Cardiovascular system

 Dr Madhavi Hewadikaram

 Content 
• Basic Anatomy of the Heart
• Cardiac cycle
• Systolic and Diastolic Pressure
• Heart Sounds
• ECG
• Regulation of Heart Rate 
• Cardiac Output
• Blood Pressure
Revision – Anatomy of the Heart 
 The cardiac cycle
• The cardiac events that occur from the beginning of one
heartbeat to the next is called as cardiac cycle
• Each cycle is initiated by spontaneous action potential in
the sinus node
• The action potential travels rapidly through both atria and
then through the A-V bundle into the ventricles
• Because of this arrangement , there is a delay of more than
0.1 second during passage of the cardiac impulse from atria
into ventricles
• This allows atria to contract ahead of ventricular
contractions
• It allows pumping blood into the ventricles before the
strong ventricular contraction begins
Stages of the cardiac cycle
 Diastole and Systole Pressure 
• Diastole-
 The period of relaxation in cardiac cycle 
 The heart fills with blood
                

Systole-
The period of contraction in cardiac cycle
 Pressure and Volume Changes during the
Cardiac Cycle
• Atrial Systole- contraction of atria
• During atrial systole, which lasts about 0.1 sec, the atria are
contracting. At the same time, the ventricles are relax 
• Depolarization of the SA node causes atrial depolarization.
• Atrial depolarization causes atrial systole
• As the atria contract, they exert pressure on the blood within, which
forces blood through the open AV valves into the ventricles.
• Ventricular Systole – contraction of the ventricles
• During ventricular systole, which lasts about 0.3 sec, the ventricles are
contracting.
• At the same time, the atria are relaxed in atrial diastole.
• About 0.05 seconds, both the SL (semilunar) and AV valves are closed.
This is the period of Isovolumetric contraction.
 • During this interval, cardiac muscle fibers are not yet shortening. Thus,
the muscle contraction is isometric.
 • Because all four valves are closed, ventricular volume remains the same
(isovolumic)
• Ventricular systole cont…
• Continued contraction of the ventricles causes pressure inside the
chambers to rise sharply.
• At this point, ejection of blood from the heart begins.
• The left ventricle ejects about 70 mL of blood into the aorta and the
right ventricle ejects the same volume of blood into the pulmonary
trunk.
• Relaxation Period
 • During the relaxation period, which lasts about 0.4 sec, the atria and
the ventricles are both relaxed.
• As the heart beats faster and faster, the relaxation period becomes
shorter and shorter, whereas the durations of atrial systole and
ventricular systole shorten only slightly
Relaxation period cont…
 • As the ventricles relax, pressure within the chambers falls, and blood
in the aorta and pulmonary trunk begins to flow backward toward the
the ventricles.
 • Backflowing blood catches in the valve cusps and closes the SL
valves.
• After the SL valves close, there is a brief interval when ventricular
blood volume does not change because all four valves are closed.
• This is the period of isovolumetric relaxation.
 Heart Sounds

• Normal Heart sounds

• Lub, dub,lub, dub
• Lub- closure of the atrioventricular (A-V)
valves at the beginning of systole ( first
heart sound)
• Dub- closure of the semilunar ( aortic and
pulmonary) valves at the end of systole
( second heart sound) 
Heart sounds 
• Duration and pitch of the first and second heart sounds is slightly more than 0.10
second
• The first sound about 0.14 second
• The second sound about 0.11 second
• The shorter second sound is due to the tight semilunar valves than A-V valves and
they vibrate for  a shorter time than A-V values 
 Third Heart Sound
• Occasionally will be heard at the beginning of the middle third of
diastole 

• Reason- Oscillation of blood back and forth between the walls of the
ventricles initiated by inrushing blood from the atria.
Fourth Heart Sound

• When the atria contract by the inrush of blood

into the ventricles.

