Cardiovascular Physiology: For HO Students

Cardiovascular Physiology
For HO Students
By Zerihun S.
2022
Physiology of Heart 1
Brief contents
• Introduction to circulation
• Cardiac physiology
– Regions of the haert
– Pericardium
– Heart wall
– Chambers and valves
– Flow of blood through heart
– Innervation of heart
– Coronary circulation
– Electrical activity of heart
– Cardiac cycle
– Electrocardiogram (ECG)
– Cardiac arrhythimia
– Heart sounds
Objectives
At the end of this chapter, you will be able to:
• Describe the size, shape, and location of the heart
• Identify and describe the interior and exterior parts of the
human heart
• Describe the path of blood through the cardiac circuits
• Explain the autorhytmicity of heart
• Explain the cardiac conduction system
• Describe the process and purpose of an electrocardiogram
• Explain the cardiac cycle
• Calculate cardiac output
• Name the centers of the brain that control heart rate and
describe their function
• Identify other factors affecting heart rate
Introduction
Cardiovascular system consists of
• Heart
– Central pumping organ
• By contracting, generates the pressure to drive blood
through a series of blood vessels
• Blood vessels
– Carry blood to and from the heart
• Arteries
– Carry blood from the heart to the tissues
– Are under high pressure
– Contain a relatively small percentage of blood volume
Introduction….
• Veins
– Carry blood from the tissues back to the heart
– Are under low pressure
– Contain the largest percentage of the blood volume
• Capillaries
– Are found within the tissues
– Are thin-walled blood vessels
– Are interposed between the arteries and veins
– Are sites of exchange of nutrients, wastes, and fluid between
blood and tissues
Introduction….
• The functions of CVS

– Deliver blood to the tissues,
• Providing essential nutrients to the cells for metabolism
• Removing waste products from the cells
– Regulation of arterial blood pressure
– Delivers regulatory hormones from the endocrine
glands to their sites of action in target tissues
– Regulation of body temperature
– Homeostatic adjustments to altered physiologic
states such as
• hemorrhage,
• exercise,
• changes in posture
Two major divisions of CVS
• Pulmonary circuit
– Carries blood to the lungs for gas
exchange and then returns it to
the heart
• Systemic circuit
– Supplies blood to every organ of
the body system
Part One
Physiology of the Heart
Location, portions and size of heart
• Located in the thoracic cavity in the mediastinum

• About 2/3 of it lies to the left of the median plane
• The broad superior portion of the heart - base
– Is the point of attachment for the great vessels
• Its inferior end - apex
– Tilts to the left and tapers to a blunt point
• Roughly the size of a fist
• It weighs about 300 g
11
Physiology of Heart
Pericardium
A double-walled sac that encloses the heart
• Parietal pericardium (pericardial sac) consists of
– a tough fibrous layer of dense irregular connective tissue
– a thin, smooth serous layer
• Visceral pericardium
– Covers the heart surface
• Pericardial cavity – a potential space between the parietal and
visceral membranes
– It contains 5 - 30 mL of pericardial fluid
• An exudates of the serous pericardium that lubricates the
membranes
• Allows the heart to beat almost without friction
Read Pericarditis ???
Pericardium…
Heart Wall
Three layers
• Epicardium ( visceral pericardium)
– Is a serous membrane
– Composed of a simple squamous epithelium
• Myocardium
– Is the thickest layer
– Composed of cardiac muscle
– Performs the work of the heart
• Endocardium
– Consists of a simple squamous endothelium
– It forms the smooth inner lining of the chambers & valves
– It is continuous with the endothelium of the blood vessels
Heart Chambers & Valves
Four chambers of Human Heart

