Cardiovascular System

Heart
 Cone shape/inverted pyramid
 Relatively small roughly same size as a closed fist
 Rest: diaphragm
 Location: mediastinum
o Mass off tissue extending from the sternum to the vertebral column between 2 Lungs
o 2/3rds mass of Head (L) of body’s midline
o Base – broad portion of heart
 Posterior, Superior to the Right
o Apex – pointed end
 Anterior, Inferior to the Left

Pericardium
 Fibrous connective sac that encloses the heart
 Fxn: it protects the heart from trauma & infection
 2 Layers of Pericardium
o Fibrous Pericardium
 Outer-most layer of pericardium
 Fxn: anchors the heart on mediastinum; prevents the heart from over stretching
o Serous Pericardium
 Inner-most layer of pericardium
 2 layers of Serous Pericardium
 Visceral Serous Pericardium (Epicardium)
o Adheres tightly to the heart
 Parietal Serous Pericardium
o Outermost layer
o Adheres tightly to the fibrous pericardium
o Outer to Inner  Fibrous -> Parietal SP -> Visceral SP
 Pericardial Fluid
 ↓ friction in heart
 Location: between the Visceral and Parietal SP
 ↑ PF: Cardiac Tamponade (Excessive PF)
o (-) Pain; Death 2° to MI d/t unable to pump blood
 ↓ PF: Pericardial Friction Rub
o (+) Pain; Pericarditis

Surfaces of the Heart

1. Anterior Surface (Sternocostal S.)
a. RA & RV
b. RV forms most Anterior Surface of Heart
2. Posterior Surface (Base S.)
a. RA & LA
b. LA forms most Posterior Surface of Heart
3. Inferior Surface (Diaphragmatic S.)
a. RV & LV
b. LV forms the apex of Heart

Chambers of the Heart

1. 2 Atria
a. Receiving chambers
b. Anterior wall of the 2 atria, they are rough d/t the presence of (+) pectinate mm.
c. (+) interatrial septum
i. Oval depression: Fossa Ovalis
1. Remnant of foramen ovale

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2. Foramen Ovale: Opening of the interatrial septum of a fetal heart

2. 2 Ventricles
a. Pumping Chambers
b. Ridges of Cardiac mm. Fiber: trabeculae Carnae
c. Papillary Muscle – cone shape structure of trabeculae carnae where the chordae tendinae are attached
d. Interventricular Septum

Vales of the Heart

1. AV Valves
a. Inlet
b. Tricuspid, bicuspid (Mitral)
2. SL Valves
a. Outlet
b. Pulmonic V.
c. Aortic V.

Blood Flow of the Heart

IVC is the largest Vein in the BodyLeft side of the Heart - ↑pressure; Right side of the Heart - ↓pressure

Heart Sounds
Longer, louder, Lower
S1 LUBB
Closure of AV Valves
Stethoscope
Shorter, not as loud as S1
S2 DUBB
Closure of SL Valves
Rapid Filling
S3 In CHF: Ventricular Gallop
Phono- of Ventricles
Cardiogram Atrial
S4 In MI/Hypertension: Atrial Gallop
Systole

Controlling Centers of the Heart (2)

1. Autonomic N.S.
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 Cardiovascular System: Anatomy & Conditions

a. Dually Innervated
i. Para – ↓ contraction
1. Slow Contraction of the Heart
a. Beta-blockers (-olol)
b. Calcium Channel Blocker
c. Alpha-1-blocker
ii. Sympa – ↑ contraction
2. Conducting System
a. SA Node – Sinoatrial Node
i. Aka Sinus Node (Meyer 1, Peat 2&5)
ii. Primary Pacemaker
iii. Location: (R) Atrium (General); Superior Septal Wall of the (R) Atrium immediately below slightly
lateral to the opening of the Superior Vena Cava (Specific)
b. AV Node – Atrioventricular Node
i. Junctional Node
ii. Location: behind the tricuspid V.
iii. MC site for H.B.
c. Bundle of His
i. Location: interventricular Septum
d. Purkinje Fibers
i. Locations: surrounds the 2 Ventricles
ii. Largest Pacemaker of the Heart”

Coronary Artery
 Responsible for the blood supply in the heart

(R) Coronary A. (L) Coronary A.