• Both third and fourth sounds can be observed

by phonocardiogram 
 Electrocardiogram (ECG) 
• When the cardiac impulse passes through the heart, electrical current
also spreads from the heart into surrounding tissues.
• A small portion of current spreads all the way to the skin.
• When electrodes are placed on the skin on opposite sides of the
heart, electrical potentials generated by the current can be recorded.
• This record is the electrocardiogram
• Electrical activity is recorded as waves on a graph of voltage versus time.
•  • Give information about HR, rhythm, and some disease condition. ex-
MI, , Bundle Branch block.
Characteristics of
 ECG

• It is composed of 
- P wave
-QRS complex
- T wave
 Reasons for different waves 
P wave-
Caused by electrical potentials generated when the atria depolarize before atrial contractions
begin
This cause a slight rise in the atrial pressure curve immediately after P curve
After 0.16 seconds , the QRS waves appear

QRS complex
Caused by when the ventricles depolarize before contraction
During this process - 
Depolarization wave spreads through the ventricles
Causes the ventricular pressure
The QRS complex begins slightly before the onset of ventricular systole

• P and QRS complex are depolarization waves

T wave-
• Caused by the potentials generated as the ventricles recover from the
state of depolarization
• T wave is known as a repolarization wave
• This is repolarization of the ventricles when the ventricular muscle fibers
begin to relax
• T wave occurs slightly before the end of ventricular contraction
Relationship of Atrial and Ventricular Contraction
to the waves of the electrocardiogram
•Depolarization should spread the muscle to initiate the chemical
processes of contraction. 
P wave occurs at the beginning of contraction of the atria
QRS occurs at the beginning of contraction of the ventricles
The ventricles remain contracted until after repolarization or until after the
end of the T wave
The atria repolarize after termination of the P wave
By this time, QRS complex is being recorded in ECG
 Atrial repolarization wave, “ atrial T wave”
 Regulation of heart pumping
• When a person is at rest, the heart pumps only 4 – 6 liters of blood each minute
• During exercises , this increased up to 4-7 times
• Regulation of heart pump caused by 2 mechanisms
- Intrinsic cardiac regulation of pumping in response to changes in volume of
blood flowing into the heart
- Regulated by autonomic nervous system 
 Intrinsic Regulation of Heart Pumping
• Venous Return
  The amount of blood pumped by the heart  in each minute is determined by
the rate of blood flow into the heart from the veins.

Normal Blood Flow Mechanism

Each peripheral tissue of the body controls its own local blood flow
All local tissue flows combine
This flow will lead to the right atrium
The heart,  automatically, pumps this incoming blood into the arteries and
lets them flow around the circuit again
 Frank Starling Mechanism of the heart 
• The intrinsic ability of the heart to adapt to increasing volumes of inflowing
blood 

• " Within physiologic limits, the heart pumps all the blood that returns to it by
the way of the veins"

• Greater the heart muscle is stretched during filling; the force of contraction will
be high and the quantity of blood pump into the aorta will be high
 Autonomic Nerve System 
• Control of the heart by the sympathetic and parasympathetic nerves
• The amount of blood pump each minute can be increased more than
100 per cent via these sympathetic nerves
• The blood pump output can be decreased to low as 0 by
parasympathetic stimulation
 Mechanisms of excitation of the heart by
sympathetic nerves 
• Sympathetic nerve stimulation 
Increase the force of heart contraction to double by increasing the volume of
blood pumped and increasing the ejection pressure

This can increase the maximum cardiac output as much as 2-fold to 3-fold

Inhibition of the  sympathetic nerves to the heart can decrease cardiac

pumping to moderate extent 
 Parasympathetic stimulation of the heart
• Strong parasympathetic nerve stimulations can stop the heartbeat for
few seconds

• After that, the heart starts to beat 20 to 40 beats per minute as long

• Strong parasympathetic nerve stimulation can decrease the strength

of heart muscle by 20 to 30 percent
 Effects that cause for low heart rate
• Effect of potassium ions
• Excess potassium in the extra cellular fluids causes the heart to become
dilated and slow down the heart rate

• High potassium ion concentration in the extracellular fluids decrease the

resting membrane potential in the cardiac muscle fibers

• When the membrane potential decrease, the intensity of the action

potential decrease and lead to weak the heart rate. 
• Effect of calcium ions
-Excess Calcium ions  cause the heart towards the spastic contraction.
-Deficiency of calcium ions cause cardiac flaccidity
( Flaccid is a decrease or lack of muscle movement where the affected body part becomes floppy or
without muscle tone and with diminished reflexes)
• Effect of temperature 
- Increase body temperature increase the heart rate
This is because the heart increases the permeability of the cardiac muscle
membrane to ions that control heart rate. 
This will result to accelerate the self-excitation process
 Cardiac Output
•Cardiac output is the amount of blood the heart pumps in 1 minute