• Right and left atria
• Right and left ventricles
– Atria
• Have thin flaccid walls
• Light workload
– Ventricles
• Have thicker wall than atria
• Strong workload
Chambers & Valves…
• Four valves:
– Atrioventricular (AV) valves (tricuspid & mitral)
– Semilunar valves (aortic & pulmonary)
• Valves prevent backflow of blood
Papillary Muscles & Chordae Tendineae
Papillary Muscles
• Finger like extensions from the walls of ventricles
• Contract when the ventricular walls contract to cause the closing
of the A-V valves
• They pull the vanes of the valves inward toward the ventricles to
prevent their bulging too far backward toward the atria during
ventricular contraction
Chordae Tendineae
• Strings that attach the papillary muscles to the vanes (cusps) of
the AV valves
Flow of blood through the heart
Innervation of Heart
• Sympathetic
– Sympathetic postganglionic fibers release primarily NEN
– The receptors for NEN on cardiac muscle are mainly beta-adrenergic
receptor
– The hormone EN, from the adrenal medulla, combines with the same
receptors as NEN and exerts the same actions on the heart
– Innervate almost all parts of heart
• Parasympathetic (vagus nerves)
– Parasympathetics postganglionic fibers release primarily Ach
– The receptors for Ach are of the muscarinic type
– Mainly innervate
• SA node
• Atria
• AV node
– Almost no Ventricular innervations (Vagal escape)
Sympathetic and Parasympathetic effects
Sympathetic stimulation
–  HR (+ve chronotropic effect)
–  force of contraction (+ve Inotropic
effect)
– conduction of APs (+ve
dromotropic effect)
Parasympathetic stimulation
• Ach opens K+ channels (K+ efflux)
• Also hyperpolarize pacemaker potential
and reduce HR
•   HR (Ach and vagal stimulation)
Coronary circulation
• Myocardial cells receive their blood supply via arteries that branch from the
aorta
• The arteries supplying the myocardium are the coronary arteries
Cont…
Arterial Supply
• Aorta branches into right and left

coronary arteries
• Left coronary artery
– Anterior interventricular artery
– Circumflex artery
• Right coronary artery branch
to:
– Marginal artery
– Posterior interventricular artery
29
Physiology of Heart
Cont…
Venous Drainage
• 20% - directly from small veins into the right ventricle

• 80% returns to the right atrium by
– Great cardiac vein
• It carries blood from the apex of the heart toward the AV
sulcus
– Middle cardiac vein
• Found in the posterior sulcus
• Collects blood from the posterior aspect of the heart
– Coronary sinus
• Collects blood from the above two and smaller cardiac veins
and empties into the right atrium
• It passes across the posterior aspect of the heart
Cont…
Electrical Activity of the heart
Cardiac Muscle
• Cells are striated like skeletal muscle cells
• SR is less developed than in skeletal muscle
• The T tubules are much larger than in skeletal muscle
– Admit supplemental Ca2+ ions from the ECF
• The myocytes are joined end to end by thick connections called intercalated
discs
Cont…
• The myocytes are electrically coupled by gap junctions

• These junctions enable each myocyte to electrically stimulate its
neighbors
– So the entire myocardium of the atria, and that of the ventricles, each
acts almost as if it were a single cell (syncytium)
• Certain cells in the atria secrete the family of peptide hormones
collectively called atrial natriuretic peptide (ANP)
Autorhythmicity of heart
• Spontaneous rhythmic pulsation of heart is maintained by excitatory signals

generated within heart itself
• This is made exclusively by pacemaker and conducting systems
• The pacemaker is sianoatrial node (SA node)
– Small mass of specialised cells in the wall of the right atrium near the opening
of the superior vena cava
– It is the pacemaker of the heart because it normally initiates impulses more
rapidly than other groups of neuromuscular cells
Spread of signals from the SA node
• Atrioventricular (AV) node

– Located near the right AV valve
– Acts as an electrical gateway to the
ventricles
– The fibrous skeleton acts as an
insulator to prevent currents from
getting to the ventricles
• Atrioventricular (AV) bundle (bundle of
His)
– A pathway by which signals leave the AV
node
• Bundle branches (left & right)
– Are divisions of the AV bundle
– They enter the interventricular septum
and descend toward the apex
Cont…
• Purkinje fibers
– Nerve like processes that arise from
the bundle branches near the apex
of the heart
– They turn upward and spread
throughout the ventricular
myocardium
– They distribute the electrical
excitation to the myocytes of the
ventricles
– They form a more elaborate
network in the left ventricle than in
the right
Purkinje fibers
Impulse Conduction to the Myocardium
• Firing of the SA node excites atrial myocytes