(R) Atrium (L) Atrium
(R) Ventricle (Majority) (L) Ventricle (Majority)
(L) Ventricle (Minor) (R) Ventricle (Minor)
SA Node Interventricular Septum
 Branches
o Left Anterior Descending Artery (LADA): Supplies blood in the Anterior Wall and Apical Wall of the (L)
Ventricle
o Circumflex A.: Supplies blood to the Lateral Wall and Inferior Wall of (L) Ventricle
 Case:
o (+) MI in (R) Coronary A. is FATAL 2° SA Node Failure
o (+) MI in the (L) Coronary A. is FATAL 2° Left Ventricular Failure
o MC Coronary A. occluded – (L) CA d/t larger (L) > (R) CA – more blood flow to (L) leads to greater
disposition of deposits in that Artery

Cardiac Action Potential

 5 phases (0-4)
 -88 mV

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 Cardiovascular System: Anatomy & Conditions

Phase 0
 Depolarization
 Inward current of Na+

Phase 1
 Initial Repolarization
 ↓ influx of Na+
 Outward current of K+

Phase 2
 Plateau “Pla-two”
 Inward current of Ca2+

Phase 3
 Repolarization
 ↓ influx of Ca2+
 Outward current of K+

Phase 4
 Resting Membrane Potential
 Returns to -88 mV

Cardiac Muscle vs Skeletal Muscle

 Involuntary
 Few in Ca2+ vs Skeletal Muscle

Cardiac Cycle
 Pumping action
o Diastole – Ventricular Relaxation
o Systole – Ventricular contraction

Diastole
I. Period of Rapid Filling of the Ventricles: AV valves Open, SL valves Closed
a. First Third of Diastole – 75% of Blood gets sent from Atrias to Ventricles “Passively”
b. Middle Third of Diastole – continuous blood flow
c. Last Third of Diastole – 25% of blood gets sent from Atrias to Ventricles “Passively”; Atrial Systole/Atrial
Kick

Maximum blood flow occurs in the 1st 3rd of Diastole

Systole
II. Period of Isovolumetric Contraction
a. Blood inside the ventricles
b. ↑ ventricular pressure
c. AV Valves closed, SL Valves closed (only period where all valves closed)
III. Period of Ejection
a. Afterload – ventricular force required to open the SL Valves
b. LV = 80 mmHg (Aorta)
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 Cardiovascular System: Anatomy & Conditions

c. RV = 8 mmHg (Pulmonary A.)

d. SL Valves – open
e. First Third of Ejection: 70% of blood – Ventricles to Pulmonary A. & Aorta
i. Fast Ejection
f. Last 2/3rds of Ejection: 30% of blood – Ventricles to Pulmonary A. & Aorta
i. Slow Ejection
IV. Period of Isovolumetric Contraction
a. Distention of Blood Vessels
b. ↓ Ventricular Pressure
c. SL Valves Closed

Hemodynamics
1. Systolic – highest arterial pressure; 120 mmHg
2. Diastolic – lower arterial pressure; 80 mmHg
3. Pulse Pressure – difference between Systolic BP and Diastolic BP (SBP-DBP); Normal 40 mmHg
a. Average pressure of peripheral Pulse = Pulse Pressure
4. End Diastolic Volume (EDV) – amount of blood left after diastole (ventricular relaxation)
a. (N) 120 mL -> Preload “Initial Stretching”
5. End Systolic Volume (ESV) – amount of blood left after systole (ventricular contraction)
a. (N) 50 mL
b. ↑ ESV – (+) CHF
6. Stroke Volume – amount of blood pumped by ventricles per contraction
a. (N) 70 mL
b. EDV – ESV (120-50=70)
7. Cardiac Output – amount of blood pumped by the ventricles per minute
a. (N) 4-6 Liters of Blood (resting CO)
b. SV x HR
c. (N) HR = 60-100bpm
d. To get the Exact HR, use the Apical Pulse. If no choices, use ECG
8. Mean Arterial Pressure (MAP) – arterial pressure with respect to Time
a. DBP + 1/3rd Pulse Pressure
b. Normal MAP = 120/80 mmHg -> 80 + 13.33 = 93.33 mmHg
i. Average pressure for the large arteries in the body

