Disorders of

Cardiovascular System
By
Hakim Shah

Required Reading Book:

Carol, Porth M. (2014). Pathophysiology concept of altered health states (9th Ed). Philadelphia:
J. B. Lippincott.

(Book is available in ICoNM Library)

Chapter-29, Page No. 712
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 Unit Objectives
•Review the following structure that support the cardiac metabolism i.e.
Coronary circulation (collateral arteries) and heart action i.e.
conduction system, myocardial contraction and relaxation.
•Explain the mechanism of blood vessels obstruction in atherosclerosis.
•Discuss the factors effecting cardiac performance in the light of Frank
Starling and Lapcalce’s law i.e. preload, after load, & contractility.
•Explain the pathophysiological changes in patients with ischemic heart
diseases:
 Myocardial ischemia (angina & its types)
 Myocardial infarction
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 Circulatory System
• The circulatory system consists of:
1. The heart
• Pumps blood
2. The arterial system
• Distributes oxygenated blood to the tissues;
3. The venous system
• Collects deoxygenated blood from the tissues and returns it to the heart
4. The capillaries
• Where exchange of gases, nutrients, and wastes takes place.

• The circulatory is a closed system that is divided into two parts:

1. The low-pressure pulmonary circulation
• Linking circulation and gas exchange in the lungs,
2. The high-pressure systemic circulation
• Providing oxygen and nutrients to the tissues.
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 Pulmonary and Systemic Circulation
The circulatory system can be divided into two parts:

• The pulmonary circulation

• Moves blood through the lungs and creates a link with the gas-exchange
function of the respiratory system

• The systemic circulation

• Supplies all the other tissues of the body

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Pulmonary and Systemic Circulation

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 Volume and Pressure Distribution
• Blood flow in the circulatory system depends on:
• Blood volume that is sufficient to fill the blood vessels
• Pressure difference across the system that provides the force to move blood forward.
• The total blood volume is a function of age and body weight
• Blood volume ranges:
• From 85 to 90 mL/kg in the neonate
• From 70 to 75 mL/kg in the adult.

• Distribution of blood volume:

• Approximately 4% of the blood at any given time is in the left heart
• 16% is in the arteries and arterioles
• 4% is in the capillaries
• 64% is in the venules and veins
• 4% is in the right heart.

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Pressure and Volume Distribution

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 Flow of blood through Vessels
• Blood moves from the arterial to the venous side of the circulation
along a pressure gradient
• Moving from an area of higher pressure to one of lower pressure.

• The pressure distribution in the different parts of the circulation is

almost an inverse of the volume distribution.

• The pressure in the arterial side of the systemic is much greater than
the pressure on the venous side of the circulation.

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Relationship between Blood flow, Pressure and
Resistance
• The most important factors governing the flow of blood in the
cardiovascular system are pressure, resistance, and flow.
• Ohm law states that current (I) equals the voltage difference (∆V) divided by
the resistance (R).
• When relating this to blood flow, the voltage difference is the pressure
difference or pressure gradient (∆P), the resistance is the resistance to flow
(R), and the current is the blood flow
• Blood flow (F) through a vessel or series of blood vessels is determined by
the pressure difference (P1 − P2) between the two ends of the vessel and
the resistance (R) that blood must overcome as it moves through the vessel
(F = ∆P/R)
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Cont….
• In the cardiovascular system, blood flow is represented by the cardiac
output.
• Resistance is the opposition to flow caused by friction between the
moving blood and the stationary vessel wall.
• In the peripheral circulation, the collective resistance of all the vessels
in that part of the circulation is referred to as the peripheral vascular
resistance(PVR) or systemic vascular resistance (SVR).

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 Hemodynamics of Blood Flow

The term hemodynamics is used to describe factors such as:

1. Pressure and resistance
2. Vessel radius
3. Cross-sectional area and velocity of flow
4. Laminar versus turbulent flow

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Cross-Sectional Area and Velocity of Flow
• The velocity or rate of forward movement of the blood is affected by
the cross-sectional area of a blood vessel.

• As the cross-sectional area of a vessel increases, blood must flow

laterally as well as forward to fill the increased area. As a result, the
mean forward velocity decreases.
• In contrast, when the cross-sectional area is decreased the lateral
flow decreases and the mean forward velocity is increased.

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Velocity and Cross-Sectional Area

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 Laminar VS Turbulent Flow
• Blood flow is normally laminar, with platelets and blood cells remaining in
the center or axis of the bloodstream.
• Laminar blood flow can be described as layered flow in which a thin layer
of plasma adheres to the vessel wall, while the inner layers of blood cells
and platelets shear against this motionless layer. This allows each layer to
move at a slightly faster velocity, with the greatest velocity occurring in
the central part of the bloodstream.
• Turbulent blood flow is flow in which the blood elements do not remain
confined to a definite lamina or layer, but develop vortices (i.e., a
whirlpool effect) that push blood cells and platelets against the wall of the
vessel.
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Laminar VS Turbulent Flow

