
& left atria.
• The septum runs from the
anterior wall of the heart
backward & to the right.
 Structure of the Heart
 The ventricular portion of the heart
has thick walls.
• It is divided by the ventricular
(interventricular) septum into the
right & left ventricles.
• The septum is placed obliquely, with
one surface facing forward & to the
right & the other facing backward &
to the left.
• Its position is indicated on the
surface of the heart by the anterior
& posterior interventricular
grooves.
 Structure of the Heart
• The lower part of the
interventricular septum is thick &
formed of muscle.
• The smaller upper part of the
septum is thin & membranous & is
attached to the fibrous skeleton of
the heart.
 Skeleton of the heart consists of a
fibrous rings that surround the
atrioventricular, pulmonary &
aortic orifices & are continuous
with the membranous upper part
of the ventricular septum.
 Right Atrium
• The right atrium consists of:
 Main cavity.
 Auricle, small outpouching.
• The junction between the right
atrium & the right auricle is:
 On the outside of the heart by a
vertical groove, the sulcus
terminalis.
 On the inside is by a ridge, the
crista terminalis.
 Right Atrium
• The main part of the atrium that
lies posterior to the ridge is
smooth walled & is derived
embryologically from the sinus
venosus.
• The part of the atrium in front of
the ridge is roughened or
trabeculated by bundles of muscle
fibers, the musculi pectinati, which
run from the crista terminalis to
the auricle.
• This anterior part is derived
embryologically from the primitive
atrium.
 Openings into the Right Atrium
 The superior vena cava opens into the
upper part of the right atrium.
• Returns the blood from the upper 1/2
of the body. it has no valve
 The inferior vena cava opens into the
lower part of the right atrium.
• Returns blood from the lower ½ of the
body, has a nonfunctioning valve.
 The coronary sinus, drains most of the
blood from the heart wall.
• Guarded by a nonfunctioning valve.
 The Right atrioventricular orifice is
guarded by the tricuspid valve.
 Many small orifices of small veins drain
the heart wall, open directly into the RA.
 Fetal Remnants in Right Atrium
 The rudimentary valve of the IVC.
 The fossa ovalis is a shallow
depression, which is the site of the
foramen ovale in the fetus.
 The anulus ovalis forms the upper
margin of the fossa.
• The floor of the fossa represents the
persistent septum primum of the
heart of the embryo & the anulus is
formed from the lower edge of the
septum secundum.
• These structures lie on the atrial
septum, which separates the right
atrium from the left atrium.
 Right Ventricle
• It forms the greater part of the
anterior surface of the heart, lies
anterior to the left ventricle.
• Right Ventricle communicates with:
 The right atrium through the
atrioventricular orifice, guarded by
the tricuspid valve.
 The pulmonary trunk through the
pulmonary orifice, guarded by the
pulmonary valve.
 as the cavity approaches the
pulmonary orifice it becomes funnel
shaped, at which point it is referred
to as the infundibulum.
 Right Ventricle
• The walls of the right ventricle are
much thicker than those of the right
atrium & show several internal
projecting ridges formed of muscle
bundles give the ventricular wall a
spongelike appearance & are known
as trabeculae carneae.
• They are three types:
 The 1st type (The papillary muscles)
attached by their bases to the
ventricular wall & their apices are
connected by fibrous chords (the
chordae tendineae) to the cusps of
the tricuspid valve.
 Right Ventricle
 The second type are attached at
the ends to the ventricular wall,
being free in the middle.
• One of these, the moderator band,
crosses the ventricular cavity from
the septal to the anterior wall.
• It conveys the right branch of the
atrioventricular bundle, which is
part of the conducting system of
the heart.
 The third type is simply composed
of prominent ridges.
 The Tricuspid Valve
• Guards right atrioventricular orifice
• Consists of three cusps formed by
a fold of endocardium:
 Anterior cusp lies anteriorly.
 Septal cusp lies against the
ventricular septum.
 Inferior (posterior) cusp lies inferiorly
• The cusps are attached by their bases
to the fibrous ring of the skeleton of
the heart.
• Their free edges are attached to the
chordae tendineae which connect
the cusps to the papillary muscles.
 The Pulmonary Valve
• It guards the pulmonary orifice.
• Consists of three semilunar cusps
formed by folds of endocardium.
• The open mouths of the cusps are
directed upward into the
pulmonary trunk.
• The curved lower margins & sides
of each cusp are attached to the
arterial wall.
• No chordae or papillary muscles
are associated with these valve
cusps.
 The Pulmonary Valve
• The attachments of the sides of
the cusps to the arterial wall
prevent the cusps from prolapsing
into the ventricle.