ECG
 P Wave – A. Depo (Pacemaker Wave)
 QRS Complex – V. Depo
 T Wave – V. Repo
 PR Interval – beginning of Pwave (Board Exam: A. Depo or A. Contraction) to the beginning of QRS Complexes
(Board Exam: V. Depo or V. Contraction)
o “It is the point from A. Contraction to V. Contraction: Answer – PR Interval
 QT Interval: Beginning of QRS Complexes (V. Depo, V. Contraction) to end of T wave (V. Repo, V. Relaxation)
 PR Segment: end of P Wave (A. Depo or A. Contraction) to beginning of QRS Complexes (V. Depo, V. Contraction)
 ST Segment: end of QRS Complex (V. Depo, V. Contraction) to Beginning of T Wave (V. Repo, V. Relaxation)

Segment – lagi na start sa End

Interval – lagi na start sa beginning

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ECG Conditions
 Prolonged PR Interval – Heart Block
 Wide, Odd, Bizarre QRS Complexes – Premature Ventricular Contraction (PVC)
 ST Segment Elevated – Myocardial Infarction (death of the myocardium)
 ST Segment Depressed – Myocardial Ischemia (lack of blood in the myocardium)

Auscultation of the Valves

APMT 254 – Apartment #254

A Right
2ND ICS Sternal Border
P
M 5TH Left Midclavicular Line
T 4th ICS Sternal Border

Location of the Valves

A ICS
3rd
P Left CC
M th CC
4
T Right ICS

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 Cardiovascular System: Anatomy & Conditions

Cardiovascular Conditions
Heart Disease
1. Chest Pain (Angina)
a. (+) Levine Sign
b. Referred Pain d/t Heart Innervated by C3 & T4
i. Jaw
ii. Neck
iii. Chest
iv. Upper Trapezius
v. Shoulders
vi. Left Arm: Ulnar N. Distribution
c. Types of Angina
i. Chronic Stable Angina (Predictable Angina)
1. Physical Exertion + Emotional Stress
2. Responds to Rest and Nitrates
a. Nitrates
i. Administration: sublingual
ii. Max: 3 tablets
iii. Interval: every 5 min
iv. Effect: Vasodilation
v. After 3 tablets with no relief of pain call 911/EMS (Letter B in
Fortinberry)
vi. Relief from Anginal pain should occur within 1-2 minutes (Meyer says
how long does relief take)
ii. Unstable Angina (Pre-infarction/Progressive/Crescendo Angina)
1. Doesn’t not respond to Rest and Nitrates
2. Contraindicated for exercise either in IPD and OPD
d. Nocturnal Angina
i. Exertion caused by Dreams
ii. Seen with CHF
e. Prinzmetal Angina (Variant Angina)
i. Female > Male
ii. Coronary A. Spasm
iii. Only type of angina, Purely Vasospasm
2. Palpitations – “Arrhythmias” – Excessive Heart Beat
3. Dyspnea - (+) SOB
4. Cyanosis – Bluish discoloration of the lips, toes, nail beds
5. Cardiac Syncope – “Fainting”
6. Fatigue

Heart Conditions
1. Coronary Artery Disease (CAD)
a. Ischemic Heart Disease
b. 2° Atherosclerosis affecting the entire Coronary A.

Modifiable Risk Factor Non-Modifiable Risk Factor

Sedentary Lifestyle Age (55-67 y/o)
Obesity Gender (M>F**)
Cigarette Smoking* Race (African-American)
↑ BP Family History
↑ Cholesterol – “Statins”
*Nicotine – stimulates the fibrinogen (Clotting Factor 1; [if it has “no” in the CF, they are inactive)  Fibrin = Clot
Formation
**Menopause – M=F d/t Estrogen; Estrogen: stimulates the LDL receptor, causing ↑ Cholesterol in the Systemic
circulation
2. Myocardial Infarction (Coronary Occlusion)
a. Death of Myocardium
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 Cardiovascular System: Anatomy & Conditions

