Cardiovascular System - 4th Ed
Cardiovascular System - 4th Ed
Cardiovascular System - 4th Ed
NOTES OF THE
CARDIOVASCULAR
SYSTEM
FOURTH EDITION
PRE-SUMMARIZED FOR THE TIME-POOR
READY-TO-STUDY MEDICAL, PRE-MED,
HIGH-YIELD NOTES USMLE OR PA STUDENT
201 PAGES
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Table Of Contents:
What’s included: Ready-to-study anatomy, physiology and pathology notes of the cardiovascular system presented
in succinct, intuitive and richly illustrated downloadable PDF documents. Once downloaded, you may choose to
either print and bind them, or make annotations digitally on your iPad or tablet PC.
Pathology Notes:
• CONGENITAL HEART DEFECTS
• ANEURYSMS & DISSECTIONS
• ARRHYTHMIAS
• DRUG CLASSES FOR TREATING ARRHYTHMIAS
• DYSLIPIDAEMIA
• ATHEROSCLEROSIS
• ISCHAEMIC HEART DISEASE
• ACUTE CARDIOGENIC PULMONARY OEDEMA
• HEART FAILURE
• CARDIOMYOPATHIES (“HEART MUSCLE DISEASES”)
• PATHOLOGY OF HYPERTENSION
• PATHOLOGY OF SHOCK
• DVT & PE
• CARCINOID HEART DISEASE
• INFECTIVE ENDOCARDITIS
• NON-INFECTIVE ENDOCARDITIS (NBTE - Non Bacterial Thrombotic Endocarditis)
• LYMPHANGITIS
• MYOCARDITIS – VIRAL & TOXIC
• PERICARDITIS
• PERICARDIAL EFFUSION
• CARDIAC TAMPONADE
• ACUTE ARTERIAL OCCLUSION (“CRITICAL LIMB ISCHAEMIA”)
• PERIPHERAL VASCULAR DISEASE
• VARICOSE VEINS
• CHRONIC SKIN ULCERS
• TUMOURS OF VESSELS
• IMPORTANT VASCULITIDES
• RHEUMATIC FEVER & RHEUMATIC HEART DISEASE
• VALVULAR HEART DISEASE & MURMURS
• CARDIOVASCULAR DISEASE & OBESITY; NUTRITION & PHYSICAL EXERCISE
ANATOMY OF THE HEART
HEART ANATOMY:
Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2).
The Pericardium: (Coverings of the Heart)
• A double-walled sac
• contains a film of lubricating serous fluid
• 2 Layers of Pericardium:
o Fibrous Pericardium:
§ Tough, dense connective tissue
§ Protects the heart
§ Anchors it to surrounding structures
§ Prevents overfilling of the heart – if fluid builds up in the pericardial cavity, it can inhibit
effective pumping. (Cardiac Tamponade)
o Serous Pericardium: (one continuous sheet with ‘2 layers’)
§ Parietal Layer – Lines the internal surface of the fibrous pericardium
§ Visceral Layer – (aka Epicardium) Lines the external heart surface
Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2)
Fibrous Skeleton of the Heart:
• The network of connective tissue fibers (collagen & elastin) within the myocardium
• Anchors the cardiac muscle fibers + valves + great vessels.
• Reinforces the myocardium
• Provides Electrical Isolation
• 2 Parts:
o Septums:
§ Flat sheets separating atriums, ventricles & left and right sides of the heart.
§ Electrically isolates the left & right sides of the heart (conn. Tissue = non-conductive)
• Important for cardiac cycle
§ (interatrial septum/atrioventricular septum/interventricular septum)
o Rings:
§ Rings around great vessel entrances & valves
§ stop stretching under pressure
• Arterial Supply:
o Encircle the heart in the coronary sulcus
o Aorta → Left & Right coronary arteries
§ Left Coronary Artery → 2 Branches:
• 1- Anterior InterVentricular Artery (aka. Left Anterior Descending Artery ...or LAD).
o Follows the Anterior InterVentricular Sulcus
o Supplies Apex, Anterior LV, Anterior 2/3 of IV-Septum.
