The Cardiovascular System:

The Heart
Anatomy

1
Heart Anatomy

 Approximately the size of your fist

 Location
 Superior surface of diaphragm

 Left of the midline

 Anterior to the vertebral column, posterior to the

sternum

2
Heart Anatomy

3
Coverings of the Heart: Anatomy
 Pericardium – a double-walled sac around the
heart composed of:
1. A superficial fibrous pericardium
2. A deep two-layer serous pericardium
a. The parietal layer lines the internal surface of
the fibrous pericardium
b. The visceral layer or epicardium lines the
surface of the heart
 They are separated by the fluid-filled
pericardial cavity
4
Coverings of the Heart: Physiology

 The Function of the Pericardium:

 Protects and anchors the heart

 Prevents overfilling of the heart with blood

 Allows for the heart to work in a relatively friction-

free environment

Chapter 18, Cardiovascular System 5

Heart Wall

 Epicardium – visceral layer of the serous

pericardium
 Myocardium – cardiac muscle layer forming the
bulk of the heart
 Fibrous skeleton of the heart – crisscrossing,
interlacing layer of connective tissue
 Endocardium – endothelial layer of the inner
myocardial surface
6
External Heart: Major Vessels of the Heart
(Anterior View)
 Vessels returning blood to the heart include:
1. Superior and inferior venae cavae
2. Right and left pulmonary veins
 Vessels conveying blood away from the heart include:
1. Pulmonary trunk, which splits into right and left
pulmonary arteries
2. Ascending aorta (three branches) –
a. Brachiocephalic
b. Left common carotid
c. Subclavian arteries
Chapter 18, Cardiovascular System 7
External Heart: Vessels that Supply/Drain the
Heart (Anterior View)

 Arteries – right and left coronary (in

atrioventricular groove), marginal, circumflex, and
anterior interventricular arteries
 Veins – small cardiac, anterior cardiac, and great
cardiac veins

Chapter 18, Cardiovascular System 8

External Heart: Anterior View

Figure
9
18.4b
Chapter 18, Cardiovascular System
External Heart: Major Vessels of the Heart
(Posterior View)

 Vessels returning blood to the heart include:

1. Right and left pulmonary veins

2. Superior and inferior venae cavae

 Vessels conveying blood away from the heart

include:
1. Aorta

2. Right and left pulmonary arteries

Chapter 18, Cardiovascular System 10
External Heart: Vessels that Supply/Drain the
Heart (Posterior View)

 Arteries – right coronary artery (in atrioventricular

groove) and the posterior interventricular artery (in
interventricular groove)
 Veins – great cardiac vein, posterior vein to left
ventricle, coronary sinus, and middle cardiac vein

Chapter 18, Cardiovascular System 11

Atria of the Heart

 Atria are the receiving chambers of the heart

 Each atrium has a protruding auricle

 Pectinate muscles mark atrial walls

 Blood enters right atria from superior and inferior

venae cavae and coronary sinus
 Blood enters left atria from pulmonary veins

Chapter 18, Cardiovascular System 12

Ventricles of the Heart

 Ventricles are the discharging chambers of the heart

 Papillary muscles and trabeculae carneae muscles

mark ventricular walls
 Right ventricle pumps blood into the pulmonary
trunk
 Left ventricle pumps blood into the aorta

Chapter 18, Cardiovascular System 13

Atrial Septal Defect

Chapter 18, Cardiovascular System 14

Ventricular Septal Defect

Chapter 18, Cardiovascular System 15

Pathway of Blood Through the Heart and
Lungs
 Right atrium  tricuspid valve  right ventricle

 Right ventricle  pulmonary semilunar valve 

pulmonary arteries  lungs
 Lungs  pulmonary veins  left atrium

 Left atrium  bicuspid valve  left ventricle

 Left ventricle  aortic semilunar valve  aorta

 Aorta  systemic circulation

Chapter 18, Cardiovascular System 16
Pathway of Blood Through the Heart and
Lungs

