Structure & Function of the Cardiovascular System

FUNCTIONS OF THE CIRCULATORY SYSTEM

 TRANSPORT
 Delivers oxygen to the tissues
 Delivers nutrients to the tissues
 Carries waste products from cellular metabolism to the kidneys and
other excretory organs
 Circulates electrolytes + hormones
 Transports various immune substances that contribute to the body’s
defense mechanisms
 Helps regulate temperature

2 PARTS OF THE CIRCULATORY SYSTEM

 Pulmonary Circulation
 Moves blood through the lungs
 Creates a link w/ the gas exchange function of the respiratory system
 Systemic Circulation
 Supplies all other tissues of the body

TYPES OF CIRCULATION
 Central Circulation
 Blood in the heart + in the pulmonary circulation
 Peripheral Circulation
 Blood outside the central circulation

CHARACTERISTICS OF THE PULMONARY & SYSTEMIC CIRCULATIONS

 Both have a Pump, an Arterial System, Capillaries, + a Venous System
 Arteries + Arterioles function as a Distribution System to move blood
to the tissues
 Capillaries serve as an Exchange System where transfer of gases,
nutrients, & wastes take place
 Venules + Veins serve as a Collection + Storage Vessels that return
blood to the heart

COMPONENTS OF THE CIRCULATORY SYSTEM

 Pulmonary Circulation
  Right Heart
 Pulmonary Artery
 Capillaries
 Veins
 Systemic Circulation
 Left Heart
 Aorta + its branches
 Capillaries supplying the brain & peripheral tissues
 Systemic Venous System
 Vena Cava

CIRCULATORY SYSTEM PRESSURE

 The circulatory system is a closed system in which the heart consists of 2
pumps in series
 Blood Pressure
 Arterial
 Higher pressure 90-100 mmHg
 Propels blood to all other tissues of the body
 i.e., systemic circulation
 Venous
 Lower pressure, 12 mmHg
 Propels blood through the lungs
 i.e., pulmonary circulation

BLOOD FLOW
 Laminar Blood Flow
 Layering of blood components in the center of the bloodstream
 Reduces frictional forces
 Prevents clotting factors from coming in contact w/ the vessel wall
 Turbulent Flow
 Disordered flow
 The blood moves crosswise + lengthwise in blood vessels

LAPLACE’S LAW
 Describes the relation among Wall Tension, Transmural Pressure, + Radius
 States that wall tension becomes greater as the radius increases
 Wall tension is also affected by wall thickness
  It increases as the wall becomes thinner
 It decreases as the wall becomes thicker

COMPLIANCE
 Total quantity of blood that can be stored in a given portion of the
circulation for each mmHg rise in pressure
 A change in volume causes less of an increase in transmural pressure in
a more compliant vessel
 A vein is 24 x’s more compliant than its corresponding artery
 8 x more distensible
 3 x more volume

FUNCTIONAL ANATOMY OF THE HEART

 Pericardium
 Forms a fibrous covering around the heart
 Holding it in a fixed position
 Provides physical protection
 Barrier to infection
 Myocardium
 Muscular portion
 Forms the Wall of the Atria + Ventricles
 Endocardium
 Thin, 3-layered membrane lining the heart

 One-Way Valves
 Atrioventricular Valves + Semilunar Valves are pressure valves that
ensure 1-way flow
 Fibrous Skeleton
 Provides structural support
 Provides isolating force for electrical impulse
 DISORDERS OF BLOOD FLOW IN THE SYSTEMIC CIRCULATION

BLOOD VESSELS
 Tunica Intima
 Endothelial Cells
 Tunica Media
 Smooth Muscle Cells

ENDOTHELIAL CELLS
 Control the transfer of molecules across the vascular wall
 Control Platelet Adhesion
 Control Blood Clotting
 Modulate Blood Flow
 Modulate Vascular Resistance
 Metabolize Hormones
 Regulates Immune + Inflammatory Reactions
 Influence the growth of other cell types

ENDOTHELIAL DYSFUNCTION
 Endothelial Dysfunction describes potentially reversible changes in
endothelial function that occur in response to environmental stimuli
 Products that cause inflammation
 Cytokines
 Bacteria
 Viruses
 Hemodynamic Stresses
 Lipid Products
 Hypoxia

