CARDIOVASCULAR SYSTEM & CONDITIONS
HEART
- cone-shaped structure/ inverted pyramid
- small, same size as a closed fist
- Rest: Diaphragm
- Loc: Mediastinum- mass tissue extending from sternum to
vertebral column between 2 lungs
- 2/3 mass oh Heart= (L) body’s midline
- Base: broad portion, Post & Sup to (R)
Apex: pointed end, Ant & Inf to (L)
PERICARDIUM
- fibrous connective sac that encloses the heart
- protects the heart from trauma & infection
- 2 Layers of Pericardium
a) Fibrous Pericardium- outermost layer
- Fxn: It prevents heart from “overstretching” & Anchors
heart from mediastinum
b) Serous Pericardium- innermost layer
b.1) Visceral SP- “Epicardium”, adheres tightly in the heart
b.2) Parietal SP- outermost layer, adheres tightly in fibrous
pericardium
*PERICARDIAL FLUID- ↓friction in the heart, (N): 50mL
- Loc: between Visceral SP & Parietal SP
- ↓PF: (+)pericardial friction rub (pericarditis)
↑PF: “Cardiac Tamponade”
SURFACES of the HEART
1) Anterior Surface- aka Sternocostal Surface, RA & RV (most
ant. surface of heart)
2) Posterior Surface- base surface, RA & LA (most post
surface)
3) Inferior Surface- Diaphragmatic surface, RV & LV (forms
apex of the heart)
HEART CHAMBERS
> 2 Atria- “receiving chambers”; Ant. wall of 2 Atria, they’re
“rough” d/t presence of Pectinate ms
- RA openings: SVC (upper part), IVC (lower part), Coronary
sinus (heart)
- LA openings: 4 pulmonary veins
> Interatrial Septum- oval depression: Fossa Ovalis- remnant
of Foramen Ovale- opening of interatrial septum of a fetal
heart that normally closes p birth
> 2 Ventricles- “pumping chambers”
- Ridges of Cardiac ms fibers: “Trabeculae Carneae”
- Papillary ms: cone shape structure of trabeculae carneae
where chordae tendineae are attached
- Intraventricular Septum: divides (L) & (R) ventricles
HEART VALVES
1) AV Valves- “inlet”, Tricuspid, Bicuspid/Mitral valve
2) SL Valves- “outlet”, Pulmonic, Aortic valve
BLOOD FLOW INSIDE the HEART
> Deoxygenated blood- SVC & IVC (largest vein in the body)-
RA- Tricuspid valve- RV- Pulmonic valve- Pulmonary artery-
Lungs
> Oxygenated blood- Pulmonary veins- LA- Bicuspid valve- LV-
Aortic valve- Aorta- System
*(L) side: ↑pressure, (R) side: ↓pressure
BRANCHES of AORTA
> Ascending Aorta- Arch of Aorta- Brachiocephalic A.-
Common Carotid (External & Internal A.) & Subclavian A.
(Axillary & Vertebral A.)