Figure
17
18.5
Chapter 18, Cardiovascular System
Coronary Circulation

 Coronary circulation is the functional blood supply

to the heart muscle itself
 Collateral routes ensure blood delivery to heart
even if major vessels are occluded

Chapter 18, Cardiovascular System 18

Coronary Circulation: Arterial Supply

Chapter 18, Cardiovascular System 19

Figure 18.7a
Coronary Circulation: Venous Supply

Chapter 18, Cardiovascular System 20

Figure 18.7b
Heart Valves

 Heart valves ensure unidirectional blood flow

through the heart
 Atrioventricular (AV) valves lie between the atria
and the ventricles
 AV valves prevent backflow into the atria when
ventricles contract

 Chordae tendineae anchor AV valves to papillary

muscles

Chapter 18, Cardiovascular System 21

Heart Valves

 Semilunar valves prevent backflow of blood into the

ventricles
 Aortic semilunar valve lies between the left
ventricle and the aorta
 Pulmonary semilunar valve lies between the right
ventricle and pulmonary trunk

Chapter 18, Cardiovascular System 22

Microscopic Anatomy of Heart Muscle

Chapter 18, Cardiovascular System 23

Figure 18.11
The Cardiovascular System:
The Heart
Physiology

24
Heart Physiology: Sequence of Excitation

 Sinoatrial (SA) node generates impulses about 75

times/minute
 Atrioventricular (AV) node delays the impulse
approximately 0.1 second

Chapter 18, Cardiovascular System 25

Heart Physiology: Sequence of Excitation

 Impulse passes from atria to ventricles via the

atrioventricular bundle (bundle of His)
 AV bundle splits into two pathways in the
interventricular septum (bundle branches)

1. Bundle branches carry the impulse toward the

apex of the heart

2. Purkinje fibers carry the impulse to the heart

apex and ventricular walls

Chapter 18, Cardiovascular System 26

Heart Physiology: Sequence of Excitation

Chapter 18, Cardiovascular System 27

Figure 18.14a
Heart Excitation Related to ECG

Figure
28
18.17
Chapter 18, Cardiovascular System
Extrinsic Innervation of the Heart

 Heart is stimulated
by the sympathetic
cardioacceleratory
center
 Heart is inhibited by
the parasympathetic
cardioinhibitory
center

Chapter 18, Cardiovascular System 29

Figure 18.15
Electrocardiography
 Electrical activity is recorded by electrocardiogram
(ECG)
 P wave corresponds to depolarization of SA node

 QRS complex corresponds to ventricular

depolarization
 T wave corresponds to ventricular repolarization

 Atrial repolarization record is masked by the larger

QRS complex
InterActive Physiology®:
PLAY
Cardiovascular System: Intrinsic Conduction System
Chapter 18, Cardiovascular System 30
Electrocardiography

Figure
31
18.16
Chapter 18, Cardiovascular System
Heart Sounds

 Heart sounds (lub-dup) are associated with closing

of heart valves
 First sound occurs as AV valves close and signifies
beginning of systole (contraction)
 Second sound occurs when SL valves close at the
beginning of ventricular diastole (relaxation)

Chapter 18, Cardiovascular System 32

Cardiac Cycle

 Cardiac cycle refers to all events associated with

blood flow through the heart
 Systole – contraction of heart muscle

 Diastole – relaxation of heart muscle

Chapter 18, Cardiovascular System 33

Phases of the Cardiac Cycle

 Ventricular filling – mid-to-late diastole

 Heart blood pressure is low as blood enters atria
(passively) and flows into ventricles
 AV valves are open, then atrial systole occurs

Chapter 18, Cardiovascular System 34

Phases of the Cardiac Cycle

 Ventricular systole (contraction)