VASCULAR SMOOTH MUSCLE CELLS

 Vasoconstriction or Dilation of Blood Vessels
 Autonomic Nervous System Regulation
 Sympathetic
 Local Regulation
 Nitric oxide
 Synthesize collagen, elastin, + other components of the extracellular
matrix
  Essential for healing
 Contribute to pathologic processes

HYPERCHOLESTEROLEMIA
a.k.a. Too much cholesterol

LIPIDS
 Triglycerides
 Used in energy metabolism
 Phospholipids
 Imp. Structural Constituents of Lipoproteins, Blood-Clotting
Components, the Myelin Sheath, & Cell Membranes
 Cholesterol
 Chemical activity similar to other lipid substances
 Hyperlipidemia
 Elevated levels of one –or- all of the above

TYPES OF LIPOPROTEINS, CLASSIFIED BY DENSITY

 Chylomicrons
 80-90% Triglycerides
 2% Protein
 Very-Low-Density Lipoprotein (VLDL)
 Carries large amts. of Triglycerides
 55-65% Triglycerides
 10% Cholesterol
 5-10% Protein
 Transports: Triglycerides from liver to adipose tissue
 R/T Atherosclerosis: Probably contributes to atherosclerosis
 Intermediate-Density Lipoprotein (IDL)
 Low-Density Lipoprotein (LDL)
 Main carrier of Cholesterol
 10% Triglycerides
 50% Cholesterol
 25% Protein
 Transports: Cholesterol from liver to artery walls Main Carrier
 R/T Atherosclerosis: Definitely contributes to atherosclerosis
 High-Density Lipoprotein (HDL)
  50% Protein
 5% Triglycerides
 20% Cholesterol
 50% Protein
 Transports: Cholesterol from artery walls to the liver for recycling
 R/T Atherosclerosis: Protective, Reverse Cholesterol Support

LIPOPROTEIN RECEPTORS
 Membrane proteins that facilitate cellular uptake of LDL, VLDL,
Chylomicrons, + ILDL Proteins
 Genetic abnormality may result in  Elevated levels w/ no dietary
influence

HYPERCHOLESTEROLEMIA
 Primary Hypercholesterolemia describes elevated cholesterol levels that
develop independent of other health problems or lifestyle behaviors
 Secondary Hypercholesterolemia is associated w/ other health problems
& behaviors

NATIONAL CHOLESTEROL EDUCATION PROGRAM (NCEP) GOALS

1. Total Cholesterol <200
2. HDL > 40 (males)
3. HDL > 50 (females)
4. LDL < 130
a. < 70-100 in hi-risk
5. Triglycerides < 150

ATHEROSCLEROSIS:

MECHANISMS OF DEVELOPMENT OF ATHEROSCLEROSIS

 Injury to Endothelial Lining
 Permeability is increased  Smooth Muscle Cells enter bloodstream
 Body tries to repair damage using migration of inflammatory cells
(Monocytes)
  Monocytes migrate into Intima + transform into Macrophages
 Activated Macrophages
 Oxidize LDL
 Ingest LDL  resulting in Foam Cells
 Foam Cells are the primary component of AS Lesions -- the “Fatty
Streak”

STAGES OF LESIONS ASSOCIATED W/ ATHEROSCLEROSIS

STAGE 1: FATTY STREAK

 Lipid Accumulation
 Smooth Muscle Cell Proliferation
 Activation of Macrophages
 Foam Cell Formation

STAGE 2: FIBROUS PLAQUE DEVELOPMENT

 AS Plaque forms consisting of:
 Smooth Muscle Cells
 Macrophages
 Collagen
 Lipids
 Covered by Fibrous Cap
 As plaque grows, it occludes Vessel Lumen

STAGE 3: COMPLICATED LESION – PLAQUE RUPTURE

 Rupture, Ulceration or Erosion of Cap may lead to:
 Hemorrhage into Plaque
 Platelet Aggregation
 Thrombotic Occlusion of the Vessel Lumen
 Leads to MI, Stroke, or Peripheral Arterial Occlusion

MAJOR RISK FACTORS FOR ATHEROSCLEROSIS

 Hypercholesterolemia
 Cigarette smoking
 Hypertension
 Family history of premature CHD in a 1st-degree relative
 Age
  Men 45+
 Women 55+
 HDL Cholesterol < 40 mg/dL
 C-reactive protein levels
 Homocysteine levels