- External CCA- terminate: TMJ, supply: superficial structures
if skull; Internal CCA- turn into ACA & MCA
- Axillary- Brachial (Radial & Ulnar A.); Vertebral- Basilar- PCA
*No (L) Brachiocephalic A.: (L) CCA & (L) subclavian rises at
Arch of Aorta
> Descending Aorta- Thoracic Aorta- Abdominal Aorta-
Common Iliac A.- External CIA (Femoral- Popliteal- Tibial A.) &
Internal CIA (“hypogastric artery”, supply: pelvis, buttocks &
genitals)
HEART SOUNDS
> S1- LUBB: longer, larger, lower in path, closure of AV valves,
beginning of ventricular systole
> S2- DUBB: shorter, not as loud as S1, closure of SL valves,
beginning of ventricular diastole/relaxation
> S3- rapid filling of ventricles, CHF, Ventricular gallop
> S4- Atrial systole, MI/Hypertension, Atrial gallop
*S1 & S2: stethoscope, S3 &S4: phonocardiogram
CONTROLLING CENTERS of the HEART
1) ANS- sympathetic (↑ctxn), parasympathetic (↓ctxn)
2) Conducting System
a) SA node- aka Sinus node, Primary pacemaker (initiate
depolarization)
- Loc: RA, Sup. septal wall of RA (near opening of SVC)
b) AV node- aka Junctional node, MC site for heart block
- Loc: behind tricuspid valve
c) Bundle of His- loc: interventricular septum
d) Purkinje Fibers- loc: 2 ventricles, largest pacemaker of
heart
CORONARY ARTERY- responsible for blood supply in heart
1) (R) CA- supply: RA, RV (majority), LV (minor), SA node
*MI + RCA= SA node
2) (L) CA- supply LA, LV (majority), RV (minor)
- branches: (L) ant. des. Artery & Circumflex A.= LV
*(L) ADA- ant & apical wall of LV, Circumflex- lat & int wall
- MC coronary artery occluded
*MI + LCA= LV
CARDIAC ACTION POTENTIAL
Phase 0: Depolarization, Inward current of Na+
Phase 1: Initial repo, ↓influx of Na+, Outward current of K+
Phase 2: Plateau, Maintained depo, Inward current of Ca ++
Phase 3: Repo, ↓influx of Ca++, Outward current of K+
Phase 4: RMP, Returns into -85mV
- Skeletal ms: involuntary, sarcoplasmic reticulum= abundant
Ca++ inside
- Cardiac ms: involuntary, SR= fewer Ca++ inside
CARDIAC CYCLE- pumping action Tricuspid 4th Right ICS
- Diastole: ventricular relaxation, Systole: ventricular ctxn AUSCULTATION of the VALVES
> DIASTOLE: I. Period of Rapid Filling of Ventricles Aortic 2nd Right ICS SB
- 1st 3rd of Diastole (75%): Atria to Ventricles (passively) Pulmonic 2 nd
Left ICS SB
Middle 3rd of Diastole: continuous blood flow Mitral 5th Left Midclavicular line
Last 3rd of Diastole (25%): Atria to Ventricles (Atrial Tricuspid 4th Left ICS SB
systole/Atrial kick)
- AV valves open, SL valves close S/Sx of HEART DISEASE:
> SYSTOLE: II. Period of Isovolumic Contraction 1) Chest Pain- “Angina”, (+)Levine sign
- blood is in the ventricles, ↑ventricular pressure - Rfd pain: jaw, neck, upper trapz, chest, Sh, (L)arm= ulnar n.
- AV valves close, SL valves close distribution, C3-T4
III. Period of Ejection - Types of Angina:
- RV: 8mmHg (Pulmonary A.); LV: 80mmHg (Aorta)= a) Chronic Stable Angina- predictable angina, physical
Afterload (ventricular force required to open SL valves) exertion & emotional stress
- 1st 2nd of Ejection (70%): ventricles (pulmonary a. & aorta) - respond to rest & nitrates- MOA: sublingual
Last 2/3 of Ejection (30%): ventricles (pulmonary a. & Max: 3 tablets (if no relief of pain, call 911/EMS)
aorta) Interval: 5mins, Effect: vasodilation
- SL valves open, AV valves close b) Unstable Angina- aka Pre-infarction, Progressive,
IV. Period of Isovolumic Relaxation Crescendo
- blood is in blood vessel, ↓ventricular pressure - does not respond to rest & nitrates
- SL valves close, AV valves close - C/I to exercise; Duration: 20-30mins
c) Prinzmetal Angina- “Variant Angina”, Coronary Angina
