5 - Heart - Ecg

HEART & ECG
from : Elaine N. Marieb & Dee Unglaub Sylverthorn
Dr. BAMBANG PURWANTO, dr., M.Kes

Medical Physiology Department, Faculty of Medicine
UNIVERSITAS AIRLANGGA
INTRODUCTION
The Heart
· Location
· Thorax between the lungs
· Pointed apex directed toward left hip
· About the size of your fist
· Less than 1 lb.
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

The Heart
Figure 11.1

The Heart: Coverings
· Pericardium – a double serous

membrane
· Visceral pericardium
· Next to heart
· Parietal pericardium
· Outside layer
· Serous fluid fills the space between the
layers of pericardium

The Heart: Heart Wall
· Three layers
· Epicardium
· Outside layer
· This layer is the parietal pericardium
· Connective tissue layer
· Myocardium
· Middle layer
· Mostly cardiac muscle
· Endocardium
· Inner layer
· Endothelium
External Heart Anatomy
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 11.2a Slide 11.5
The Heart: Chambers
· Right and left side act as separate pumps
· Four chambers
· Atria
· Receiving chambers
· Right atrium
· Left atrium
· Ventricles
· Discharging chambers
· Right ventricle
· Left ventricle
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 11.6
Structure of the Heart
The heart valves ensure one-way flow
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-7g
The Heart: Valves
· Allow blood to flow in only one direction
· Four valves
· Atrioventricular valves – between atria and
ventricles
· Bicuspid valve (left)
· Tricuspid valve (right)
· Semilunar valves between ventricle and
artery
· Pulmonary semilunar valve
· Aortic semilunar valve
The Heart: Valves
· Valves open as blood is pumped

through
· Held in place by chordae tendineae
(“heart strings”)
· Close to prevent backflow, result in
heart sound
Operation of Heart Valves
Figure 11.4
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
Valve Pathology
• Incompetent valve = backflow and repump
• Stenosis = stiff= heart workload increased
• What if incompetent or stenosis? Change?
– Shape
– Percussion
– Auscultation : sound of heart beat
– Radio image
Great Vessels : The Heart in/out port
· Aorta
· Leaves left ventricle
· Pulmonary arteries
· Leave right ventricle
· Vena cava
· Enters right atrium
· Pulmonary veins (four)
· Enter left atrium
THE HEART MUSCLE CONTRACTION
MYOCARD
Heart Contractions
Figure 11.5

Histology of Myocardium
 Involuntary muscle
 Striated, has sarcomeres
 Many mitochondria
 Uni- or binucleated
 Branched
 Intercalated Disc
 Rhythmic contractions
 Does not fatigue as
easily as skeletal
 Does not have individual
neuromuscular junctions
 Independent contractions
 Require high O2
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings
Cardiac Muscle versus Skeletal Muscle
 Smaller and have single nucleus per fiber

 Have intercalated disks
 Desmosomes allow force to be transferred
 Gap Junctions provide electrical connection
 T-tubules are larger and branch
 Sarcoplasmic reticulum is smaller
 Mitochondria occupy one-third of cell volume

Excitation-contraction coupling and relaxation
in cardiac muscle
1 Action potential enters
Ca2+ from adjacent cell.
1 ECF
2 Voltage-gated Ca2+
ICF channels open. Ca2+
Ryanodine enters cell.
receptor-channel
3 Ca2+ induces Ca2+ release
2 through ryanodine
3 receptor-channels (RyR).
SR Sarcoplasmic
reticulum
Ca 2+ 4 Local release causes
(SR) Ca2+ spark.
T-tubule 5 Summed Ca Sparks

2+
4 create a Ca signal.
2+
Ca2+
spark
6 Ca ions bind to troponin
2+
5 to initiate contraction.
Ca2+ signal
Contraction
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-11, steps 1–6
Excitation-contraction coupling and relaxation
in cardiac muscle
1 Action potential enters
Ca2+ from adjacent cell.
1 ECF
2 Voltage-gated Ca2+
ICF channels open. Ca2+
Ryanodine enters cell.
receptor-channel
3 Ca2+ induces Ca2+ release
2 through ryanodine
3 receptor-channels (RyR).
SR Sarcoplasmic
reticulum Ca2+
Ca 2+ 4 Local release causes
(SR) stores Ca2+ spark.
T-tubule 5 Summed Ca Sparks

2+
4 ATP
create a Ca signal.
2+
Ca2+ Ca2+
spark 8
6 Ca ions bind to troponin
2+
5 to initiate contraction.
7 Relaxation occurs when