•It is dependent on the heart rate, contractility, preload, and afterload

of blood

•Cardiac output is logically equal to the product of the stroke volume

and the number of beats per minute (heart rate).
= Heart Rate * stroke volume ( 5lilters/min).
Cardiac Output 
 Heart Rate
• Sympathetic  nerves increase the heart rate. 
• How??
• Sympathetic nervous system (SNS) releases the hormones
(catecholamines - epinephrine and norepinephrine) to accelerate the
heart rate
• Parasympathetic nerves decrease the heart rate
 parasympathetic nervous system (PNS) releases the hormone
acetylcholine to slow the heart rate.
• Hormones 
- Increased levels of T4 stimulate the heart to beat more quickly and
more strongly, producing a fast heart rate
-T3 generally increases the force and speed of systolic contraction and
the speed of diastolic relaxation.
-(High amounts of T4, T3, or both can cause an excessively high
metabolic rate. This is called a hypermetabolic state. When in a
hypermetabolic state, you may experience a rapid heart rate, elevated
blood pressure, and hand tremors. You may also sweat a lot and
develop a low tolerance for heat). 
• Body Temperature
-  Increasing body temperature, will increase the heat through the
blood flowing in the veins and arteries.
-Heart beats faster and pumps harder and may circulate two to four
times as much blood each minute as it does on a cool day.
• Ions
- Calcium ions – high concentration of calcium ions increase the heart
rate 
(The calcium that enters the heart cell through the calcium ion channel
activates the ryanodine receptor to release enough calcium from the
sarcoplasmic reticulum to initiate heart muscle contraction.
This is done by binding to another structure, named troponin, inside
the heart muscle cell)
• Potassium Ions 
-High levels of potassium cause abnormal heart and skeletal muscle
function by lowering cell-resting action potential and preventing
repolarization, leading to muscle paralysis.

• Partial Pressure of oxygen and carbon dioxide 

- low partial pressure of oxygen and high partial pressure of carbon
dioxide activate the chemoreceptors that will eventually increase the
heart rate.
• Age
- Fetus / infants have higher heart rate ( 120-140 beats per minute)
- Females ( 72-80 beats per minute)  have higher heart rate than males
( 64-72 beats per minute). 
-Older people have higher heart rate
Bradycardia
• When the heart does not operate as it is supposed to and develops
an abnormally slow heart rate that is less than 60 beats per minute,
the condition is known as bradycardia.
•  Bradycardia can be life threatening if the heart is unable to maintain
a rate that pumps enough oxygen-rich blood throughout the body.
Tachycardia
• Tachycardia is the medical term for a heart rate over 100 beats per
minute. There are many heart rhythm disorders (arrhythmias) that
can cause tachycardia.
                     Stroke Volume
• Stroke Volume (SV) 
The volume of blood in milliliters ejected from each ventricle due to the
contraction of the heart muscle which compresses these ventricles.

• SV is the difference between end diastolic volume (EDV) and end

systolic volume (ESV).

SV= EDV-ESV
• End-Diastolic Volume (EDV) is the volume of blood in the right
and/or left ventricle at end load or filling in (diastole) or the amount
of blood in the ventricles just before systole.
•  Greater EDVs cause greater distention of the ventricle
• End-Systolic Volume (ESV)  

The volume of blood in the left or right ventricle at the end of the
systolic ejection phase immediately before the beginning of diastole or
ventricular filling
 Factors affecting the Stroke Volume
• Preload
• Contractility
• Afterload
Preload 
• It is the degree of myocardial distension prior to shortening
• An intrinsic property of myocardial cells is that the force of their
contraction depends on the length to which they are stretched: 
• The greater the stretch (within certain limits), the greater the force of
contraction. 
• An increase in the distension of the ventricle will therefore result in an
increase in the force of contraction, which will increase cardiac output.
• Preload can be increased by increasing the EDV by getting more venous
return
• Increasing ventricular filling time can increase the heart rate
•  Frank–Starling law of the heart !!!
Contractility ( Increase in the force of contraction)
•Increased contractility of the heart muscle, resulting in increased cardiac
output.