HEMODYNAMICS Spasm; F>M
1) Systolic- highest arterial pressure, 120mmHg d) Nocturnal Angina- exertion caused by dreams, CHF
2) Diastolic- lowest arterial pressure, 80mmHg 2) Palpitations- arrhythmias, excessive heart beat
3) Pulse Pressure- difference between SBP & DBP (PP= SBP- 3) Dyspnea- SOB
DBP); (N): 40mmHg 4) Cyanosis- bluish discoloration of lips, toes & nail beds
- average pressure of peripheral pulse 5) Cardiac syncope- “fainting”
4) EDV (End Diastolic Volume)- amount of blood left p 6) Fatigue
diastole, Ventricular relaxation
- (N): 120mL ~Preload- “initial stretching” CARDIAC CONDITIONS
5) ESV (End Diastolic Volume)- amount of blood left p systole, 1) CAD (Coronary Heart Dse)- “Ischemic heart dse”, 2° to
Ventricular ctxn, (N): 50mL- ↑EXV= CHF atherosclerosis affecting the entire coronary artery
6) Stroke Volume- amount of blood pumped by ventricles per - Modified RF: sedentary lifestyle, obesity, cig. smoking,
ctxn, (N): 70mL, SV= EDV-ESV ↑BP, ↑cholesterol *Nicotine- stimulates fibrinogen
7) Cardiac Output- amount of blood pumped by ventricles - Non-modifiable RF: age (>65y/o), M>F (menopause: F=M),
per minute, (N): 4-6L, CO= SVxHR Race (African-American), Family Hx
8) Mean Arterial Pressure (MAP)- arterial pressure c respect *Estrogen- stimulates LDL receptor
to time, MAP= DBP+1/3(PP) 2) M.Infraction- “Coronary Occlusion”
- average pressure of large artery in the body - death of the myocardium
- True M.I= ST segment elev + ↑cardiac enzymes
ECG 3) CHF (Congestive Heart Failure)- “Cardiac Decompensation”
P wave- atrial depolarization - Inability of ventricles to contract effectively
QRS complex- ventricular depolarization - Most serious complication: M.Infarction
T wave- ventricular repolarization - 2 Types: a) (R) sided heart failure- inability of RV to
PQ/PR Interval- beginning of P wave & QRS complex contract effectively, Congestion in periphery & organs
QT Interval- beginning of QRS complex to end of T wave - S/Sx: Bipedal edema, Ascites, Hepatomegaly, Distention of
PR Segment- end of P wave to beginning of T wave Jugular veins, Cyanosis
ST Segment- end of QRS complex to beginning of T wave b) (L) sided heart failure- inability of LV to contract
> Conditions: Prolonged PR Interval- Heart block effectively, Lungs
Wide, bizarre, odd QRS complex- PVC - S/Sx: Pulmonary edema, Cough, Dyspnea/SOB,
ST segment elevation- M.Infarction (more deadlier) Orthopnea, PND (Paroxysmal Nocturnal Dyspnea), Cerebral
ST segment depression- M.Ischemia hypoxia, Fatigue
> Functional Classifications of Patients c Heart Dse
LOCATION of the VALVES Class 1: No limitation of physical act
Aortic 3rd Left ICS Ordinary physical act does not cause: Anginal Sx,
Pulmonic 3rd Left CC Palpitations, Dyspnea, Fatigue
Mitral 4th Left CC Max: 6.5 METs
Class 2: Slight limitation of physical act
Ordinary physical act causes: Anginal Sx, Palpitations,
Dyspnea, Fatigue
Max: 4.5 METs
Class 3: Marked limitation of physical act
Less than ordinary physical act results in: Anginal Sx,
Palpitations, Dyspnea, Fatigue
Max: 3 METs
Class 4: Inability to carry on any physical act s discomfort
(+)Sx of cardiac insuff & anginal pain even at rest
↑discomfort during physical act
Max: 1.5 METs
4) Pericarditis- inflammation of pericardium, 2° to
bacterial/viral agent, ↓pericardial fluid, (+)pericardial friction
- Aggravating factors to mimic chest pain: trunk mvnt (side
to side)
- Relieving factor: kneeling on all 4s or leaning forward
CONGENITAL ANOMALIES
- Hereditary, Shunts do not close, Mother: (+)german measles
1) ASD (Atrial Septal Defect)- interatrial septum defect
- L to R shunt; Acyanosis
2) VSD (Ventricular Septal Defect)- interventricular septum