• 2- Circumflex Artery
o Follows the Coronary Sulcus (aka. AtrioVentricular Groove)
o Supplies the Left Atrium + Lateral LV
• Venous Drainage:
o Venous blood – collected by the Cardiac Veins:
§ Great Cardiac Vein (in Anterior InterVentricular Sulcus)
§ Middle Cardiac Vein (in Posterior InterVentricular Sulcus)
§ Small Cardiac Vein (along Right inferior Margin)
o - Which empties into the Right Atrium.
Heart Valves:
• Ensure unidirectional flow of blood through the heart.
• Valve Sounds:
o 1- “Lubb”:
§ Sound of AV Valve Closure
§ (M1 = Mitral Component)
§ (T1 = Tricuspid Component)
o 2- “Dupp”:
§ Sound of Semilunar Valve Closure
§ (A2 = Aortic Component)
§ (P2 = Pulmonary Component)
• Where to Listen:
Adaptation of File:Precordial Leads 2.svg (by Jmarchn) and Rib_Cage (Jeroen Hut)
ELECTROPHYSIOLOGY OF THE HEART:
ELECTROPHYSIOLOGY OF THE HEART
The Heartbeat:
- Heart is a Muscle & Requires:
o O2
o Nutrients, &
o Action Potentials; to function.
- However, these neural signals don’t come from the brain;
o Rather, the heart has its own conduction systems.
§ These systems allow it to contract autonomously
o Hence why a transplanted heart still operates (if provided with O2 & nutrients)
- Cardiac Activity is Coordinated:
o To be effective, the Atria & Ventricles must contract in a coordinated manner.
o This activity is coordinated by the Heart’s Conduction Systems......
NOTE: There is a considerable delay between Myocardial Contraction & the Action Potential.
Refractory Periods:
- In Cardiac Muscle, the Absolute Refractory Period continues until muscle relaxation;
o Therefore summation isn’t possible → tetany cannot occur (critical in heart)
o Ie: The depolarised cell won’t respond to a 2nd stimulus until contraction is finished.
- Absolute Refractory Period:
o Approx 200ms
o Duration: from peak → plateau → halfway-repolarised.
- Relative Refractory Period:
o Na+ channels are closed – but can still respond to a stronger-than-normal stimulus.
o Approx 50ms
o Duration: Last half of repolarisation
The SinoAtrial (SA) Node:
- = The “PaceMaker” of the Heart: Unregulated Rate: 90-100bpm......however;
o Parasympathetic NS lowers heart rate → Keeps Normal Resting HR at 70bpm
o Sympathetic NS raises heart rate.
- Location:
o Posterior Wall of the Right Atrium near the opening of the Superior Vena Cava
- Nature of Action Potentials:
o Continually Depolarizing 90-100bpm
o Takes 50ms for Action-Potential to reach the AV Node.
- Role in Conduction Network:
o Sets the pace for the heart as a whole.
- Portion of Myocardium Served:
o Contracts the Right & Left Atrium
CardioNetworks: De-Conduction_ap.png
Effects of the Autonomic Nervous System (ANS):
- Although the heart can operate on its own, It normally communicates with the brain via the A.N.S.
- Parasympathetic NS:
o Innervates SA & AV Nodes → Slows Heart Rate
o Direct Stimulation → Releases AcetylCholine → Muscarinic receptors in SA/AV Nodes →
§ Causes increased K+ permeability (Efflux) → Hyperpolarises the cell →
• Cell takes longer to reach threshold → Lower Heart Rate
- Sympathetic NS:
o Innervates the SA & AV Nodes & Ventricular Muscle.