• At the root of the pulmonary trunk
are three dilatations called the
sinuses & one is situated external
to each cusp.
• The three semilunar cusps are
arranged with one posterior (left
cusp) & two anterior (anterior &
right cusps).
•
The Pulmonary
The cusps of the pulmonary & aortic
Valve
valves are named according to their
position in the fetus before the heart
has rotated to the left.
• This, unfortunately, causes a great deal
of unnecessary confusion.)
• During ventricular systole, the cusps of
the valve are pressed against the wall
of the pulmonary trunk by the out-
rushing blood.
• During diastole, blood flows back
toward the heart & enters the sinuses;
the valve cusps fill, come into
apposition in the center of the lumen &
close the pulmonary orifice.
 Left Atrium
• Similar to the right atrium, the
left atrium consists of a main
cavity & a left auricle.
• The left atrium is situated behind
the right atrium & forms the
greater part of the base or the
posterior surface of the heart.
• Behind it lies the oblique sinus of
the serous pericardium & the
fibrous pericardium separates it
from the esophagus.
 Left Atrium
• The interior of the left atrium is
smooth, but the left auricle
possesses muscular ridges as in
the right auricle.
• Openings into the Left Atrium
 The four pulmonary veins, two
from each lung, open through
the posterior wall & have no
valves.
 The left atrioventricular orifice
is guarded by the mitral valve.
 Left Ventricle
• Situated largely behind the right
ventricle, small portion projects to
the left & forms the left margin of
the heart & the heart apex.
• It communicates with:
 The left atrium through the
atrioventricular orifice, guarded by
mitral valve.
 The aorta through the aortic orifice
guarded by aortic valve.
• The walls of the left ventricle are
three times thicker than those of
the right ventricle.
 Left Ventricle
• The left intraventricular blood
pressure is six times higher than that
inside the right ventricle.
• In cross section: the left ventricle is
circular & the right is crescentic.
 because of the bulging of the
ventricular septum into the cavity of
the right ventricle.
• There are well-developed trabeculae
carneae, two large papillary muscles,
but no moderator band.
• The part of the ventricle below the
aortic orifice is called the aortic
vestibule.
 The mitral valve
• It guards the atrioventricular orifice.
• It consists of two cusps, one
anterior & one posterior, which
have a structure similar to that of
the cusps of the tricuspid valve.
• The anterior cusp is the larger &
intervenes between the
atrioventricular & the aortic
orifices.
• The attachment of the chordae
tendineae to the cusps & the
papillary muscles is similar to that
of the tricuspid valve.
 Aortic Valve
• It guards the aortic orifice & is
similar in structure to the
pulmonary valve.
• One cusp is situated on the
anterior wall (right cusp) & two
are located on the posterior wall
(left and posterior cusps).
• Behind each cusp the aortic wall
bulges to form an aortic sinus.
 The anterior aortic sinus gives
origin to the right coronary
artery.
 The left posterior sinus gives
origin to the left coronary artery.
 Surface Anatomy of the Heart Valves
 The tricuspid valve lies behind the
right half of the sternum opposite
the fourth intercostal space.
 The mitral valve lies behind the left
half of the sternum opposite the
fourth costal cartilage.
 The pulmonary valve lies behind
the medial end of the third left
costal cartilage and the adjoining
part of the sternum.
 The aortic valve lies behind the left
half of the sternum opposite the
third intercostal space.
 Auscultation of the Heart Valves
• Two sounds: lub-dup.
 The first sound is produced by the contraction of the
ventricles & the closure of the tricuspid & mitral valves.
 The second sound is produced by the sharp closure of the
aortic & pulmonary valves.
• It is important for a physician to know where to place the
stethoscope on the chest wall to hear sounds produced at
each valve with the minimum of distraction or interference.
 Tricuspid valve -right ½ of lower end of the body of sternum.
 The mitral valve - over the apex beat, that is, at the level of
the fifth left intercostal space.
 The pulmonary valve is heard with least interference over the
medial end of the second left intercostal space .
 The aortic valve is best heard over the medial end of the
second right intercostal space.
 Valvular Disease of the Heart
• Inflammation of a valve can cause
the edges of the valve cusps to stick
together.
• Later, fibrous thickening occurs,
followed by loss of flexibility &
shrinkage.
• Narrowing (stenosis) & valvular
incompetence (regurgitation) result
& the heart ceases to function as
an efficient pump.
 Valvular Heart Murmurs
• Turbulence & vibrations that are
heard as heart murmurs.