b. True MI – ST Segment Elevation + ↑ Cardiac Enzyme

3. Congestive Heart Failure (Cardiac Decompensation)
a. Inability of the ventricles to contract effectively
b. Most serious complication: Myocardial Infarction
c. 2 types of CHF
i. (R) Sided Heart Failure -> inability of the (R) Ventricle to contract effectively
1. (+) Congestion in the periphery & organ
2. (+) Bipedal Edema
3. (+) Ascites
4. (+) Hepatomegaly (enlargement of liver)
5. (+) Distention of Jugular Veins
6. (+) Cyanosis
ii. (L) Sided Heart Failure -> inability of the (L) Ventricle to contract effectively
1. “Le-Le-Left-Luh-Luh-Lungs”
2. (+) Pulmonary Edema
3. (+) Cough
4. (+) Orthopnea
5. (+) Paroxysmal Nocturnal Dyspnea
6. (+) Cerebral Hypoxia
7. (+) Fatigue
8. (+) Dyspnea (SOB)
4. Pericarditis
a. Inflammation of pericardium
b. 2°
i. bacterial/viral agent
ii. Cancer
iii. Renal Failure
iv. HIV
c. (+) Pericardial Friction Rub
i. Aggravating Factors: Trunk Movements (side to side movements); mimics chest pain
ii. Relieving Factors: Kneeling on all 4’s; position decreases cardiac workload

Congenital Anomalies
 Hereditary
 Shunts they are not closing
 Mother: (+) German Measles
1. Atrial Septal Defect (ASD)
a. Defect: interatrial Septum
b. Shunt: (L) to (R)
c. Acyanosis
2. Ventricular Septal Defect (VSD)
a. Defect: interventricular septum
b. Shunt: (L) to (R)
c. Acyanosis
3. Coarctation of Aorta
a. Defect: constriction of proximal & distal aorta
b. ↑ BP especially in the UE
4. Patent Ductus Arteriosus (PDA)

*Ductus Arteriosus -> connects the Pulmonary A. to the Aorta

Placenta (Oxygenated Blood) --> Umbilical Cord (contains veins with oxygenated blood; arteries with deoxygenated
blood)
a. A connection between the Pulmonary A. and the aorta after birth
b. Shunt: (L) to (R)

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 Cardiovascular System: Anatomy & Conditions

5. Tetralogy of Fallot (TOS)

P ulmonary A. Stenosis
Overriding of the A orta to the right
R ight Ventricular Hypertrophy/Cor Pulmonale
I nterventricular Septal Defect (VSD)

a. Shunt: (R) to (L)

b. True Blue Baby

Conditions Affecting the Heart Valves

1. Stenosis - inability of the valve to open fully
a. Blood Passes with Difficulty
2. Insufficiency - Inability of the valve to close fully
a. Backflow of Blood
3. Prolapse - excessive bulging of the cusp of the valve
a. 2 weakness of cusp
b. MC Valve: Mitral Valve
i. MVP/Barlow’s Syndrome/Floppy Valve Syndrome/Click Murmur Syndrome

Laboratory Evidence
SGOT Serum Gluthamic Oxalo-acetic Transaminase Peak: 24-48 hours

↑ CPK
CK-MB
LDH
Creatinine Phosphokinase
Creatine Kinase-Myocardial Band
Lactate Dehydrogenase
Peak: 24 hours
Peak: 12-24 hours
Peak: 3-6 day
Diagnostic Tools
1. Chest X-ray – Assess the size of the heart
2. Thallium Stress Test
a. Nuclear Stress Test
b. Treadmill
c. Injection of a Radioactive Agent – Thallium
i. Thallium attaches to Normal Tissues (tissues with blood supply)
3. Cardiac Cauterization
a. Insertion of a Catheter via the Femoral A.
b. Injection of dye – cinefluroscopy “Viewing the entire arterial system”
4. Echocardiogram
a. Use of Ultrasound
b. Movements of the walls and the valves of the heart
5. Central Line
a. Swan Ganz Catheter
b. Insertion of a catheter
c. Measure the pressure in the heart

Surgical Intervention
1. PTCA – Percutaneous Transluminal Coronary Angioplasty
a. Insertion of a ballooning tip catheter to compress the occlusion
2. IV Stent – Intravascular Stent
a. Wire pliable mesh
b. To keep the lumen of the blood vessel open

*Cannot place IV Stent without PTCA first

3. CABG – Coronary A. Bypass Graft

a. Re-route blood vessels
b. Great Saphenous V.
c. Internal Mammary A., Internal Thoracic A.
d. Radial A.