§ → Raises Heart Rate
§ → Increases Force of Contraction
§ → Dilates Arteries
o Indirect Stimulation → Sympathetic Nerve Fibres Release NorAdrenaline (NorEpinephrine) @ their
cardiac synapses → Binds to Beta 1 Receptors on Nodes & Muscles →
§ Initiates a Cyclic AMP Pathway → Increases Na+ + Ca+ Permeability in Nodal Tissue &
Increases Ca+ Permeability(Membrane & SR) in Muscle Tissue.
o Effects on Nodal Tissue:
§ ++Permeability to Na+ → more influx of Na+ → Membrane ‘drifts’ quicker to threshold →
Increased Heart Rate
§ ++Permeability to Ca+ → more influx of Ca+ → Membrane Depolarisation is quicker →
Increased Heart Rate
o Effects on Contractile Tissue:
§ ++ Membrane Permeability to Ca+ → More influx of Ca+ →
§ ++Sarcoplasmic Reticulum Permeability to Ca+ →Efflux of Ca+ into cytoplasm→
• Increases available Ca+ for contraction → Contractile Force Increases
What Is An ECG?
- A Recording of all Action Potentials by Nodal & Contractile Cells in the heart at a given time.
o NOTE: It IS NOT a single action potential.
o NOTE: A “Lead” refers to a combination of electrodes that form an imaginary line in the body, along
which the electrical signals are measured.
§ Ie: A 12 ‘lead’ ECG usually only uses 10 electrodes.
- Measured by VoltMetres → record electrical potential across 2 points:
o 3x Bipolar Leads: Measure Voltages between the Arms...OR...Between an Arm & a LEg:
§ I = LA (+) RA (-)
§ II = LL (+) RA (-)
§ III = LL (+) LA (-)
o 9x Unipolar Leads:
§ Look at the heart in a ‘3D’ Image.
o (A “Lead” refers to a combination of electrodes that form an imaginary line in the body, along which
the electrical signals are measured. Ie: A 12 ‘lead’ ECG usually only uses 10 electrodes.)
- Graphic Output:
o X-axis = Time
o Y-axis = Amplitude (voltage) – Proportional to number & size of cells.
- Understanding Waveforms:
o When a Depolarisation Wavefront moves toward a positive electrode, a Positive deflection results in
the corresponding lead.
o When a Depolarisation Wavefront moves away from a positive electrode, a Negative deflection
results in the corresponding lead.
o When a Depolarisation Wavefront moves perpendicular to a positive electrode, it first creates a
positive deflection, then a negative deflection.
PR-Segment:
- Reflects the delay between SA Node & AV Node.
- Atrial Contraction is occurring at this time.
Q – Wave:
- Interventricular Septum Depolarization
- Wave direction (see blue arrow) is perpendicular to the Main Electrical
Axis → results in a ‘Biphasic’ trace.
o Only the –ve deflection is seen due to signal cancellation by Atrial
Repolarization.
o Sometimes this wave isn’t seen at all
R – Wave:
- Ventricular Depolarization
- Wave Direction (blue arrow) is the same as the Main Electrical Axis →
Positive Deflection.
- R-Wave Amplitude is large due to sheer numbers of depolarizing
myocytes.
S – Wave:
- Depolarisation of the Myocytes at the last of the Purkinje Fibres.
- Wave Direction (black arrow) opposes the Main Electrical Axis → Negative
Deflection
- This wave is not always seen.
ST – Segment:
- Ventricular Contraction is occurring at this time.
o Due to the lag between excitation & contraction.
T – Wave:
- Ventricular Repolarisation
- Positive deflection despite being a Repolarisation wave – because Repol.
Waves travel in the opposite direction to Depol Waves.
Relating ECG Waves To Events In The Cardiac Cycle:
- Contractions of the Heart ALWAYS Lag Behind Impulses Seen on the ECG.
- Fluids move from High Pressure → Low Pressure
- Heart Valves Ensure a UniDirectional flow of blood.