 Conducting System of the Heart
• The heart contracts rhythmically at 70-
90 beats/minute in the resting adult.
• The contractile process originates
spontaneously in the conducting
system.
• The atria contract first & together
followed later by the contractions of
both ventricles together.
• The slight delay in the passage of the
impulse from the atria to the ventricles
allows time for the atria to empty their
blood into the ventricles before the
ventricles contract.
 Conducting System of the Heart
• The conducting system of the heart
consists of specialized cardiac
muscle present in:
 The sinuatrial node, (SA node).
 The atrioventricular node (AV node).
 The atrioventricular bundle & its
right & left terminal branches.
 The subendocardial plexus of
Purkinje fibers (specialized cardiac
muscle fibers that form the
conducting system of the heart).
 Sinuatrial Node
• Located in the wall of the right
atrium in the upper part of the
sulcus terminalis just to the right of
the opening of the superior vena
cava.
• The node spontaneously gives
origin to rhythmic electrical
impulses that spread in all
directions through the cardiac
muscle of the atria & cause the
muscle to contract.
 Atrioventricular Node
• The AV is strategically placed on the
lower part of the atrial septum just
above the attachment of the septal
cusp of the tricuspid valve.
• From it, the cardiac impulse is
conducted to the ventricles by the
atrioventricular bundle.
• Stimulated by the excitation wave as it
passes through the atrial myocardium.
AV node is an electrical
• The speed of conduction of cardiac relay station between
impulse through the AV node(0.11 sec) the atria & ventricles
allows sufficient time for the atria to
empty their blood into the ventricles
before the ventricles start to contract.
 Atrioventricular Bundle
• AV bundle (bundle of His) is the only
pathway of cardiac muscle that
connects the myocardium of the
atria & the ventricles.
• It is the only route traveling cardiac
impulse from the atria to ventricles.
• The bundle descends through the
fibrous skeleton of the heart.
• It descends behind the septal cusp
of the tricuspid valve to reach the
inferior border of the membranous
part of the ventricular septum.
• At the upper border of the muscular
part of the septum it divides into 2
branches, one for each ventricle.
 Atrioventricular Bundle
• The right bundle branch (RBB) passes
down on the right side of the
ventricular septum to reach the
moderator band, where it crosses to
the anterior wall of the right ventricle
& becomes continuous with the fibers
of the Purkinje plexus.
• The left bundle branch (LBB) pierces
the septum & passes down on its left
side beneath the endocardium.
usually divides into two branches
(anterior & posterior), which become
continuous with the fibers of the
Purkinje plexus of the left ventricle.
 The Purkinje fibers
• Purkinje tissue or subendocardial
branches: are specialized
conducting fibers composed of
electrically excitable cells
• Located in the inner ventricular
walls just beneath the
endocardium in a space called the
subendocardium.
• Impulse reach through Bundle of
His & branches into smaller
elements & form terminal ends
that borrow into the right & left
ventricular muscle.
 Internodal Conduction Paths
• Impulses from the sinuatrial
node have been shown to travel
to the atrioventricular node
more rapidly than they can travel
by passing along the ordinary
myocardium.
• This phenomenon has been
explained by the description of
special pathways in the atrial
wall which have a structure
consisting of a mixture of
Purkinje fibers & ordinary cardiac
muscle cells.
 Internodal Conduction Paths
 The anterior internodal pathway
leaves the anterior end of SA node &
passes anterior to SVC opening.
• It descends on the atrial septum &
ends in the atrioventricular node.
 The middle internodal pathway
leaves the posterior end of SA node
& passes posterior to SVC opening.
• It descends on the atrial septum to
the atrioventricular node.
 The posterior internodal pathway
leaves the posterior part of SA node
& descends through crista terminalis
& the valve of IVC to the AV node.
Failure of the Conduction System of the Heart
• SA node is the spontaneous source of cardiac impulse.
• The AV node is responsible for picking up the cardiac
impulse from the atria.
• The AV bundle is the only route by which the cardiac
impulse can spread from the atria to the ventricles.
• Failure of the bundle to conduct the normal impulses
results in alteration in the rhythmic contraction of the
ventricles (arrhythmias) or, if complete bundle block
occurs, complete dissociation between the atria &
ventricular rates of contraction.
• The common cause of defective conduction through the
bundle or its branches is atherosclerosis of the coronary
arteries, which results in a diminished blood supply to the
conducting system.
 Commotio cordis
• Commotio cordis is an often lethal disruption of heart
rhythm that occurs as a result of a blow to the area
directly over the heart at a critical time during the cycle
of a heart beat causing cardiac arrest.
