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The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
The cardiovascular system
Farley A et al (2012) The cardiovascular system.
Nursing Standard. 27, 9, 35-39. Date of acceptance: February 28 2012.
Abstract
This article, which forms part of the life science series, examines
the cardiovascular system, focusing on the anatomy and physiology
of the heart. The blood flow through the heart is described and the
regulatory mechanisms of the heart are identified and discussed.
The cardiac conduction system is examined, outlining the normal
sequence of events in the cardiac cycle. In addition, a brief overview
of some common cardiac disorders is provided.
Author
Alistair Farley
Lecturer in Nursing, School of Nursing and Midwifery,
University of Dundee.
Ella McLafferty
Retired, was senior lecturer, School of Nursing and Midwifery,
University of Dundee.
Charles Hendry
Retired, was senior lecturer, School of Nursing and Midwifery,
University of Dundee.
Correspondence to: a.h.farley@dundee.ac.uk
Keywords
Cardiac cycle, cardiovascular system and disorders,
pulmonary circulation, pulse, systemic circulation
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© NURSING STANDARD / RCN PUBLISHING october 31 :: vol 27 no 9 :: 2012  35
p35-39w9.indd 35
MUCH INFORMATION ABOUT the condition
and functioning of the cardiovascular system
can be attained by taking a person’s pulse and
blood pressure. These are two essential skills
undertaken by nurses and other healthcare
workers. Every cell in the body requires oxygen
and nutrients to carry out its metabolic functions,
and each cell produces carbon dioxide and
other waste products that must be removed
from the cell and excreted. It is the role of the
cardiovascular system to transport oxygen and
nutrients to cells and remove waste, thereby
maintaining a stable internal environment
(homeostasis). Another important function
of the cardiovascular system is to transport
an adequate blood supply to the vital organs,
including the lungs, brain, kidneys and liver.
Location of the heart
The heart is a hollow, muscular organ shaped
like a blunt cone and about the size of a clenched
adult fist (Thibodeau and Patton 2010). It lies in
the thoracic cavity in the mediastinum (the space
between the lungs) with the trachea, oesophagus
and related structures (Seeley et al 2008). The
blunt end of the cone forms the apex of the heart
and the flat end lying opposite is called the base.
The heart lies obliquely in the mediastinum
with the base lying posteriorly and somewhat
superiorly and the apex lying anteriorly and
somewhat inferiorly. The apex lies to the left
of the midline at the level of the fifth intercostal
space in the midclavicular line (on the left side
of the chest wall). The base of the heart extends
to the level of the second rib. The apex of
the heart rests on the central tendon of the
diaphragm. Posteriorly, the heart rests against
the vertebral bodies of the fifth to eighth
thoracic vertebrae and is located behind the
sternum (Thibodeau and Patton 2010).
 
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 Art & science life sciences: 9

Anatomy and physiology muscle cells contain one or sometimes two nuclei
Layers of the heart located centrally (Seeley et al 2008), and because
The heart is composed of three layers of tissue: the cells are particularly active they contain
the pericardium, myocardium and endocardium. numerous mitochondria.
Pericardium The pericardium or pericardial sac Cardiac muscle cells, in addition to being bound
is a double-layered, closed sac that surrounds the end-to-end, are bound to adjacent cells at contact
heart. It is composed of a tough, fibrous outer layer points known as intercalated discs, increasing the
termed the fibrous pericardium, which consists of area of contact between cells. Each intercalated
fibrous connective tissue, and a thin, transparent disc contains many gap junctions – these are
inner layer termed the serous pericardium, which areas of low electrical resistance that allow action
consists of simple squamous epithelium (Seeley potentials to pass easily between cells (Seeley et al
et al 2008). The fibrous pericardium prevents 2008). This arrangement of cardiac muscle cells
overdistension of the heart and anchors it in the is known as a syncytium (joined cells) and enables
mediastinal space. It is attached inferiorly to the cardiac muscle cells to act as a single unit, resulting
diaphragm (Seeley et al 2008). in co-ordinated contraction of the atria and
The serous pericardium is divided into two ventricles (Thibodeau and Patton 2010). A further
layers. The parietal pericardium lines the fibrous advantage of the syncytium structure is that
pericardium and the visceral pericardium covers cardiac muscle fibres form a continuous sheet of
the surface of the heart. The space between the muscle that wrap around the cavities of the heart.
two layers is termed the pericardial space and is When the fibres contract around the cavities, they
lubricated by a thin layer of serous fluid (pericardial generate pressure ejecting blood out of the heart
fluid), which helps to reduce friction as the heart into and around the pulmonary and systemic
beats in the pericardial sac (Berne and Levy circulatory systems.
2001). Inflammation of the pericardium is called Endocardium The endocardium is the innermost
pericarditis and can be caused by trauma, infection layer of the heart. It consists of flattened epithelial
or myocardial infarction. cells that line the heart and blood vessels. This
Myocardium The myocardium is the middle layer smooth inner lining assists blood flow through
of the heart – a strong muscular layer composed of the cardiovascular system. Folds of endothelium
cardiac muscle, which is responsible for pumping make up the valves that control the flow of blood
blood around the body. Cardiac muscle is unique. through the heart (Thibodeau and Patton 2010).
It is striated like skeletal muscle, but is not under
voluntary or conscious nervous control. Cardiac Valves, chambers and blood flow
The heart is divided by the septum (Figure 1).
FIGURE 1 Although the right and left sides of the heart
function simultaneously, there is no direct
Internal anatomy of the heart communication between them after birth,
Arch of aorta meaning blood cannot cross the septum from
Superior vena cava Pulmonary one side to the other. It may be helpful to think
artery
of the heart not as a single pump, but rather as
Right pulmonary Left pulmonary a left pump and a right pump. The left pump
artery artery
circulates blood throughout the body (systemic
circulation), whereas the right pump circulates
Left pulmonary blood through the lungs (pulmonary circulation)
veins (Tortora and Derrickson 2009).
Right
pulmonary LA Blood flow through the heart is one directional.
veins Left
atrioventricular This is maintained by the presence of two distinct
RA valve sets of valves. One set of valves separates the upper
Pulmonary chambers, the atria, from the lower chambers, the
valve LV ventricles, and hence these valves are referred to as
Aortic valve
atrioventricular (AV) valves. The other set of valves,
Right RV semilunar valves, are located between the ventricles
atrioventricular Septum
valve and major arteries – where the pulmonary artery
and aorta exit the ventricles. Valves consist of dense
Chordae Aorta
Inferior
tindinae Papillary connective tissue covered by endothelium (Tortora
vena cava muscle and Derrickson 2007), which open and close as a
result of changes in pressure in the heart. The AV
RA – right atrium; LA – left atrium; RV – right ventricle; LV – left ventricle
valves are limited in their movement by fine strands