– The two atria contract almost simultaneously
• In the AV node, the signal slows down because the myocytes here
– Are thinner
– Have fewer gap junctions
• This delays the signal at the AV node for about 100 msec
• This delay (AV nodal delay) is essential
– It gives the ventricles time to fill with blood before they begin to contract
• Signals travel through the Purkinje fibers at a speed of 4 m/sec, the fastest in
the conduction system
• The entire ventricular myocardium depolarizes within 200 msec after the SA
node fires
– The ventricles to contract in near unison
Numbers = Time lapse from the origin of
impulse (SA node) in second
Electrical Behavior of the Myocardium
• The action potentials of cardiac muscle are significantly different from
those of neurons and skeletal muscle
• Cardiac muscle has a stable resting potential of -90 mV
• It depolarizes only when stimulated (opposed to the autorhythmic cells of the
SA node)
• Cardiac muscle has three types of membrane ion channels that are
responsible for voltage changes of the action potential
• They are
– Fast Na+ channels
– Slow Ca2+ channels
– K+ channels
Cont…
• Opening of the fast Na+ channels

– Cause rapid upstroke spike
• Opening of the slow Ca2+ channels
– The “plateau” of the ventricular
AP
• Opening of K+ channels
– Returns the membrane potential to
its resting level
cont…
• Refractory Period of Cardiac Muscle
– The long action potential results in a correspondingly long absolute refractory
period
– These refractory periods last almost as long as the contraction
• No tetanization in cardiac muscle
AP - contraction relation
 AP in skeletal muscle is very short-

lived
 AP is basically over before an increase
in muscle tension can be measured
 AP in cardiac muscle is very long-

lived
 AP has an extra component, which
extends the duration
 The contraction is almost over before
the action potential has finished
The cardiac cycle
• Is the events that occur from the beginning of one heartbeat to the beginning
of the next
• Is the repeating pattern of contraction and relaxation of the heart
– The phase of contraction is called systole
– The phase of relaxation is called diastole
• The right and left atria contract almost simultaneously (atrial systole)
• Atrial systole is followed by the almost simultaneous contraction of the right
and left ventricles (ventricular systole)
Phases of the Cardiac Cycle
1. Ventricular filling
• Ventricular filling occurs in three phases:
– Rapid ventricular filling
– Slower filling – diastasis
– Atrial systole
• At the end of ventricular filling, each ventricle

contains an end-diastolic volume (EDV) of
about 130 mL of blood
– Only 40 mL (31%) of this is contributed by atrial

systole
Cont…
2. Isovolumetric contraction
• The atria repolarize (relax) and remain in diastole
• The ventricles depolarize and begin to contract
• Pressure in the ventricles rises sharply
• The AV valves close
• The ventricles do not eject blood yet
– No change in their volume (isovolumetric)
• Pressures in
– Aorta = 80 mmHg
– Pulmonary trunk =10 mmHg
• These pressures are still greater than the pressures in the
respective ventricles
– Thus oppose the opening of the semilunar valves
• The myocytes exert force, but with all four valves
closed, the blood cannot go anywhere
Cont…
3. Ventricular ejection
• Correspond to plateau of ventricular AP
• Ventricular pressure exceeds arterial pressure – semilunar
valves open
• The pressure peaks at
– 120 mmHg in the left ventricle
– 25 mmHg in the right ventricle
• Has two phases – Rapid ejection, Reduced ejection
• The ventricles do not expel all their blood
• The amount ejected is about 70 mL = the stroke
volume (SV)
• The percentage of the EDV ejected is the ejection
fraction (54%)
• The blood remaining behind is called the end-systolic
volume (ESV) =60ml
– (EDV – SV = ESV)
Cont…
4. Isovolumetric relaxation
• Is early ventricular diastole
• Ventricles repolarize and begin to expand
• Semilunar valves are closed
• AV valves have not yet opened
• Ventricles are therefore not taking in blood
Ventricular pressure-volume loops
• Describes one complete cycle of ventricular contraction, ejection, relaxation,

