THE CARDIOVASCULAR SYSTEM

INTRODUCTION.

The heart is the major component of the cardiovascular system which comprises of the heart,

blood, blood vessels and the lymphatic vessels. The heart is an organ that pumps blood that is

circulated throughout the body through the complex network of blood vessels that comprises of

the arteries and veins. The cardiovascular system supplies oxygen and nutrients to the tissues and

remove waste product of metabolism. It also helps to protect the body, regulate body temperature

and transport of hormone and other chemicals in the body.

ANATOMY OF THE HEART:

The heart is a hollow cone shaped muscular pump that is about the size of a fist located

within the middle mediastinum of thoracic cavity. The inferior surface sits on the central crux

of the diaphragm while the base faces posteriorly and lies immediately anterior to the

oesophagus and posterior to the descending aorta. It is made up of three layers which include

the pericardium, myocardium and endocardium. The pericardium is the outer layer of the

heart which protects the heart and provides sufficient potential space for filling and emptying

of the chambers. The pericardium blends with the adventitia of the aorta, the pulmonary

trunk, superior vena cava and the central tendon of the diaphragm. The pericardium has two

layers which includes the visceral and parietal layers. Both layers are continuous with each

other as they reflect off the major vessels behind and above the heart. The myocardium is the

middle layer of the heart wall. It is composed of muscle fibres which enable heart

contraction. The myocardium of the left ventricle is the thickest as this ventricle is

responsible for generating the power needed to pump oxygenated blood from the heart to the
rest of the body. The Endocardium is a thin membrane which is made of epithelial cells that

lines the inner heart. It provides covers the valves and contains the Purkinje fibres which

convey electrical impulses that cause the heart to contract. These muscles form a four

chambered cavity which are the right and left atria and right and left ventricles with the right

being separated by the left by both inter atrial septum and interventricular septum

respectively.

FIG 1: IMAGE OF THE HEART SHOWING ITS CHAMBERS

ANATOMY OF THE BLOOD VESSELS:

The blood vessels which are made up of arteries and veins are tubular structures which is

composed of three layers- The outer tunica adventitia, the middle tunica media and the inner

tunica intima. The tunica adventitia is composed of fibrous connective tissues while the
 tunica media is made up of smooth muscles. The tunica intima is made up of endothelial

cells. The thickness of the vessels decreases as the vessels divides into smaller diameter with

the capillaries having only one layer as exchange of nutrients, hormones and waste products

of metabolism takes place in the capillaries.

BLOOD:

Blood is the only liquid connective tissue in the body and is composed of formed cells

suspended in the liquid fraction. The formed cells include the red blood cell, white blood cells

and cell fragments called platelets while the liquid fraction is the plasma. The general functions

of blood include transportation (e.g. oxygen, carbon dioxide, nutrients, hormones and waste

product), regulation (eg pH, temperature and osmotic pressure) and protection (e.g. against

foreign molecules and diseases as well as for clotting to prevent excessive loss of blood).

BLOOD VESSELS:

Blood vessels are conduits through which blood flows from the heart to all parts of the body.

These blood vessels include the arteries and the veins. The arteries divide repeatedly into small

caliber with thinner wall from aorta- arteries- arterioles-capillaries while the veins also divide

repeatedly from Inferior vena cava- veins- venules-capillaries. An extraordinary degree of

branching of the blood vessels which exists in human body makes it possible for nearly all cells

in the body lies within a short distance from at least one of the smallest branches of the capillary

system. This enables movement of nutrient and waste product of metabolism between the

surrounding cells and the blood vessels. Nevertheless, blood flow through all the organs of the

body can be considered as passive and occurs only because arterial pressure is kept higher than

venous pressure via the pumping action of the heart.

PHYSIOLOGY/CARDIAC CONDUCTION SYSTEM OF THE HEART

The heart functions by coordinated contraction and relaxation of the chambers of the heart

thereby pumping blood through the blood vessels to the different parts of the body. These orderly

contractions of the atria and ventricles are regulated by the transmission of electrical impulses

that pass through modified cardiac muscle cells interposed within the contractile myocardium.