Ca2+ signal Ca2+ unbinds from troponin.
Ca2+
8 Ca is pumped back
2+
6 7 Actin
into the sarcoplasmic
reticulum for storage.
Contraction Relaxation Myosin
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-11, steps 1–8
Myocardial Contractile Cells
Action potential of a cardiac contractile cell
PNa PX = Permeability to ion X
1
+20
2 PK and PCa
Resting membrane 0
Membrane potential (mV)

potential is -90mv. -20
3 PK and PCa
-40 0
Na+ passes through -60 PNa
double gated voltage
channels -80 4 4
-100
Plateau results from 0 100 200 300
decreased K+ and Phase

Time (msec)
Membrane channels
increased Ca++ 0 Na+ channels open
Plateau end when flux 1

2
Na+ channels close
Ca2+ channels open; fast K+ channels close
is reversed 3 Ca2+ channels close; slow K+ channels open
4 Resting potential
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-13
Myocardial Contractile Cells
Refractory periods and summation in skeletal and
cardiac muscle- this prevents summation as it
happens in skeletal muscle
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-14c
Electrical Conduction in Myocardial Cells
1% of
myocardial cells
are designed to
spontaneously
generate an
action potential.
They can
contract without
outside signal=
autorhythmic.
Pacemaker cells
do not have
sarcomeres
The Heart: Conduction System
· Intrinsic conduction system

(nodal system)
· Heart muscle cells contract, without nerve
impulses, in a regular, continuous way
· One directly pathway in depol/ repolarization
· SA node (up right) to ventricle wall (down left)

The Heart: Conduction System
· Special tissue sets the pace
· Sinoatrial node (right atrium)
· Pacemaker
· Atrioventricular node (junction of right &
left atria and ventricles)
· Atrioventricular bundle (Bundle of His)
· Bundle branches (right and left)
· Purkinje fibers
Electrical Conduction in Heart
1
1
SA node
AV node
2
THE CONDUCTING SYSTEM 1 SA node depolarizes.

OF THE HEART
2 Electrical activity goes

rapidly to AV node via
SA node internodal pathways.
3
Internodal
pathways
3 Depolarization spreads
more slowly across
atria. Conduction slows
through AV node.
AV node
4 Depolarization moves
A-V bundle rapidly through ventricular
4
Bundle branches conducting system to the
Purkinje apex of the heart.
fibers
5 Depolarization wave
5 spreads upward from
the apex.
Purple shading in steps 2–5 represents depolarization.

Question
 There is a little bit of delay in time conduction of AV
junction.
 What is it effect on?
 How can you prove the delay?
 What if it shorter and longer than normal?

Electrocardiography
ECG: Electrical activity

observation
Electrical Conduction & Einthoven’s Triangle
 AV node
 Direction of electrical
signals
 Delay the transmission of
action potentials
 SA node
 Set the pace of the
heartbeat at 70 bpm
 AV node (50 bpm) and
Purkinje fibers (25-40
bpm) can act as
pacemakers under some
conditions

Question
 What is the differences between electrocardiogram of
right electrodes vs left electrodes?
 Give an example of right electrodes
 Give an example of left electrodes
 Explain the electrocardiogram differences!
 What if the electrode is putted between right and left?
Give an example!

Electrical Activity
Comparison of an ECG and a myocardial action potential
The Electrocardiogram
ECG give info on
heart rate, heart
rhythm, conduction
velocity, and heart
condition. Three
major waves: P wave,
QRS complex, and T
wave
Waves correspond to
events of the cardiac
cycle.
Electrical Activity
Correlation between an ECG and electrical events in the heart
P wave: atrial
START depolarization
The end
R PQ or PR segment:
conduction through
AV node and A-V
P T bundle
QS P
Atria contract.
T wave:
ventricular Repolarization ELECTRICAL
Repolarization R EVENTS
OF THE
CARDIAC CYCLE
P T
QS
P Q wave
Q
ST segment
R
R wave
P R
QS
P
Ventricles contract. R
Q
P S wave
QS
Electrical Activity
The P wave START

P wave: atrial
depolarization
reflects the P
activity of the PQ or PR segment:

conduction through
atria. The atria

AV node and A-V
bundle
P
contract from top Atria contract.
to bottom so the ELECTRICAL

EVENTS
P-wave ends
OF THE
CARDIAC CYCLE
after full atrial

depolarization
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-21 (2 of 9)
Electrical Activity
The P-Q P wave: atrial
segment reflects
START depolarization
the flow of PQ or PR segment:
current along the conduction through