defect; L to R shunt; Acyanosis
3) Coarctation of Aorta- constriction of proximal & distal
Aorta; ↑BP in UE
4) PDA (Patent Ductus Arteriosus)- Fetus: Ductus Arteriosus-
connects the pulmonary a. to aorta
- Placenta (oxygenated blood): umbilical cord- veins
(deoxygenated blood)- still there’s connection between
pulmonary a. to aorta
- L to R shunt; Acyanosis
5) TOF (Tetralogy of Fallot)- “PARI” Pulmonary artery stenosis,
Overriding of aorta to (R), (R) ventricular hypertrophy/Cor
pulmonale, Interventricular septal defect (VSD)
- True blue baby; R to L shunt
CONDITIONS AFFECTING the HEART VALUES
1) Stenosis- inability of valves to open fully~ ”blood passes c
difficulty”
2) Insufficiency/Regurgitation- inability of valves to close
fully~ “backflow of blood”
3) Prolapse- excessive bulging of cusp valve, 2° weakness of
cusp valve
- MC valve: Mitral valve- if bulged= MVP/Floppy valve syn/
Click murmur syn/Barlowe’s syndrome
LABORATORY EVIDENCE
- ↑SGOT (Serum Glutamic Oxaloacetic Transaminase): 24-
48hrs peak
- ↑CPK (Creatine Phosphokinase): 24hrs peak
- ↑CK-MB (Creatine Kinase-Myocardial Band): 12-24hrs peak
- ↑LDH (Lactate Dehydrogenase): 3-6days peak
DIAGNOSTIC TOOLS
1) Chest X-ray- to asses the size of the heart
2) Echocardiogram- US, movements of heart wall & valves
3) Cardiac Catherization- insertion of catheter via Femoral a.
- injection of dye: Cinefluoroscopy (viewing entire arterial
sys)
4) Thallium Stress Test- Nuclear Stress Test, Treadmill
- injection of radioactive agent at peak of exercise: thallium
- attachment: (N) tissues (c blood supply)
5) Central Line- “Swanz Ganz Catheter”, insertion of catheter
- reassure the pressure inside the heart
SURGICAL INTERVENTION
1) PTCA (Percutaneous Transluminal Coronary Angioplasty)-
insertion of a ballooning tip catheter
2) IV Stent- wire pliable mesh, keep the lumen of BV open
3) CABG (Coronary Artery Bypass Graft)- re-route, BV: Great
saphenous vein, IMA, ITA, Radial artery
CARDIAC REHAB
> Braddom
I. Acute Phase- in-patient; D/C MET: 5 METs
- Goal: to prevent deformities/complications, Family educ.
II. Convalescent/Transitional Phase
- Goal: to promote strong scar formation
- Act: bicycling, walking
- D/C MET: 9 METs
III. Training- out-patient, most vigorous
- Act: stretching, aerobics, plyometrics, calisthenics
IV. Maintenance- most important cardiac rehab
- lifelong routine of Px
> Sullivan
I. In-patient- Goal: monitoring ECG & VS, to prepare the Px for
discharge
Level 1: 1-1.5 METs ( arm support for every meal, bed ex.)
Level 2: 1.5-2 METs (“SLRS” sitting, leg ex, reclining upright
chair, commode privileges)
Level 3: 2-2.5 METs (bathroom priv., room amb for 5mins)
Level 4: 2.5-3 METs (trunk ex, room/hall amb for 5-7mins)
Level 5: 3-4 METs (arm ex, hall amb for 8-10mins)
Level 6: 4-5 METs (progressive amb)
II. Out-patient- actual exercise training program
- intense exercise: THR= 60-80% (HRmax-HRrest) + HRrest
III. Maintenance- endurance training, risk modif. Continue
CRITERIA for TERMINATING EXERCISE
1) Unstable angina
2) Active Pericarditis
3) Resting BP (200/100mmHg)
4) Acute Systemic Illness/Fever
5) Recent embolism
6) Uncontrolled DM & arrythmias
8) 2nd-3rd deg heart block: 1st degree- prolonged PR interval
2nd deg- progressive lengthening of PR interval
3rd deg- (-)QRS complex
9) ST segment displacement ≥2mm
10) ↑DBP: CHF *↑intensity: ↑SBP, ↓intensity: ↓SBP
NOTES
1) SOB, confused, fatigue= early warning signs of MI
2) Post MI + DM (silent ischemia)= ECG
3) Post Mi + CHF + Claudication= walking 10-15mins daily
4) Post MI= resistive training criteria: ≥5 METs, no anginal
pain
5) Post CABG= no heavy ex during the 1st 3mos