This intrinsic conducting system is composed of specialized subpopulation of cells that

spontaneously generate electrical activity or preferentially conduct its activity throughout the

heart. Following the initiating activation (or depolarization) within the myocardium, the

electrical excitation spreads throughout the heart in a rapid and highly coordinated fashion. This

system of cells also functions to control the timing of the transfer of activity between the atrial

and ventricular chambers.

Figure 11: Schematic diagram of the conduction pathways of heart impulses

This conducting system composed of the sinoatrial (SA) node, the atrioventricular node (AV),

Bundle of His which has both right and left branches and then the Purkinje fibers. The sinoatrial
(SA) node is located in the right atrium and serves as the natural pacemaker for the heart. These

pacemakers are responsible for generating the cardiac rhythm. The rhythm emanates from the SA

node leading to the atrial depolarization. The signal is therefore transmitted to the AV node.

From the AV node, the signal moves to the Bundle of His and through the right and left bundle

branches to the Purkinje fibres which leads to ventricular depolarization. The conduction

velocities and intrinsic pacemaker rates of various structures within the cardiac conduction

pathway are different. These velocities and pacemaker rates in the order of activation during

normal cardiac contraction beginning with the sinoatrial (SA) node are as follows:

Table 1: Showing the velocities and pacemaker rates.

Normal Structure Conduction Pacemaker

Activation Velocity rate
Sequence (m/sec) (beat/min)

1 SA node <0.01 60-100

2 Atrial 1.0-1.2 None

myocardium

3 AV node 0.02-0.05 40-55

4 Bundle of His 1.2-2.0 25-40

5 Bundle branches 2.0-4.0 25-40

6 Purkinje 2.0-4.0 25-40

network

7 Ventricular 0.3-1.0 None

myocardium

The excitation of the muscles by these pacemakers leads to change from the resting action

potential of the myocytes from approximately -90 mV to a more positive value of approximately

-60 to -70 Mv. This leads to the opening of the sodium (Na +) and calcium (Ca2+) gated channels
for the influx of Na and Ca ions into the cell which leads to contraction of the chambers of the

heart with subsequent opening of the potassium (K +) channel for the diffusion of potassium ion

out of the cell that leads relaxation of the walls of the chambers.

PATHWAYS OF BLOOD FLOW WITHIN THE CARDIOVASCULAR SYSTEM

Blood low in oxygen flows into the heart through the superior and inferior vena cava. The

superior vena cava carries blood from the head, neck, chest and arms while the inferior vena cava

carries blood from the remaining part of the trunk and the legs. Blood from these great veins

flows into the right atrium from where it flows through the right atrioventricular valve into the

right ventricle. From the right ventricle, it enters the pulmonary circuit with the deoxygenated

blood flowing into the right and left pulmonary arteries and their small branches where

oxygenation takes place. The oxygenated blood then flows through the right and left pulmonary

veins into the left atrium. Blood from the left atrium flows into the left ventricle through the

mitral valve into the left ventricle from which blood is circulated to the whole body through the

aorta.
FIGURE III: PATHWAYS OF BLOOD FLOW THROUGH THE HEART

CARDIOVASCULAR DISEASES:

When there is impairment in the normal function of the heart, blood vessels or the blood itself,

cardiovascular disease occurs. Cardiovascular diseases therefore are a class of disease that

involves the heart or blood vessels. Cardiovascular diseases includes coronary artery disease like

angina and myocardial infarction (Heart attack), heart failure, hypertensive heart disease,

rheumatic heart disease, Cardiomyopathy, heart arrhythmia, congenital heart disease, valvular

heart disease, aortic aneurysms, peripheral artery disease, thromboembolic disease and venous

thrombosis. Cardiovascular diseases can be classified as those involving the blood vessels and

those involving the heart. Those involving the blood vessels include the following:

A. Coronary artery disease. This is also known as coronary heart disease or ischemic heart

disease.
 B. Peripheral arterial disease. These include diseases of the blood vessels that supply blood

to the arms and legs.

C. Cerebrovascular disease. Disease of blood vessels that supply blood to the brain e.g

stroke.

D. Renal artery stenosis

E. Aortic aneurysm.

Cardiovascular diseases that involve the heart include:

A. Cardiomyopathy- Diseases of the cardiac muscle

B. Hypertensive heart disease- Diseases of the heart secondary to high blood pressure or

hypertension.