 Atria relax

 Rising ventricular pressure results in closing of AV

valves
 Isovolumetric contraction phase

 Ventricular ejection phase opens semilunar valves

Chapter 18, Cardiovascular System 35

Cardiac Output (CO) and Reserve

 Cardiac Output is the amount of blood pumped by

each ventricle in one minute
 CO is the product of heart rate (HR) and stroke
volume (SV)
 HR is the number of heart beats per minute

 SV is the amount of blood pumped out by a

ventricle with each beat

 Cardiac reserve is the difference between resting

and maximal CO
Chapter 18, Cardiovascular System 36
Cardiac Output: Example

 CO (ml/min) = HR (75 beats/min) x SV (70 ml/beat)

 CO = 5250 ml/min (5.25 L/min)

Chapter 18, Cardiovascular System 37

Regulation of Stroke Volume

 SV = end diastolic volume (EDV) minus end

systolic volume (ESV)
 EDV = amount of blood collected in a ventricle
during diastole
 ESV = amount of blood remaining in a ventricle
after contraction

Chapter 18, Cardiovascular System 38

Congestive Heart Failure (CHF)

 Congestive heart failure (CHF) is caused by:

 Coronary atherosclerosis

 Persistent high blood pressure

 Multiple myocardial infarcts

 Dilated cardiomyopathy (DCM) – main pumping

chambers of the heart are dilated and contract
poorly

Chapter 18, Cardiovascular System 39

Developmental Aspects of the Heart

Figure
40
18.24
Chapter 18, Cardiovascular System
Developmental Aspects of the Heart

 Fetal heart structures that bypass pulmonary

circulation
 Foramen ovale connects the two atria

 Ductus arteriosus connects pulmonary trunk and

the aorta

Chapter 18, Cardiovascular System 41

Examples of Congenital Heart Defects

Figure
42
18.25
Chapter 18, Cardiovascular System
Age-Related Changes Affecting the Heart

 Sclerosis and thickening of valve flaps

 Decline in cardiac reserve

 Fibrosis of cardiac muscle

 Atherosclerosis

Chapter 18, Cardiovascular System 43

Congestive Heart Failure
 Causes of CHF

 coronary artery disease, hypertension, MI, valve disorders,

congenital defects
 Left side heart failure
 less effective pump so more blood remains in ventricle
 heart is overstretched & even more blood remains
 blood backs up into lungs as pulmonary edema
 suffocation & lack of oxygen to the tissues

 Right side failure

 fluid builds up in tissues as peripheral edema

Chapter 18, Cardiovascular System 44
Coronary Artery Disease

 Heart muscle receiving

insufficient blood supply
 narrowing of vessels---
atherosclerosis, artery
spasm or clot
 atherosclerosis--smooth
muscle & fatty deposits in
walls of arteries

 Treatment
 drugs, bypass graft,
angioplasty, stent
Chapter 18, Cardiovascular System 45
Clinical Problems
 MI = myocardial infarction

 death of area of heart muscle from lack of O2

 replaced with scar tissue

 results depend on size & location of damage

 Blood clot

 use clot dissolving drugs streptokinase or t-PA & heparin

 balloon angioplasty

 Angina pectoris

 heart pain from ischemia (lack of blood flow and oxygen )

of cardiac muscle
Chapter 18, Cardiovascular System 46
By-pass Graft

Chapter 18, Cardiovascular System 47

Percutaneous Transluminal Coronary
Angioplasty

Chapter 18, Cardiovascular System 48

Artificial Heart

Chapter 18, Cardiovascular System 49

8.Chapter 8: Diseases of the Ear and Mastoid Process (H60-H95)
Reserved for future guideline expansion
9.Chapter 9: Diseases of the Circulatory System (I00-I99)

a. Hypertension
The classification presumes a causal relationship between hypertension and heart involvement and between hypertension and
kidney involvement, as the two conditions are linked by the term “with” in the Alphabetic Index. These conditions should be
coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states
the conditions are unrelated.

For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the
classification, provider documentation must link the conditions in order to code them as related .

1) Hypertension with Heart Disease

Hypertension with heart conditions classified to I50.- or I51.4- I51.7, I51.89, I51.9, are assigned to a code from category I11,
Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in
those patients with heart failure.