AV node and A-V
bundle
interventricular P
septum via the

Atria contract.
ELECTRICAL
AV node and AV EVENTS

OF THE
CARDIAC CYCLE
bundle. This is
the time when
P Q wave
the ventricles
are relaxed and
filling with blood
Electrical Activity
The QRS complex START
P wave: atrial
depolarization
occurs while the P
ventricles contraction PQ or PR segment:
(depolarize) from the conduction through

AV node and A-V
bundle
apex & upwards. At the P
end of the contraction Atria contract.
all blood volume to be ELECTRICAL
expelled as been
EVENTS
OF THE
CARDIAC CYCLE
pushed out.
P Q wave
S-T segment happens ST segment

Q
during ventricular R
repolarization (relax)
R wave
P R
QS
P
Q
P S wave
QS
Electrical Activity
The T-wave START

P wave: atrial
depolarization
indicates P
ventricular The end

R PQ or PR segment:
repolarization-
conduction through
AV node and A-V
P T bundle
meaning that
QS P
Atria contract.
the muscle is T wave:

ventricular Repolarization ELECTRICAL
coming back to
Repolarization R EVENTS
OF THE
CARDIAC CYCLE
P T
a resting state. QS
P Q wave
At this point the ST segment

Q
chambers are
R
R wave
P R
ready to QS
P
receive blood P S wave

Q
QS
Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings Figure 14-
Electrical Activity
Normal and abnormal electrocardiograms
Pathology of the Heart
• Damage to AV node = release of ventricles
from control = slower heart beat
• Slower heart beat can lead to fibrillation
• Fibrillation = lack of blood flow to the heart
• Tachycardia = more than 100 beats/min
• Bradychardia = less than 60 beats/min
HEART CYCLE
The Heart: Cardiac Cycle
· Atria contract simultaneously

· Atria relax, then ventricles contract
· Systole = contraction
· Diastole = relaxation

Filling of Heart Chambers –
the Cardiac Cycle
Figure 11.6

Wiggers Diagram
Time (msec)
This diagram Electro-
0 100
QRS
200 300 400 500 600 700 800
QRS
shows the complex Cardiac cycle complex

cardiogram
(ECG) P T P
relationship 120
between the 90 Aorta Dicrotic
cardiac cycle,
Pressure notch
(mm Hg)
Left
60 ventricular
the ECG, the Left atrial

30 pressure
pressure
heart sounds,
and pressure Heart
sounds
135
S1 S2
changes in the Left

ventricular
left ventricle volume

(mL) 65
Atrial Ventricular Ventricular Atrial
and aorta
systole systole diastole systole
Atrial systole Isovolumic Ventricular Early Late Atrial

ventricular systole ventricular ventricular systole
contraction diastole diastole
Wiggers Diagram
This shows the correlation between the
carciac cycle and the ECG. Notice between
the T wave of one and P wave of another
the ventricles are relaxed while the atria are
filling and beginning to empty prior to atrial
depolarization
Time (msec)
0 100 200 300 400 500 600 700 800
Electro- QRS Cardiac cycle QRS
cardiogram complex complex
(ECG) P T P


Wiggers Diagram
This phase shows the changes in

blood volume as the ventricle contracts
(depolarizes) or relaxes (repolarizes)
Time (msec)
0 100 200 300 400 500 600 700 800
135
Left
ventricular
volume
(mL) 65

Wiggers Diagram
You can see the relationship between pressure chages in teh
atrium and the cardiac cycle. Notice that the lowest atrial
pressure is during ventricular diastole.
Time (msec)
0 100 200 300 400 500 600 700 800
90
Pressure
(mm Hg)
60
30
Left atrial
pressure
Left 135
ventricular
volume
(mL)
65

ventricular
Copyright © 2007 Pearson Education, systole Cummingsventricular
Inc., publishing as Benjamin ventricular systoleFigure 14-26
Wiggers Diagram
This shows changes in ventricular pressure and
valve sounds as the AV valve (S1) and
semilunar valves (S2) close.
Time (msec)
0 100 200 300 400 500 600 700 800
120
90
Pressure
(mm Hg)
Left
60 ventricular
pressure
30
Heart S1 S2
sounds
135 Atrial Ventricular Ventricular Atrial

Wiggers Diagram
This shows changes in ventricular pressure
and ventricular blood volume.
Time (msec)
0 100 200 300 400 500 600 700 800
90
Pressure
(mm Hg)
60
Left
ventricular
30 pressure
Left 135 S2
S1
ventricular
volume
(mL)
65

Wiggers Diagram
The top line shows changes in pressure of the aorta as the left
ventricle contracts or relaxes. The dicrotic notch occurs as a
sharp drop in pressure results from a drop in blood flow once
the ventricle begins to relax
Time (msec)
0 100 200 300 400 500 600 700 800
120
90 Aorta Dicrotic
Pressure notch
(mm Hg)
Left
60 ventricular
pressure
30
Heart S1 S2
sounds