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 The Heart
• The heart is a four-chambered muscular pump approximately the size of a man’s
fist. It beats an average of 70 times each minute, 24 hours each day, 365 days
each year for a lifetime.
• In 1 day, this pump moves more than 1800 gallons of blood throughout the body.
• The heart is a four-chambered pump consisting of two atria (the right atrium,
which receives blood returning to the heart from the systemic circulation, and
the left atrium, which receives oxygenated blood from the lungs) and two
ventricles (a right ventricle, which pumps blood to the lungs, and a left ventricle,
which pumps blood into the systemic circulation).
• The heart valves control the direction of blood flow from the atria to the
ventricles (the AV valves), from the right side of the heart to the lungs (pulmonic
valve), and from the left side of the heart to the systemic circulation (aortic
valve).
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 Location of Heart

The heart is located between the lungs in the

mediastinal space of the intrathoracic cavity in
a loose-fitting sac called the pericardium. It is
suspended by the great vessels, with its
broader side (i.e., base) facing upward and its
tip (i.e., apex) pointing downward, forward, and
to the left. The heart is positioned obliquely, so
that the right side of the heart is almost fully in
front of the left side of the heart, with only a
small portion of the lateral left ventricle on the
frontal plane of the heart.

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Anterior View of Heart

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Heart Valves and fibrous skeleton

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Valvular Structure of Heart

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Layers of Heart

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 Cardiac Cycle
• “Cardiac cycle refers to the sequence of events that take place when
the heart beats.”
• The term cardiac cycle is used to describe the rhythmic pumping
action of the heart.
• The cardiac cycle is divided into two parts:
• Systole, the period during which the ventricles are contracting
• Diastole, the period during which the ventricles are relaxed and filling with
blood

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Normal event of cardiac cycle for left ventricular function, including changes in aortic pressure, atrial
pressure, ventricular pressure, ventricular volume, ECG and PCG.

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 Stroke Volume
• Stroke volume (SV) is the volume of blood ejected from the left
ventricle with each cardiac cycle or heartbeat.
• SV is calculated by subtracting the left ventricular end systolic volume
(ESV) from the left ventricular end diastolic volume (EDV).
• Not all the blood that fills the heart by the end of diastole (EDV) can
be ejected from the heart during systole.
• Therefore, the volume of blood left in the heart at the end of systole
is the ESV.
• Cardiac output = Stroke Volume × Heart Rate

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 Calculation of SV
• For an average-sized man, the end-diastolic volume is about 120
milliliters (mL) of blood and the end-systolic volume is about 50 mL of
blood. Thus, the average stroke volume is approximately 70 milliliters
(mL).
• These values can be calculated using diagnostic tests such as a left-
heart catheterization, transesophageal echocardiogram (TEE) or
transthoracic echocardiogram (TTE).

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 Ejection Fraction
• Left ventricular ejection fraction (LVEF) indicates how much blood the
left ventricle pumps out with each contraction.
• A more clinical definition of LVEF is the percentage of blood ejected
during systole in relation to the total end-diastolic volume.

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 Categories of LVEF
• The American College of Cardiology classifies LVEF into the following
categories (Kosaraju et al., 2021):

• Hyperdynamic = LVEF greater than 70%

• Normal = LVEF 50% to 70%
• Mild dysfunction = LVEF 40% to 49%
• Moderate dysfunction = LVEF 30% to 39%
• Severe dysfunction = LVEF less than 30%

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 Preload
• The preload represents the volume work of the heart.
• It is usually considered the end-diastolic pressure when the ventricle
has been filled.
• It is called the preload because it is the work or load imposed on the
heart before the contraction begins.
• Preload represents the amount of blood that the heart must pump
with each beat.
• It is largely determined by the venous return to the heart and the
accompanying stretch of the cardiac muscle fibers.

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 Frank-Starling mechanism
• The increased force of contraction that accompanies an increase in
ventricular end-diastolic volume is referred to as the Frank-Starling
mechanism or Starling law of the heart.
• The maximum force of contraction and cardiac output is achieved
when venous return produces an increase in left ventricular end-
diastolic filling (i.e., preload) such that the muscle fibers are stretched
about two and one half times their normal resting length.
• When the muscle fibers are stretched to this degree, there is optimal
overlap of the actin and myosin filaments needed for maximal
contraction.

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Cont….
• When a greater amount of blood flows into the ventricles, the cardiac
muscle is stretched to a greater length.
• Cardiac output is less when decreased filling causes excessive overlap
of the actin and myosin filaments or when excessive filling causes the
filaments to be pulled too far apart.

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Frank-Starling

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 Afterload
• The afterload is the pressure in which the muscle exerts its contractile
force in order to move blood into the aorta.
• It is called the afterload because it is the work presented to the heart
after the contraction.
• The systemic arterial blood pressure is the main source of afterload
work on the left heart, and the pulmonary arterial pressure is the
main source of afterload work on the right heart.

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 Cardiac Contractility
• Cardiac contractility refers to the ability of the heart to change its
force of contraction without changing its resting (i.e., diastolic) length.
• The contractile state of the myocardial muscle is determined by
biochemical and biophysical properties that govern the actin and
myosin interactions in the myocardial cells.
• It is strongly influenced by the number of calcium ions that are
available to participate in the contractile process.

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