The same heart conditions (I50.-, I51.4-I51.7, I51.89, I51.9) with hypertension are coded separately if the provider has

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documented they are unrelated to the hypertension. Sequence according to the circumstances of the admission/encounter.

2)Hypertensive Chronic Kidney Disease

Assign codes from category I12, Hypertensive chronic kidney disease, when both hypertension and a condition classifiable to category
N18, Chronic kidney disease (CKD), are present. CKD should not be coded as hypertensive if the provider indicates the CKD is not
related to the hypertension.

The appropriate code from category N18 should be used as a secondary code with a code from category I12 to identify the stage of
chronic kidney disease.

See Section I.C.14. Chronic kidney disease.

If a patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is required.

3)Hypertensive Heart and Chronic Kidney Disease

Assign codes from combination category I13, Hypertensive heart and chronic kidney disease, when there is hypertension with both heart
and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure.

The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to
identify the stage of chronic kidney disease.

See Section I.C.14. Chronic kidney disease.

The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease
and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13. If a
patient has hypertension, heart disease and chronic kidney disease, then a code from I13 should be used, not individual codes for
hypertension, heart disease and chronic kidney disease, or codes from I11 or I12.

For patients with both acute renal failure and chronic kidney disease, an additional code for acute renal failure is required.

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4) Hypertensive Cerebrovascular Disease
For hypertensive cerebrovascular disease, first assign the appropriate code from categories I60-I69, followed by the
appropriate hypertension code.

5) Hypertensive Retinopathy
Subcategory H35.0, Background retinopathy and retinal vascular changes, should be used with a code from category
I10
– I15, Hypertensive disease to include the systemic hypertension. The sequencing is based on the reason for the
encounter.

6) Hypertension, Secondary
Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying
etiology and one from category I15 to identify the hypertension. Sequencing of codes is determined by the
reason for admission/encounter.

7) Hypertension, Transient
Assign code R03.0, Elevated blood pressure reading without diagnosis of hypertension, unless patient has an
established diagnosis of hypertension. Assign code O13.-, Gestational [pregnancy-induced] hypertension
without significant proteinuria, or O14.-, Pre-eclampsia, for transient hypertension of pregnancy.

8) Hypertension, Controlled
This diagnostic statement usually refers to an existing state of hypertension under control by therapy. Assign the
appropriate code from categories I10-I15, Hypertensive diseases.

9) Hypertension, Uncontrolled
Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic
regimen. In either case, assign the appropriate code from categories I10- I15, Hypertensive diseases.

10) Hypertensive Crisis

Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency
or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is
based on the reason for the encounter.

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11) Pulmonary Hypertension
Pulmonary hypertension is classified to category I27, Other pulmonary heart diseases. For secondary pulmonary
hypertension (I27.1, I27.2-), code also any associated conditions or adverse effects of drugs or toxins. The sequencing is
based on the reason for the encounter, except for adverse effects of drugs (See Section I.C.19.e.).

b.Atherosclerotic Coronary Artery Disease and Angina

ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these
codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of
coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.

When using one of these combination codes it is not necessary to use an additional code for angina pectoris. A causal
relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates
the angina is due to something other than the atherosclerosis.

If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be
sequenced before the coronary artery disease.

See Section I.C.9. Acute myocardial infarction (AMI)

c.Intraoperative and Postprocedural Cerebrovascular Accident

Medical record documentation should clearly specify the cause- and- effect relationship between the medical intervention
and the cerebrovascular accident in order to assign a code for intraoperative or postprocedural cerebrovascular accident.
Proper code assignment depends on whether it was an infarction or hemorrhage and whether it occurred intraoperatively or
postoperatively. If it was a cerebral hemorrhage, code assignment depends on the type of procedure performed.

d.Sequelae of Cerebrovascular Disease

1) Category I69, Sequelae of Cerebrovascular disease
Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits),
themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions

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classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may
arise at any time after the onset of the condition classifiable to categories I60-I67.

Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify
whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or
nondominant, and the classification system does not indicate a default, code selection is as follows:
For ambidextrous patients, the default should be dominant.
If the left side is affected, the default is non-dominant.
If the right side is affected, the default is dominant.

2)Codes from category I69 with codes from I60-I67 Codes from category I69 may be assigned on a health care record with
codes from I60-I67, if the patient has a current
cerebrovascular disease and deficits from an old cerebrovascular disease.

3)Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction
(Z86.73)
Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

See Section I.C.21. 4. History (of) for use of personal history codes

e. Acute myocardial infarction (AMI)

1) Type 1 ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction
(NSTEMI)
The ICD-10-CM codes for type 1 acute myocardial infarction (AMI) identify the site, such as anterolateral wall or true posterior
wall. Subcategories I21.0-I21.2 and code I21.3 are used for type 1 ST elevation myocardial infarction (STEMI). Code I21.4, Non-
ST elevation (NSTEMI) myocardial infarction, is used for type 1 non ST elevation myocardial infarction (NSTEMI) and
nontransmural MIs.

If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a type 1 STEMI converts to NSTEMI due to thrombolytic
therapy, it is still coded as STEMI.

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For encounters occurring while the myocardial infarction is equal to, or less than, four weeks old, including transfers to another acute
setting or a postacute setting, and the myocardial infarction meets the definition for “other diagnoses” (see Section III, Reporting
Additional Diagnoses), codes from category I21 may continue to be reported. For encounters after the 4 week time frame and the
patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code
from category I21. For old or healed myocardial infarctions not requiring further care, code I25.2, Old myocardial infarction, may be
assigned.

2)Acute myocardial infarction, unspecified

Code I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type. If
only type 1 STEMI or transmural MI without the site is documented, assign code I21.3, ST elevation (STEMI) myocardial infarction of
unspecified site.

3)AMI documented as nontransmural or subendocardial but site provided

If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.

See Section I.C.21.3 for information on coding status post administration of tPA in a different facility within the last 24 hours.

4)Subsequent acute myocardial infarction

A code from category I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, is to be used
when a patient who has suffered a type 1 or unspecified AMI has a new AMI within the 4 week time frame of the initial AMI. A code
from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the
circumstances of the encounter.

Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified. For subsequent type 2 AMI assign only
code I21.A1. For subsequent type 4 or type 5 AMI, assign only code I21.A9.

If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type,

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 assign the appropriate codes from category I21 to identify each type. Do not assign a code from I22.
Codes from category I22 should only be assigned if both the initial and subsequent myocardial
infarctions are type 1 or unspecified.

5) Other Types of Myocardial Infarction

The ICD-10-CM provides codes for different types of myocardial infarction. Type 1 myocardial infarctions
are assigned to codes I21.0-I21.4 and I21.9.

Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic
balance) is assigned to code I21.A1, Myocardial infarction type 2 with a code for the underlying cause. Do
not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia.
Sequencing of type 2 AMI or the underlying cause is dependent on the circumstances of admission. When
a type 2 AMI code is described as NSTEMI or STEMI, only assign code I21.A1.
Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

Acute myocardial infarctions type 3, 4a, 4b, 4c and 5 are assigned to code I21.A9, Other myocardial
infarction type.

The "Code also" and "Code first" notes should be followed related to complications, and for coding of
postprocedural myocardial infarctions during or following cardiac surgery.

10.Chapter 10: Diseases of the Respiratory System (J00-J99)

a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma

1) Acute exacerbation of chronic obstructive bronchitis and asthma
The codes in categories J44 and J45 distinguish between uncomplicated cases and those in acute
exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute
exacerbation is not equivalent to an infection superimposed on a chronic condition, though an
exacerbation may be triggered by an infection.

b. Acute Respiratory Failure

1) Acute respiratory failure as principal diagnosis
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2019