Wiggers Diagram
Time (msec)
0 100 200 300 400 500 600 700 800
120
90 Aorta Dicrotic
Pressure notch
(mm Hg)
Left
60 ventricular
pressure
Left atrial
30 pressure
Heart S1 S2
sounds

Wiggers Diagram
Time (msec)
0 100 200 300
Electro- QRS
cardiogram complex
(ECG) P T
This shows 120
all the events Pressure

90 Aorta
that are (mm Hg)

60
Left
ventricular
happening Left atrial

30 pressure
pressure
during one
complete Heart
sounds
135
S1
ECG wave Left

ventricular
volume
(mL) 65
Atrial Ventricular
systole systole
Ventricular
systole
Wiggers Diagram
Time (msec)
0 100 200 300 400 500 600 700 800
Electro- QRS
complex Cardiac cycle
cardiogram
P T
This
(ECG)
120
shows all
the 90 Aorta Dicrotic
Pressure notch
(mm Hg)
Left
changes 60
Left atrial
ventricular
pressure
happening 30 pressure
during Heart S1 S2
ventricular
sounds
135
Left
diastole ventricular
volume
(mL) 65
Atrial Ventricular Ventricular
systole systole diastole
Late
ventricular
diastole
Wiggers Diagram
Time (msec)
0 100 200 300 400 500 600 700 800
Electro- QRS QRS
These complex Cardiac cycle complex

cardiogram
(ECG) P T P
are all 120
the Pressure
90 Aorta Dicrotic
events
notch
(mm Hg)
Left
60 ventricular
during Left atrial

30 pressure
pressure
one
complete Heart
sounds
135
S1 S2
cardiac Left
ventricular
cycle
volume
(mL) 65

CARDIAC OUTPUT
Cardiac Cycle
Left ventricular pressure-volume changes during one
cardiac cycle
KEY
EDV = End-diastolic volume
ESV = End-systolic volume
Stroke volume
120
D
Left ventricular pressure (mm Hg)
ESV
80 C
One
cardiac
cycle
40
EDV
B
A
0 65 100 135
Left ventricular volume (mL)
Cardiac Cycle
At the beginning of the diastolic phase the
ventricles are relax and contain a very small
amount of blood
KEY
120
80
40
A
0 65 100 135
Cardiac Cycle
At then of the diastolic phase the volume as
increased because the ventricle has filled after
the ventricles contracted
KEY
120
80
40
EDV
B
A
0 65 100 135
Cardiac Cycle
At point C (systole phase) the pressure has
increased but the volume has not changed
KEY
120
80 C
40
EDV
B
A
0 65 100 135
Cardiac Cycle
At the end of systole the pressure is at is
highest and the volume has dropped.
Stroke volume= EDV - ESV
KEY
Stroke volume
120
D
ESV
80 C
One
cardiac
cycle
40
EDV
B
A
0 65 100 135
The Heart: Cardiac Output
· Cardiac output (CO)

· Amount of blood pumped by each side of
the heart in one minute
· CO = (heart rate [HR]) x (stroke volume
[SV])
· Stroke volume
· Volume of blood pumped by each ventricle
in one contraction

Cardiac output, cont.
• CO = HR x SV
• 5250 ml/min = 75 beats/min x 70 mls/beat
• Norm = 5000 ml/min
• Entire blood supply passes through body
once per minute.
• CO varies with demands of the body.
Cardiac Output Regulation
Figure 11.7

Regulation of Heart Rate
· Stroke volume usually remains relatively

constant
· Starling’s law of the heart – the more that
the cardiac muscle is stretched, the
stronger the contraction
· Changing heart rate is the most
common way to change cardiac output

Regulation of Heart Rate
· Increased heart rate
· Sympathetic nervous system
· Crisis
· Low blood pressure
· Hormones
· Epinephrine
· Thyroxine
· Exercise
· Decreased blood volume

The Heart: Regulation of Heart
Rate
· Decreased heart rate
· Parasympathetic nervous system
· High blood pressure or blood volume
· Dereased venous return
· In Congestive Heart Failure the heart is
worn out and pumps weakly. Digitalis
works to provide a slow, steady, but
stronger beat.
Congestive Heart Failure (CHF)
• Decline in pumping efficiency of heart
• Inadequate circulation
• Progressive, also coronary atherosclerosis, high
blood pressure and history of multiple Myocardial
Infarctions
• Left side fails = pulmonary congestion and
suffocation
• Right side fails = peripheral congestion and edema
VASCULAR
Blood Vessels: The Vascular
System
· Taking blood to the tissues and back