MAJOR COMPLICATIONS OF ATHEROSCLEROSIS

 Ischemic Heart Disease
 Stroke
 Peripheral Vascular Disease

SPECIFIC ARTERIAL INVOLVEMENT IN ATHEROSCLEROSIS

 Larger Vessels
 The imp. complications are those of Thrombus Formation + Weakening
of the Vessel Wall
 Medium-Sized Arteries
 Ischemia + Infarction  due to Vessel Occlusion are more common
 Arteries supplying the Heart, Brain, Kidneys, Lower Extremities, &
Small Intestine
 Most frequently involved

CLINICAL MANIFESTATIONS OF ATHEROSCLEROSIS

 Narrowing of the Vessel + Production of Ischemia
 Sudden Vessel Obstruction due to Plaque Hemorrhage or Rupture
 Thrombosis + Formation of Emboli resulting from damage to the vessel
endothelium
 Aneurysm Formation due to weakening of the vessel wall

PERIPHERAL ARTERIAL DISEASE (PAD)

 Atherosclerosis NOT in coronaries, aortic arch, or brain (carotids)
 Primary targets:
 Iliac Artery
 Common Femoral Artery
 Superficial Femoral Artery
 Distal Popliteal Artery

SYMPTOMS/INCIDENCE OF PAD
  Intermittent Claudication
 Cramping, aching pain in the legs caused by ischemia in the muscles
 Precipitated by activity + resolves w/i 10 min. or less of rest
 Classic symptom of PAD
 PAD
 Affects 1/3 people 70+ yrs. old
 May present as young as 50, esp. in smokers

ACUTE ARTERIAL OCCLUSION

 Sudden event that interrupts arterial flow to the affected tissues or organ
when clot occurs @ site of plaque
 Signs + Symptoms
 Limb Ischemia
 Pain
 Paresthesia
 Motor weakness distal to the site of occlusion
 Loss of Peripheral Pulses, Cool Skin, + Pallor –or- Cyanosis distal to the
obstruction site

OTHER ARTERIAL DISEASE OF THE EXTREMITIES

 Thromboangitiis Obliterans (Buerger’s Disease)
 Inflammatory arterial disorder that causes thrombus formation
 Disease of Small + Medium Arteries of the feet & lower legs
characterized by:
 Pain + Inflammation
 Thrombus Formation
 Vasospasm
 **Most common in young men who smoke**
 Raynaud’s Disease
 Intense vasospasm of the arteries + arterioles in the fingers (& less often
in the toes)
 Raynaud’s Phenomenon
 1) Fingers become white due to lack of blood flow
 2) Fingers become blue as vessels dilate to keep blood in tissues
 3) Fingers become red as blood flow returns

ANEURYSMS
  Wall of artery weakens + stretches
 Risk of rupture and hemorrhage
 Risk of clot formation
 Types
 Berry Aneurysm
 Most often found in the Circle of Willis in the brain circulation
 Consists of a small, spherical vessel dilation
 Fusiform + Saccular Aneurysms
 Most often found in the Thoracic & Abdomen Aorta
 Characterized by gradual + progressive enlargement of the aorta

AORTIC ANEURYSM – RUPTURE

 The larger the aneurysm, the more at risk for rupture
 Symptoms (AAA): Sudden severe abdominal pain/back pain, shock
 Ruptures have a high mortality rate
 KEEP BP CONTROLLED!!

AORTIC DISSECTION
 Result of a tear or split in the intimal lining of the aortic wall
 Most common cause is chronic hypertension
 Seen mostly in men ages 40-70 -- Severe back pain
 Can heal over time with  BP

VENOUS CIRCULATION
 Low pressure thin-walled vessels
 Skeletal muscle contraction & changes in abdominal and thoracid pressure
return of the blood to the heart
 Valves prevent retrograde blood flow

DISORDERS OF THE VENOUS CIRCULATION

 Produce congestion of the affected tissues
 Predispose to clot formation b/c of stagnation of flow + activation of the
clotting system
 Types of Disorders:
 Varicose Veins
 Chronic Venous Insufficiency
  Thrombophlebitis
 DVT

VARICOSE VEINS
 Valvular Incompetence  Backflow of Blood w/ Increased Pressure 
Venous Distention  Edema
 Causes:
 Aging
 Decreased Muscle Mass
 Increased Hydrostatic Pressure from Standing