• It is a form of ventricular fibrillation (V-Fib), not
mechanical damage to the heart muscle or surrounding
organs & not the result of heart disease.
• The fatality rate is about 65% even with prompt CPR &
defibrillation, & more than 80% without.
• Commotio cordis occurs mostly in boys & young men,
usually during sports, most frequently baseball, but can
also caused by the blow of an elbow or other body part.
• Being less developed, the thorax of an adolescent is likely
more prone to this injury given the circumstances.
 Arterial Supply of the Heart
• The arterial supply of the heart is
provided by:
 The right coronary artery.
 The Left coronary artery.
• Both arise from the ascending
aorta immediately above the
aortic valve.
• The coronary arteries & their
major branches are distributed
over the surface of the heart,
lying within subepicardial
connective tissue.
 Right coronary artery (RCA)
• Arises from the anterior aortic sinus of
the ascending aorta.
• Runs forward between the pulmonary
trunk & the right auricle.
• It descends almost vertically in the right
atrioventricular groove & at the inferior
border of the heart it continues
posteriorly along the atrioventricular
groove to anastomose with the left
coronary artery in the posterior
interventricular groove.
• Its branches supply the right atrium &
right ventricle & parts of left atrium &
left ventricle & atrioventricular septum.
 Branches of RCA
 The right conus artery supplies
the anterior surface of the
pulmonary conus (infundibulum
of the right ventricle) & the upper
part of the anterior wall of the
right ventricle.
 The anterior ventricular branches
are 2 or 3 in number & supply the
anterior surface of the right
ventricle.
 The marginal branch is the largest
& runs along the lower margin of
the costal surface to reach the
apex.
 Branches of RCA
 The posterior ventricular branches
usually two in number & supply
the diaphragmatic surface of the
right ventricle.
 The atrial branches supply the
anterior & lateral surfaces of the
right atrium.
• One branch supplies the posterior
surface of both right & left atria.
• The artery of the SA node supplies
the node & the right & left atria, in
35% of individuals it arises from
the left coronary artery.
 Branches of RCA
 The posterior interventricular
(descending) artery runs toward the
apex in the posterior groove.
• It gives off branches to right & left
ventricles, including its inferior wall.
• It supplies branches to the posterior
part of the ventricular septum but
not to the apical part, which receives
its supply from the anterior
interventricular branch of the LCA.
• Large septal branch supplies AV node
• In 10% of individuals the posterior
interventricular artery is replaced by
a branch from the LCA.
 Left coronary artery (LCA)
• It is usually larger than the RCA.
• Supplies the major part of the
heart, including the greater part of
the left atrium, left ventricle, and
ventricular septum.
• It arises from the left posterior
aortic sinus of the ascending aorta.
• Passes forward between the
pulmonary trunk & the left auricle
• It then enters the atrioventricular
groove & divides into:
 Anterior interventricular branch.
 Circumflex branch.
Anterior interventricular (descending) branch
• It runs downward in the anterior interventricular groove
to the apex of the heart.
• In most individuals it then passes around the apex of the
heart to enter the posterior interventricular groove &
anastomoses with the terminal branches of the RCA.
• In 1/3 of individuals it ends at the apex of the heart.
• The anterior interventricular branch supplies the right &
left ventricles with numerous branches that also supply
the anterior part of the ventricular septum.
• One of these ventricular branches (left diagonal artery)
may arise directly from the trunk of the LCA.
• A small left conus artery supplies the pulmonary conus.
 The circumflex artery
• It is the same size as the anterior
interventricular artery.
• It winds around the left margin of
the heart in atrioventricular
groove.
• Left marginal artery is large
branch that supplies the left
margin of the left ventricle down
to the apex.
• Anterior & posterior ventricular
branches supply the left ventricle.
• Atrial branches supply the left
atrium.
Variations in the Coronary Arteries
• The most common variations affect
blood supply to the diaphragmatic
surface of both ventricles.
• Here the origin, size & distribution
of the posterior interventricular
artery are variable.
• In right dominance, the posterior
interventricular artery is a large
branch of the right coronary artery,
present in most individuals (90%).
• In left dominance, the posterior
interventricular artery is a branch
of the circumflex branch of the left
coronary artery (10%).
 Coronary Artery Anastomoses
• Anastomoses exist between the
terminal branches of the RCA & LCA
(collateral circulation).
• But they are usually not large
enough to provide an adequate
blood supply to the cardiac muscle
when one of the large branches
become blocked by disease.
• A sudden block of one of the larger
branches of either coronary artery
usually leads to myocardial death
(myocardial infarction), sometimes
collateral circulation is enough to
sustain the muscle.