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Intensity of Exercise
Target Heart Rate = Karvonen’s Formula

60 − 80% (𝑀𝑎𝑥 𝐻𝑅 − 𝑅𝑒𝑠𝑡𝑖𝑛𝑔 𝐻𝑅) + 𝑅𝑒𝑠𝑡𝑖𝑛𝑔 𝐻𝑅

𝑤ℎ𝑒𝑟𝑒 𝑀𝑎𝑥𝐻𝑅 𝑖𝑠 220 − 𝑎𝑔𝑒

Eg. Age: 20, RHR 60

. 6(200 − 60) + 60 → .6(140) + 160 → 84 + 60 = 144𝑏𝑝𝑚

. 8(140) + 60 → 112 + 60 = 172𝑏𝑝𝑚
Answer = 144-172

Vitalic is Age: 23 with RHR of

Cardiac Rehab (Braddom)

I. Acute Phase (Inpatient)
a. Goal: prevent deformities/complications
b. (+) Family Education
c. Discharge MET Requirement: 5 METS
II. Convalescent Phase (Transitional)
a. Goal: to promote a strong scar formation
b. Activity: walking, bicycling
c. 5-6 METS: descending stairs, sex with wife
d. 8-9 METS: Ascending Stairs, playing competitive basketball, sex with mistress
e. Discharge MET Requirements: 9 METS
III. Training (Outpatient)
a. Most Vigorous
b. Activity: Stretching, Aerobics, Calisthenics, Plyometrics
IV. Maintenance
a. Most important cardiac rehab
b. Life-long routine of the px

Cardiac Rehab (O’Sullivan)

I. Inpatient
a. Goal: to prepare patient for discharge
b. Vital Signs/ECG Monitoring
c. Discharge MET Requirement: 5 METS

Level METS Activity

Level 1 1-1.5 Bed Exercises
Arm Support for every meal
Level 2 1.5-2 S itting 15-30 minutes
L eg Exercises
R eclining Upright Chair
C ommode Privileges
Level 3 2-2.5 Bathroom Privileges
Room/Hall Ambulation for 5 minutes
Level 4 2.5-3 Trunk Exercises
Room/Hall Ambulation 5-7 minutes
Level 5 3-4 Arm Exercises
Hall Ambulation for 8-10 minutes
Level 6 4-5 Progressive Ambulation

II. Outpatient
a. Actual Exercise Training Program
b. THR = Karvonen’s Formula
III. Maintenance
a. Endurance Training
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 Cardiovascular System: Anatomy & Conditions

b. Risk Modification continues

Criteria for Terminating the Exercise

1. Unstable Angina
2. Active Pericarditis
3. Resting BP 200⁄100 mmHg
4. Acute Systemic Illness/Fever
5. Recent Embolism
6. Uncontrolled Arrhythmias
7. Uncontrolled DM
8. 2nd to 3rd Degree Heart Block
a. 1st Degree Heart Block – prolonged PR Interval
b. 2nd Degree Heart Block – progressive lengthening of PR Interval
c. 3rd Degree Heart Block – Absence of QRS Complex
9. ST Segment Displacement ≥ 2mm
a. If you are exercising and there is a 1.5mm downsloping, stop the exercise, (+) Ischemia
10. ↑ Diastolic BP = indicative of CHF

* ↑ Intensity = ↑ Systole, Diastolic stays the same

* ↓ Intensity = ↓ Systole, Diastolic stays the same

Further Notes
1. Patient: (+) SOB, Weakness, Confused -> early warning sign of MI
2. Patient: Post MI + CHF + Claudication (leg pain) -> best initial exercise: 10-15 min daily (low intensity, moderate
duration, high in frequency)
3. Patient: Post MI + DM -> while observing the patient in exercise, use ECG throughout exercise -> px prone to
silent ischemia
4. Patient: Post MI -> resistive training, make sure training is ≥ 5 METS and has no anginal sx
5. Patient: CABG -> no heavy exercises during the first 3 months

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