C. Heart failure- A clinical syndrome caused by the inability of the heart to supply sufficient

blood to the tissues to meet their metabolic requirements.

D. Pulmonary heart disease- A failure at the right side of the heart with respiratory system

involvement.

E. Cardiac dysrhythmias- Abnormalities of the heart rhythm.

F. Inflammatory heart disease- This can be Endocarditis which is the inflammation of the

inner layer of the heart or Myocarditis which is the inflammation of the muscular layer of

the heart. It can also be inflammatory cardiomegaly.

G. Valvular heart disease- The disease of the valves of the heart.

H. Congenital heart disease- Heart structural malformations existing at birth.

I. Rheumatic heart disease- Heart muscles and valves damage due to rheumatic fever

caused by Streptococcus pyogenes.

PATHOPHYSIOLOGY OF CARDIOVASCULAR DISEASES (CVDs)

The pathophysiology of cardiovascular diseases varies depending on the disease in question.

Atherosclerosis has been implicated in coronary artery diseases, stroke and peripheral artery

disease and may be caused by high blood pressure, smoking, diabetes, lack of exercise, obesity,

high blood cholesterol, poor diet and excessive alcohol consumption, among others (Shanthi et al

2011). Rheumatic heart disease is usually associated with untreated Streptococcal pharyngitis

(sore throat).

PATHOPHYSIOLOGY OF ATHEROSCLEROSIS:

Atherosclerosis begins in the inner lining of the arteries- the intima. The low density lipoprotein

(LDL) particles leave the blood and enter the arterial intima, where, if LDL levels are increased,

they accumulate and are then modified by enzymes and are oxidized into proinflammatory

particles which promote the reaction of the innate inflammatory systems within the intima. Fat

droplets may accumulate in the cytoplasm of smooth muscle cells. These changes in the arterial

wall occur at the branch points of arteries where adaptive intima thickening occurs in response to

normal hemodynamic stresses. Inflammation begins when the endothelial cells become activated

and secrete adhesion molecules, and the smooth muscle cells secrete chemokines and

chemoattractants, which together draws monocytes, lymphocytes, mast cells and neutrophils into

the arterial wall. Intima smooth muscle cells also secrete into the extracellular matrix

proteoglycans, collagen and elastic fibres. Upon entry, the monocytes transform into

macrophages, takes up lipids as multiple small inclusions, and become foam cells. Increased

accumulation of extracellular lipid coalesces into pools and cause cell necrosis. This

progressively distorts the normal architecture of the intima until it is completely disrupted.
Fibrous tissue is added to form a fibrous cap (atheroma) over the lipid-rich necrotic cores and

just under the endothelium at the blood interface. This forms the fibrous plaque lesions that

develop to become the dominant lesion (Li J (2012); Stary.H (2003); Burke. AP et al( 2001);

Virmani. R (2000).

PATHOPHYSIOLOGY OF CARDIOMYOPATHIES:

DILATED CARDIOMYOPATHY:

Dilated Cardiomyopathy is characterized by dilated and poorly functioning left or both

ventricles. It is associated with both systolic and diastolic dysfunction which leads to an increase

in end diastolic and end systolic volumes. Dilated Cardiomyopathy can be diagnoses in

association with recognized cardiovascular disease; however, to qualify as DCM, the extent of

myocardial dysfunction cannot be explained exclusively by abnormal loading (hypertension or

valve disease) or ischemic heart disease (Jefferies JL, Towbin JA, 2010; Rosamond et al, 2008).

Signs and symptoms of cardiovascular diseases include chest pain that irradiate to the left arm,

shortness of breath, sweating and nausea.

There are so many factors that predispose someone to having cardiovascular disease. These risk

factors include smoking, high blood pressure (hypertension), high cholesterol, diabetes, history

of heart problem especially heart attack and strokes and obesity.

Diagnosis of cardiovascular disease: Diseases of the heart can be diagnosed by the following

methods

1. History taking by health professional

2. Electrocardiogram (ECG)
3. Echocardiography

4. Nuclear imaging

5. Cardiac catheterization.