Summary of the Overall Arterial Supply to
the Heart in Most Individuals
 The right coronary artery supplies all of the right
ventricle (except for the small area to the right of the
anterior interventricular groove), the variable part of the
diaphragmatic surface of the left ventricle, the
posteroinferior third of the ventricular septum, the right
atrium & part of the left atrium, & the SA node & the AV
node & bundle. The LBB also receives small branches.
 The left coronary artery supplies most of the left
ventricle, a small area of the right ventricle to the right of
the interventricular groove, the anterior 2/3 of the
ventricular septum, most of the left atrium, the RBB &
the LBB.
Arterial Supply to the Conducting System
• The sinuatrial node is usually
supplied by the right but
sometimes by the left coronary
artery.
• The atrioventricular node & the
atrioventricular bundle are
supplied by the right coronary
artery.
• The RBB of the atrioventricular
bundle is supplied by the left
coronary artery.
• The LBB is supplied by the right &
left coronary arteries.
 Venous Drainage of the Heart
• Most blood from the heart wall
drains into the right atrium through
the coronary sinus, which lies in the
posterior part of the atrioventricular
groove & is a continuation of the
great cardiac vein.
• It opens into the right atrium to the
left of the inferior vena cava.
• The small & middle cardiac veins are
tributaries of the coronary sinus.
• The remainder of blood is returned
to the right atrium by the anterior
cardiac vein & by small veins that
open directly into heart chambers.
 Coronary Artery Disease
• A sudden block of one of the large branches of either
coronary artery will usually lead to necrosis of the cardiac
muscle (myocardial infarction) in that vascular area
• Most cases are caused by an acute thrombosis on top of a
chronic atherosclerotic narrowing of the lumen.
• Arteriosclerotic disease present in three ways, depending
on the rate of narrowing of the lumina of the arteries:
 General degeneration & fibrosis of the myocardium occur
over years with gradual narrowing of the coronary arteries.
 Angina pectoris is cardiac pain that occurs on exertion & is
relieved by rest.
 Myocardial infarction: coronary flow is suddenly reduced or
stopped & the cardiac muscle undergoes necrosis. It is the
major cause of death in industrialized nations.
 Nerve Supply of the Heart
• Sympathetic & parasympathetic fibers
reach the heart via cardiac plexuses
situated below the arch of aorta
 The sympathetic supply arises from
the cervical & upper thoracic portions
of the sympathetic trunks.
• The postganglionic sympathetic fibers
terminate on the SA & AV nodes,
cardiac muscle fibers & on the
coronary arteries.
• Activation of these nerves results in
cardiac acceleration, increased force
of contraction of the cardiac muscle &
dilatation of the coronary arteries.
 Nerve Supply of the Heart
 The parasympathetic supply from the vagus nerves.
• The postganglionic parasympathetic fibers terminate on the
SA & AV nodes & on the coronary arteries.
• Activation of the parasympathetic nerves results in a
reduction in the rate & force of contraction of the heart & a
constriction of the coronary arteries.
• Afferent fibers running with the sympathetic nerves carry
nervous impulses that normally do not reach consciousness.
• When the blood supply to myocardium become impaired
pain impulses reach consciousness via this pathway.
• Afferent fibers running with the vagus nerves take part in
cardiovascular reflexes.
 Cardiac Pain
• Pain originating in the heart as the result of acute
myocardial ischemia is assumed to be caused by oxygen
deficiency & the accumulation of metabolites, which
stimulate the sensory nerve endings in the myocardium.
• The afferent nerve fibers ascend to the CNS through the
cardiac branches of the sympathetic trunk & enter the
spinal cord through the posterior roots of the upper four
thoracic nerves.
• The nature of the pain varies from a severe crushing pain
to nothing more than a mild discomfort.
• The pain is not felt in the heart, but is referred to the skin
areas supplied by the corresponding spinal nerves.
 Cardiac Pain
• Pain is felt in medial side of the arm, sometimes felt in
the neck & the jaw.
• Myocardial infarction involving the inferior wall of the
heart often gives rise to discomfort in the epigastrium.
• One must assume that the afferent pain fibers from the
heart ascend in the sympathetic nerves and enter the
spinal cord in the posterior roots of the T7, T8, & T9
spinal nerves & give rise to referred pain in the T7, T8, &
T9 thoracic dermatomes in the epigastrium.
• Because the heart & the thoracic part of the esophagus
probably have similar afferent pain pathways, painful
acute esophagitis can mimic the pain of myocardial
infarction.