and refilling
– Isovolumetric contraction (1 → 2)
– Ventricular ejection (2 → 3)
– Isovolumetric relaxation (3 → 4)
– Ventricular filling (4 → 1)
• The width of the pressure-volume

loop is the volume of blood ejected,
or the stroke volume (70 ml)
Changes in Ventricular Pressure-Volume Loops
• Effects of changes in the following on

ventricular pressure-volume loops
– Preload (Δ in venous return /EDV)
– Afterload (Δ in aortic pressure)
– Contractility
• Increased preload causes increase in stroke

volume
– Frank-Starling relationship:
• States that the greater the EDV (end-
diastolic fiber length), the greater the
stroke volume ejected in systole
53
Physiology of Heart
Cont…
• Increased afterload (increased aortic pressure)
– Causes decrease in stroke volume
– Causes less blood to be ejected from the ventricle
during systole
– Left ventricle must eject blood against a greater-than-
normal pressure
• Stroke volume decreases
• More blood remains in the ventricle at the end of
systole
• End-systolic volume increases
• Increased contractility causes

– Increase in Stroke volume
– Decrease in end-systolic volume
– i.e., ventricle can develop greater tension and pressure during
systole and eject a larger volume of blood than normal
Electrocardiogram (ECG)
• Detection of electrical currents in the heart by means of electrodes (leads)

applied to the skin
• Electrocardiograph – an instrument that amplifies these signals and
produces a record called an electrocardiogram
• To record an ECG, electrodes are typically attached to the
– Wrists
– Ankles
– Chest (6 areas)
ECG…
Cont…
Information obtained from ECG:

– Anatomical orientation of the heart
– Relative size of chambers
– Rhythm and conduction disturbance
– Extent, location and progress of ischemic damage
– Electrolyte disturbance
– Influence of drugs
– HR=1/cycle length
– Origin of excitation
Cont…
• Electric current generated by heart muscle conducted through body fluid

• A small portion reach surface of body, which can be detected and recorded
by electrodes
• This record represents sum of electrical activity in all muscle undergoing
depolarization and repolarization
• The waves represent comparison in voltage detected by electrodes at 2
different points on body surface
• A typical ECG shows three principal deflections above and below the
baseline:
• P wave
• QRS complex
• T wave
Cont…
a. P wave
• Is produced when atria depolarize
– A signal from the SA node spreads through the atria
Cont…
b. QRS complex
• Marks the
– Firing of the AV node and the
– Onset of ventricular depolarization
• Its complex shape is due to
– Different sizes of the two ventricles
– Different times required for them to depolarize
• The S–T segment corresponds to the plateau in the myocardial AP
– The time during which the ventricles contract and eject blood
Cont…
c. T wave
• Generated by ventricular repolarization immediately before diastole
Atrial repolarization ???
ECG recording technique
1. Bipolar lead recording:

• Uses 2 active electrodes & measure
potential difference between them
• Standard limb leads (I, II, III) each
record potential difference between 2
limbs
Lead I= between LA (+) & RA
Lead II= between RA & LL (+)
Lead III= between LA & LL (+)
Cont…
2. Unipolar lead recording:

 Use exploring electrode connected to an
indifferent electrode at zero potential, &
measure potential difference between an
exploring and indifferent electrode
– Augmented limb leads (Unipolar limb
leads)
• Designated by the letter a (aVR, aVL, aVF)
• Record between one limb and the other 2
limbs
– Unipolar chest leads/precordial leads
• Designated V1-V6
Summary of
Cardiac arrhythmias
Cardiac arrhythmias are divided into two groups:

1. Pacemaker abnormalities
– Abnormal rhythmicity of pacemaker
• Sinus tachycardia – HR above 100beats/min
• Sinus bradycardia – HR below 60 beats/min
• Sinus arrhythmias
– Shift of pace making from SA node to other part of the heart
• Ectopic beats
• Shifting pacemaker
2. Conduction abnormalities (cardiac block )
– Blockage at different points in the transmission of impulse through the heart
• Sianoatrial nodal block
• Atrioventricular Heart Block
– Abnormal pathways of transmission through the heart
Cont…
Heart Sounds
• Causes of the heart sound include

– Vibration of valves (mainly)
– Movement of great vessels
– Acceleration of the ventricular wall
– Turbulence in the blood as it surges
against the closed AV valves
– Impact of the heart against the
chest wall
Auscultation
Cont…
The four heart sounds

1. The first heart sound (S1) – “lub” sound
• Occurs as the ventricle contracts and ventricular pressure rises above atrial
pressure,
• Is mainly due to the closure of the atrioventricular valves
• Relatively low-pitched sound
2. The second heart sound (S2) – “dub” sound

• Often has two components
• The first corresponds to aortic valve closure and the second to pulmonic
valve closure
• In normal individuals, splitting widens with inspiration and narrows or
disappears with expiration
Cont…
3. The third heart sound (S3)

• Results from vibrations during the rapid phase of ventricular filling
• Is associated with ventricular filling that is too rapid
• May be heard in normal children and adolescents
• Its appearance in a patient older than age 35 usually signals the presence of a
cardiac abnormality
4. The fourth heart sound (S4)

• May be heard during atrial systole
• It is caused by blood movement resulting from atrial contraction
• Like S3, it is more common in patients with abnormal hearts
Auscultation areas
Pathological heart sounds
• Murmur - valvular disease

• Turbulent blood flow (may be normal when flow increases)
Examples of valvular diseases

 Stenosis
 Valves do not close properly(e.g. narrowing )
 Swish sound
 Regergitations (Insufficiency, incompetency)
 valve does not close properly
 whistle sound = murmur
 Timing of murmur indicate which valve damaged
 E.g. Mitral insufficiency – regurgitation of blood into left atrium during ventricular
systole
Cont…
• Murmur throughout systole – Stenotic Pulmonic or Aortic valve

• Murmur throughout diastole – stenotic tricuspid or mitral valve
Stroke volume, cardiac output and ejection fraction
Factors influencing CO
 Intrinsic:
• Arterial pressure (afterload) –
decrease CO
• Filling pressure (preload) –
increase CO
 Extrinsic :
• Parasympathetic effects –
decrease CO
• sympathetic effects
- increase CO

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Cardiovascular Physiology

• The functions of CVS

Physiology of the Heart

• Located in the thoracic cavity in the mediastinum

Four chambers of Human Heart

• Aorta branches into right and left

• 20% - directly from small veins into the right ventricle

• The myocytes are electrically coupled by gap junctions

• Spontaneous rhythmic pulsation of heart is maintained by excitatory signals

• Atrioventricular (AV) node

• Firing of the SA node excites atrial myocytes

• Opening of the fast Na+ channels

 AP in skeletal muscle is very short-

 AP in cardiac muscle is very long-

• At the end of ventricular filling, each ventricle

– Only 40 mL (31%) of this is contributed by atrial

• Describes one complete cycle of ventricular contraction, ejection, relaxation,

• The width of the pressure-volume

• Effects of changes in the following on

• Increased preload causes increase in stroke

• Increased contractility causes

• Detection of electrical currents in the heart by means of electrodes (leads)

Information obtained from ECG:

• Electric current generated by heart muscle conducted through body fluid

Atrial repolarization ???

1. Bipolar lead recording:

2. Unipolar lead recording:

Cardiac arrhythmias are divided into two groups:

• Causes of the heart sound include

The four heart sounds

2. The second heart sound (S2) – “dub” sound

3. The third heart sound (S3)

4. The fourth heart sound (S4)

• Murmur - valvular disease

Examples of valvular diseases

• Murmur throughout systole – Stenotic Pulmonic or Aortic valve

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