- Coordinated Contraction Timing – Critical for Correct Flow of Blood.
o Normal Axis. QRS positive in I and aVF (0 90 degrees). Normal axis is actually 30 to 105 degrees.
o Left Axis Deviation (LAD). QRS positive in I and negative in aVF, 30 to 90 degrees
o Right Axis Deviation (RAD). QRS negative in I and positive in aVF, +105 to +180 degrees
o Extreme RAD. QRS negative in I and negative in aVF, +180 to +270 or 90 to 180 degrees
Algorithm For Looking At ECGs:
- Check Pt ID
- Check Voltage & timing
o 25mm/sec
o 1large square = 0.2s (1/5sec)
o 1small square = 0.04s
- What is the rate?
o 300/number of large squares between QRS Complexes
§ Tachycardia
• >100bpm
§ Bradycardia
• <60bpm
- What is the Rhythm?
o Sinus? (are there P-Waves before each QRS complex)
o If Not Sinus?
§ Is it regular
§ Irregular?
§ Irregularly Irregular (AF)
§ Brady/Tachy
- Atrial Fibrillation:
o Irregularly Irregular
o P-Waves @ 300/min
- QRS:
o Is there one QRS for each Pwave?
o Long PR Interval? (1st degree heart block)
o Missed Beats? (Second degree block)
o No relationship? Complete heart block
- Look for QRS Complexes:
o How wide – should be < 3 squares
o If wide – It is most likely Ventricular
o (Sometimes atrial with aberrant conduction (LBBB/RBBB)
o IF Tachycardia, & Wide Complex → VT is most likely. (If hypotensive → Shock; if Normotensive → IV
Drugs)
- Look for TWaves:
o Upright or Inverted
- Look at ST-Segment
o Raised, depressed or inverted
o ST Distribution → Tells you which of the coronaries are blocked/damaged
§ Inferior ischaemia (II, III, AVF)
§ Lateral ischaemia (I, II, AVL, V5, V6)
§ Anterior ischaemia (V, leads 2-6)
o NOTE: Normal ECG Doesn’t exclude infarct.
o ST Depression → Ischaemia
o ST Elevation → Infarction
o If LBBB or Paced, you CANNOT comment on ST-Segment
MECHANICAL EVENTS OF THE CARDIAC CYCLE
MECHANICAL EVENTS OF THE CARDIAC CYCLE
Terms:
- Systole = Myocardial Contraction
- Diastole = Myocardial Relaxation
- Stroke Volume = Output of Blood from the Heart Per Contraction (≈80mL of blood)
- Heart Rate = #Heart Beats/Minute
- Cardiac Output:
o Volume of Blood Ejected from the Heart Per Minute (Typically ≈5L/min)
o Cardiac Output = Heart Rate x Stroke Volume
o Chronotropic Influences:
§ Affect Heart Rate
o Inotropic Influences:
§ Affect Contractility (& :. stroke volume)
o Dromotropic Influences:
§ Affect AV-Node Delay.
- End Diastolic Volume = Ventricular Volume @ end of Diastole (When Ventricle is Fullest)
- End Systolic Volume = Ventricular Volume After Contraction (Normal ≈ 60-65%)
- Preload = The degree of Stretching of the Heart Muscle during Ventricular Diastole.
o (↑Preload = ↑cross linking of myofibrils = ↑Contraction (“Frank Starling Mechanism”)
- Afterload = The Ventricular Pressure required to Eject blood into Aorta/Pulmonary Art.
o (↑Afterload = ↓SV due to ↓ejection time)
Overview of the Cardiac Cycle in One Diagram:
Source: antranik.org
- PHASE 2- Ventricular Systole:
o a) AV Valves Close:
§ Ventricular Pressure Exceeds Atrial Pressure → AV Valves shut
§ Brief period of ‘IsoVolumetric’ Contraction:
• Where the ventricular pressure rises, but Volume Stays Constant.
• The beginning of ventricular systole
• All valves are still Closed.
Source: antranik.org
Source: antranik.org
- PHASE 3- Ventricular Diastole:
o Ventricles relax → Ventricular Pressure falls below Atrial Pressure → AV-Valves Open:
§ Blood → from Atria into Ventricles
§ (NOTE: Passive filling from venous return is responsible for 70% of ventricular filling.)
Source: https://www.humanbiomedia.org/cardiac-cycle-lesson/
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