CHRONIC VENOUS INSUFFICIENCY

 Chronic Inadequate Venous Return 
 Damage to valves
 Retrograde flow + pooling
 Can lead to:
 Hyperpigmentation
 Severe Edema
 Ulceration

VENOUS THROMBOSIS
 Blood clot attached to vessel wall (usually legs)
 Remember: Virchow’s Triad
 1. Venous Stasis
 2. Hypercoagulability
 3. Vessel Injury

RISK FACTORS FOR VENOUS STASIS

 Bed Rest
 Immobility
 Spinal Cord Injury
 Acute Myocardial Infarction
 Congestive Heart Failure
 Shock
 Venous Obstruction

VENOUS THROMBOSIS
  Signs & Symptoms:
 Tenderness
 Pain
 Redness
 Swelling at site
 Treatment:
 Anticoagulation
 Prevention is the Key!!!!

PULMONARY EMBOLISM
If blood clot dislodges
 DISORDERS OF BLOOD PPRESSURE REGULATION

ARTERIAL BLOOD PRESSURE (DEFINITIONS)

 Systolic Pressure
 Pressure @ the height of the pressure pulse
 Diastolic Pressure
 The lowest pressure
 Pulse Pressure
 The difference b/w Systolic + Diastolic Pressure
 Mean Arterial Pressure
 The Average Pressure in the Arterial System during Ventricular
Contraction + Relaxation

ARTERIAL BLOOD PRESSURE

 Represents the pressure of the blood as it moves through the Arterial
System
 Mean Arterial Pressure (MAP) = Cardiac Output (CO) x Vascular Resistance (VR)
 MAP = CO x VR
 Cardiac Output (CO) = (HR) x Stroke Volume (SV)
 Vascular Resistance (VR)

MECHANISMS OF BLOOD PRESSURE REGULATION

 Short-Term Regulation: corrects temporary imbalances in blood pressure
 Neural Mechanisms
 Humoral Mechanisms
 Long-Term Regulation: controls the daily, weekly, + monthly regulation
of blood pressure
 Renal Mechanism

REGULATION OF BLOOD PRESSURE

KNOW THE MECHANISMS!!
FACTORS DETERMINING SYSTOLIC & DIASTOLIC BLOOD PRESSURE
 Systolic Pressure
 The characteristics of the stroke volume being ejected from the heart
 The ability of the aorta to stretch & accommodate the stroke volume
 Diastolic Pressure
 The energy stored in the aorta as its elastic fibers are stretched during
systole
 The resistance to the runoff of blood from the peripheral blood vessels

FACTORS INFLUENCING MEAN ARTERIAL BLOOD PRESSURE

  Physical
 Blood volume & the elastic properties of the blood vessels
 Physiologic Factors
 Cardiac Output
 Peripheral Vascular Resistance

RENIN-ANGIOTENSION-ALDOSTERONE SYSTEM
Know this system!!

QUESTION: Which of the following does not directly affect arterial blood
pressure?
A. Heart Rate
B. Vascular Resistance
C. Venous Constriction
D. Blood Volume

Venous Constriction will not affect arterial pressure, but the other factors will
have immediate effects.
JOINT NATIONAL COMMITTEE ON DETECTION, EVALUATION, and
TREATMENT OF HYPERTENSION

Classification Systolic Diastolic

(mm/Hg) (mm/Hg)
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Stage I: 140-159 or 90-99
Hypertension
Stage 2:  160 or  100
Hypertension

 For adults w/ Diabetes Mellitus, the goal is BP < 130/80 mm Hg

FACTORS AFFECTING HYPERTENSION

 Gender
 More common in younger men than younger women
 Age
 More common in the elderly
 Race
 More common in blacks than whites
 Socioeconomic Group
 More common in lower socioeconomic groups

CATEGORIES OF HYPERTENSION
 Primary Hypertension (Essential Hypertension)
 Chronic elevation in blood pressure that occurs w/o evidence of other
disease (90-95%)
 Secondary Hypertension
 Elevation of blood pressure that results from some other disorder, such
as kidney disease (5-10%)
 Malignant Hypertension
 An accelerated form of hypertension

CLASSIFICATIONS OF ESSENTIAL HYPERTENSION

 Systolic/Diastolic Hypertension
 Both the systolic and diastolic pressures are elevated
  Diastolic Hypertension
 The diastolic pressure is selectively elevated
 Systolic Hypertension
 The systolic pressure is selectively elevated