· Arteries
· Arterioles
· Capillaries
· Venules
· Veins

The Vascular System
Figure 11.8b

Blood Vessels: Anatomy
· Three layers (tunics)
· Tunic intima
· Endothelium
· Tunic media
· Smooth muscle
· Controlled by sympathetic nervous
system
· Tunic externa
· Mostly fibrous connective tissue

Differences Between Blood Vessel
Types
· Walls of arteries are the thickest
· Lumens of veins are larger
· Skeletal muscle “milks” blood in veins
toward the heart
· Walls of capillaries are only one cell
layer thick to allow for exchanges
between blood and tissue

Movement of Blood Through
Vessels
· Most arterial blood is

pumped by the heart
· Veins use the milking
action of muscles to
help move blood
Figure 11.9

Capillary Beds
· Capillary beds
consist of two
types of vessels
· Vascular shunt –
directly connects an
arteriole to a venule
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 11.10 Slide
Capillary Beds
· True capillaries –
exchange vessels
· Oxygen and
nutrients cross to
cells
· Carbon dioxide
and metabolic
waste products
cross into blood
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Figure 11.10 Slide
Diffusion at Capillary Beds
Figure 11.20

VITAL SIGN MEASUREMENT
Vital Signs
• Arterial pulse
• Blood pressure
• Repiratory Rate
• Body Temperature
• All indicate the efficiency of the system
Pulse
· Pulse –
pressure wave
of blood
· Monitored at
“pressure
points” where
pulse is easily
palpated
Figure 11.16
Blood Pressure
· Measurements by health professionals
are made on the pressure in large
arteries
· Systolic – pressure at the peak of
ventricular contraction
· Diastolic – pressure when ventricles relax
· Pressure in blood vessels decreases as
the distance away from the heart
increases
Measuring Arterial Blood Pressure
Figure 11.18

Blood Pressure: Effects of Factors
· Neural factors
· Autonomic nervous system adjustments
(sympathetic division)
· Renal factors
· Regulation by altering blood volume
· Renin – hormonal control

Blood Pressure: Effects of Factors
· Temperature
· Heat has a vasodilation effect
· Cold has a vasoconstricting effect
· Chemicals
· Various substances can cause increases or
decreases
· Diet

Variations in Blood Pressure
· Human normal range is variable
· Normal
· 140–110 mm Hg systolic
· 80–75 mm Hg diastolic
· Hypotension
· Low systolic (below 110 mm HG)
· Often associated with illness
· Hypertension
· High systolic (above 140 mm HG)
· Can be dangerous if it is chronic

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HEART & ECG

from : Elaine N. Marieb & Dee Unglaub Sylverthorn

Dr. BAMBANG PURWANTO, dr., M.Kes

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

· Pericardium – a double serous

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

· Valves open as blood is pumped

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

 Smaller and have single nucleus per fiber

Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings

T-tubule 5 Summed Ca Sparks

T-tubule 5 Summed Ca Sparks

7 Relaxation occurs when

Contraction Relaxation Myosin

Membrane potential (mV)

decreased K+ and Phase

Plateau end when flux 1

· Intrinsic conduction system

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

THE CONDUCTING SYSTEM 1 SA node depolarizes.

2 Electrical activity goes

Purple shading in steps 2–5 represents depolarization.

Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings

ECG: Electrical activity

Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings

Copyright © 2007 Pearson Education, Inc., publishing as Benjamin Cummings

The P wave START

activity of the PQ or PR segment:

atria. The atria

contract from top Atria contract.

to bottom so the ELECTRICAL

after full atrial

The P-Q P wave: atrial

the flow of PQ or PR segment:

current along the conduction through

septum via the

AV node and AV EVENTS

occurs while the P

ventricles contraction PQ or PR segment:

(depolarize) from the conduction through

end of the contraction Atria contract.

all blood volume to be ELECTRICAL

S-T segment happens ST segment

The T-wave START

ventricular The end

the muscle is T wave:

At this point the ST segment

receive blood P S wave

· Atria contract simultaneously

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide

shows the complex Cardiac cycle complex

between the 90 Aorta Dicrotic

the ECG, the Left atrial

changes in the Left

left ventricle volume

Atrial systole Isovolumic Ventricular Early Late Atrial

Atrial Ventricular Ventricular Atrial

Atrial systole Isovolumic Ventricular Early Late Atrial

This phase shows the changes in

Atrial systole Isovolumic Ventricular Early Late Atrial

Atrial systole Isovolumic Ventricular Early Late Atrial