• Impaired contractility, will reduce cardiac output; however, too much

effort will result in fatigue, sometimes leading to a complete collapse, with
the need to slow down substantially or even to stop.
• Contractility depends on sympathetic nerve system. 
• Hormones can control the contractility 
• Drugs can increase the contractility ( eg- dopamine) 
Afterload
•Afterload is the force against which the ventricles must act in order to eject blood
and is largely dependent on the arterial blood pressure and vascular tone/ vascular
resistance.
• Afterload is largely dependent upon aortic pressure.
• Systolic hypertension (HTN) (elevated blood pressure) increases the left ventricular
(LV) afterload because the LV must work harder to eject blood into the aorta.
• This is because the aortic valve won't open until the pressure generated in the left
ventricle is higher than the elevated blood pressure in the aorta.
• Systemic vascular resistance (SVR) reflects changes in the arterioles, which can
affect emptying of the left ventricle.
•  For example, if the blood vessels tighten or constrict, SVR increases, resulting in
diminished ventricular compliance, reduced stroke volume and ultimately a drop in
cardiac output.
 Blood Pressure
• It is measured in millimeters of mercury ( mmHg) ( mercury manometer is
used) 
• Definition 
 The force exerted by the blood against any unit area of the vessel wall

Ex- If the blood pressure is 50mmHg 

This means that the force exerted is sufficient to push a column of mercury
against gravity up to a level 50mm high. 
 Basic techniques of blood pressure measurement

• Location of measurement
The standard location for blood pressure measurement is the brachial
artery

Brachial Artery
 Auscultatory and Oscillometric methods 
• Auscultatory method – Involves listening to arterial sounds
• Oscillometric method - This detects variations in pressure oscillations due to
arterial wall movement.

• Both methods use a measuring device attached to an inflatable cuff that is

placed around the patient’s upper arm
•  Inflated to clog the artery under the cuff, then released in a controlled manner
 Manual auscultatory measurement

• Manual BP measurement devices require the user to inflate the upper-arm cuff to
clog  the brachial artery
• Then listen to the Korotkoff sounds through a stethoscope while the cuff is slowly
deflated. 
• When the cuff is slowly deflated, five different sound phases can be heard:
• Phase I – a thud;
• Phase II – a blowing or swishing noise;
• Auscultatory gap – in some patients, the sounds disappear for a short period;
• Phase III – a softer thud than in phase I;
• Phase IV – a disappearing blowing noise;
• Phase V – silence: all sounds disappear 
• Practically, the systolic reading is when the Korotkoff sounds are first heard, and
• Devices that are generally used for manual BP measurement include:

• Aneroid sphygmomanometer –
This replaces the mercury manometer
 Requires use of a stethoscope

• Electronic sphygmomanometer –
This battery-powered device replaces the mercury manometer with a pressure
sensor and electronic display.
The display may be numerical, or a circular or linear bar graph. No stethoscope
is needed.
 Automated electronic BP devices

• In current clinical practice use the oscillometric

method

• The oscillometric method relies on detection of

variations in pressure oscillations due to arterial
wall movement beneath an occluding cuff to
calculate the systolic and diastolic BP readings
Arm selection and patient position
• BP should initially be measured in both arms, after which the arm with the
higher reading(s) should be used for subsequent measurements

• The patient’s arm should be supported while BP is measured; if it is

unsupported muscle contraction in the arm can lead to an erroneous
increase in the BP reading by as much as 10%

• The arm should be positioned at heart level: if it is lower than the heart, this
can lead to overestimation, while being above the level of the heart can lead
to an underestimation.
• If seated, the patient should not cross their legs as this can lead to an
increase in BP.
 Cuff size

• Miscuffing – particularly using a cuff that is too small – can lead to inaccurate
readings
If a cuff is too small, the BP will be overestimated and, if it is too big, the BP
will be underestimated. 