RISK FACTORS FOR HYPERTENSION

 Family History
 Age-Related Changes in Blood Pressure
 Race
 Insulin-Resistance & Metabolic Abnormalities
 Circadian Variations
 Lifestyle Factors
 High Salt Intake
 Obesity
 Excess Alcohol Consumption
 Dietary Intake of Potassium, Calcium, + Magnesium
 Oral Contraceptive Drugs
 Stress

TARGET ORGAN DAMAGE

 Heart
 Hypertrophy
 Brain
 Dementia
 Cognitive Impairment
 Peripheral Vascular
 Atherosclerosis
 Kidney
 Nephrosclerosis
 Retinal Complications

PHARMACOLOGIC AGENTS
 Diuretics
 -Adrenergic-blocking drugs
 Angiotensin-Converting Enzyme (ACE) Inhibitors
 Angiotensin II Receptor Blockers
 Calcium-channel-blocking drugs
  Central 2-adrenergic agonists
 1-adrenergic receptor blockers
 Vasodilators

TREATMENT OF HTN

FACTORS AFFECTING TREATMENT STRATEGIES FOR HYPERTENSION

 Lifestyle
 Demographics
 Motivation for adhering to the drug regimen
 Other disease conditions and therapies
 Potential for side effects

Question: Renal failure results in Na+ and water retention. This results in
Hypertension. How would you classify this type of Hypertension?

A. Primary hypertension
 B. Secondary hypertension
C. Malignant hypertension
D. Systolic hypertension

Secondary hypertension accompanies an underlying disease

MOST COMMON CAUSES OF SECONDARY HYPERTENSION

 Kidney Disease (Renovascular Hypertension)
 Adrenal Cortical Disorders
 Pheochromocytoma (tumor of the adrenal medulla)
 Coarctation of the aorta
 Sleep Apnea

TYPES OF HYPERTENSION IN PREGNANCY

 Gestational Hypertension
 Chronic Hypertension
 Preeclampsia/eclampsia
 Preeclampsia superimposed on chronic hypertension

DIAGNOSIS AND TREATMENT OF HYPERTENSION IN PREGNANCY

 Early prenatal care
 Refraining from alcohol and tobacco use
 Salt restriction
 Bed rest
 Carefully chosen antihypertensive medications

HIGH BLOOD PRESSURE IN CHILDREN AND ADOLESCENTS

 Blood pressure norms for children are based on age, height, + gender-
specific percentiles
 Secondary Hypertension is the most common form of high blood pressure
in infants & children
 Kidney abnormalities
 Coarctation of the aorta
 Pheochromocytoma + Adrenal Cortical Disorders
 In infants, hypertension is assoc. most commonly w/ high umbilical
catheterization & renal artery obstruction caused by Thrombosis.
ORTHOSTATIC HYPOTENSION
 Definition: An abnormal decrease in blood pressure on assumption of the
upright position
 Causes
 Decrease in venous return to the heart due to pooling of blood in lower
part of the body
 Inadequate circulatory response to decreased cardiac output + decrease
in blood pressure

CAUSES OF ORTHOSTATIC HYPOTENSION

 Conditions that decrease vascular volume
 Dehydration
 Conditions that impair muscle pump function
 Bed Rest
 Spinal Cord Injury
 Conditions that interfere w/ Cardiovascular Reflexes
 Medications
 Disorders of Autonomic Nervous System
 Effects of Aging on BaroReflex Function

COMMON CAUSES OF ORTHOSTATIC HYPOTENSION RELATED TO

HYPOVOLEMIA
 Excessive use of diuretics
 Excessive diaphoresis
 Loss of gastrointestinal fluids through vomiting + diarrhea
 Loss of fluid volume assoc. w/ prolonged bed rest

COMPLAINTS ASSOC. W/ ORTHOSTATIC INTOLERANCE

 Dizziness
 Visual changes
 Head & Neck discomfort
 Poor concentration while standing
 Palpitations
 Tremor, Anxiety
 Presyncope
 & in some cases, Syncope
QUESTION: Increased vascular compliance may contribute to which condition?
A. Systolic hypertension
B. Orthostatic hypotension
C. Orthostatic hypertension
D. Diastolic hypertension

Orthostatic hypertension is the result of lower pressures, and increased compliance

would decrease the vascular resistance and result in lower pressures.