There are three cuff sizes:

• Children or small adults;
• Standard adults;
• Obese adults.
 Factors that can affect blood pressure.
• Cardiac output 
• The higher the cardiac output, the higher the volume of blood
in the vessels. Therefore, this increases the pressure in the
vessels.
• Peripheral resistance 
A  decrease in the diameter of the vessels, increases resistance
and blood pressure.

Changes to the blood viscosity and length of the blood vessels

also alter resistance to blood flow.
 Short-Term Regulation of Blood Pressure
• Short-term regulation of blood pressure is controlled by the autonomic
nervous system (ANS).
• Changes in blood pressure are detected by baroreceptors.
• These are in the arch of the aorta and the carotid sinus.
• Increased arterial pressure stretches the wall of the blood vessel, triggering
the baroreceptors.
• These baroreceptors then feedback to the autonomic nervous system. The
ANS then acts to reduce the heart rate via the efferent parasympathetic
fibres. This reduces the blood pressure.
• Decreased arterial pressure is detected by baroreceptors, which trigger
a sympathetic response. This stimulates an increase in heart rate and cardiac
contractility leading to increased blood pressure.
What we have covered 
• Basic Anatomy of the Heart
• Cardiac cycle
• Systolic and Diastolic Pressure
• Heart Sounds
• ECG
• Regulationd of Heart Rate
• Cardiac Output
• Blood Pressure
• Arteries are blood vessels that:
A. carry blood away from the heart
 B. carry oxygenated blood
 C. carry blood towards the heart
D. carry deoxygenated blood
 E. carry blood at low pressure
• The expression ‘cardiac cycle’ refers to:
• A. the sequence of events in the heart that take place every minute
• B. the volume of blood pumped by the ventricles every minute
• C. the sequence of events that can be seen on an electrocardiogram
• D. the sequence of events that create heart sounds 
• E. the sequence of events that take place between one heartbeat and
the next
• Put these parts of the electrical conducting system of the heart in the correct
order for conduction of the cardiac impulse: 
1. Atrioventricular node
2. Atrioventricular (AV) bundle (bundle of His)
3. Left and right bundle branches
4. Sinoatrial node
5. Purkinje fibres 
A. 5 – 3 – 2 – 1 – 4
B. 4 – 1 – 2 – 3 – 5 
C. 1 – 4 – 2 – 3 – 5 
D. 4 – 3 – 1 – 2 – 5 
E. 3 – 1 – 2 – 5 – 4 
• The cardiac output is determined by:
A. the heart rate
B. the volume of blood returning to the heart (preload)
C. afterload which depends on systemic vascular resistance
D. mechanical properties of the heart
E. all the above
• Within the circulation, where is blood pressure highest?
A. in the vena cava (great veins)
B. in the left ventricle
C. in the right ventricle
D. in the pulmonary artery
E. in the left atrium 
• The rhythm and electrical activity of the heart can be detected with
electrodes on the skin and displayed in the form of an:
A. electro-oculogram 
B. electroencephalogram
C. electrocardiogram
D. echocardiogram
E. electromyogram 
• The atrioventricular (AV) node is important for heart function
because:
A. it directs the cardiac impulse from the atria to the ventricles
B. it serves as the pacemaker for the heart
C. it delays the transmission of the cardiac impulse from the atria to the
ventricles
 D. Options A and B are correct
 E. Options A and C are correct 
• Which of the following events is the first to take place in a cardiac
cycle?
A. the SA node depolarises
B. the AV node depolarises
C. the P wave develops
D. the QRS complex develops
 E. the ventricles relax 
• Which of the following terms describes the volume of blood ejected
by the heart in one minute?
A. end diastolic volume (EDV)
B. stroke volume (SV)
C. heart rate (HR)
D. cardiac output (CO)
E. blood pressure (BP)
• These questions consist of two statements:
• an assertion, and • a reason.
You must first determine whether each statement is TRUE or FALSE.
• If both statements are true, you must next determine whether the
reason correctly explains the assertion.
The answer will be option 1 or option 2.
• If one statement is true and the other is false then the answer is
option 3 or option 4, depending on which of the statements is correct.
• If both statements are false, then the answer is option 5.
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• Physiology of GI Track
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