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 of connective tissue known as chordae tendineae,
which are attached to the myocardial wall by
papillary muscles. The chordae tendineae ensure
that the valves are prevented from opening upwards
into the atria as a result of the high pressures
reached during ventricular contraction (Tortora
and Derrickson 2007).
The heart is divided into four chambers that
receive blood. The two upper chambers are the
right and left atria and the lower chambers are the
right and left ventricles (Figure 1). The atria are
smaller than the ventricles and have a relatively
thin muscle wall. Their principal role is to complete
ventricular filling – they top up the ventricles with
blood before ventricular contraction (Seeley et al
2008). The ventricles are larger and more
muscular because they have to pump blood some
distance. The right ventricle pumps blood to the
lungs, which is later returned to the left atrium.
The left ventricle pumps blood around the body
and is therefore more muscular than the right
(Tortora and Derrickson 2007); blood then
returns to the right atrium.
Deoxygenated blood returns to the right atrium
via the main veins, the superior and inferior
vena cavae and the coronary sinus (Tortora and
Derrickson 2007). From the right atrium, blood
flows into the right ventricle through the open
right AV valve, also known as the tricuspid valve.
As this occurs, oxygenated blood returns from the
lungs via the pulmonary veins to the left atrium. It
passes through the open left AV valve, also known
as the biscuspid valve or mitral valve, into the left
ventricle (Thibodeau and Patton 2010).
The flow of blood through the heart occurs
through both atria simultaneously and then
through both ventricles (Figure 2). When the
ventricles contract, blood from the right ventricle
is pumped through the open pulmonary valve
into the pulmonary artery. The pulmonary artery
divides into right and left branches taking blood to
each lung (Seeley et al 2008). This blood circulates
through the lungs, excreting carbon dioxide and
absorbing oxygen. At the same time, blood is
pushed from the left ventricle through the open
aortic valve into the aorta from where it circulates
to every system of the body, including the heart
itself. On reaching the tissues, oxygen is released
and carbon dioxide is absorbed into the blood
and returned to the right atrium (Tortora and
Derrickson 2007).
The heart begins beating around the end of the
third week of gestation and continues until death,
and unlike other tissues does not experience
periods of rest. It has a high demand for oxygen
and nutrients and generates a substantial amount
of waste in the form of carbon dioxide and other
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p35-39w9.indd 37
FIGURE 2
Direction of blood flow through the heart
Superior vena cava Arch of aorta
Right pulmonary Left pulmonary
artery artery
Left pulmonary
Right
pulmonary veins
veins
Left atrium
Right atrium
Left ventricle
Inferior vena cava
Right ventricle
metabolites. It is important that the heart has
an effective vascular system or blood supply.
The heart is supplied with arterial blood by
the right and left coronary arteries (Thibodeau
and Patton 2010). The left coronary artery
almost immediately divides into the left anterior
descending artery and the left circumflex artery
(Seeley et al 2008). It is important to note that as
the heart alternates between a relaxed (diastole)
and a contracted state (systole), blood flow
through the myocardium can only occur during
diastole (Tortora and Derrickson 2007).
Cardiac conduction system
To ensure adequate flow of blood through the
pulmonary and systemic circulations, contraction
of the myocardium must be co-ordinated
(Tortora and Derrickson 2007). This is achieved
by intrinsic (internal) and extrinsic (external)
electrical mechanisms.
Intrinsic pathway In the myocardium, there are
modified cardiac muscle cells that connect with
each other to form an electrical conduction
system (Seeley et al 2008). These cells have
the ability to generate an electrical impulse
spontaneously, a property known as
autorhythmicity (Tortora and Derrickson 2007).
The impulse causes a wave of excitation to
stimulate each cell in the myocardium to contract
in a synchronised manner (Jones 2006).
The conduction system follows a well-defined
pathway across the myocardium. Each component
of the conduction system can generate an electrical
impulse at its own pre-determined rate. The
sinoatrial (SA) node has an intrinsic rate of
60-100 beats per minute (bpm), the AV node’s
rate is slower, less than or equal to 50bpm, while
 
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 Art & science life sciences: 9
the AV bundle (bundle of His) has the slowest
intrinsic rate of less than 40bpm (Jones 2006).
The SA node with its higher rate of firing is the
natural pacemaker of the heart (Jones 2006). If
the SA or AV nodes become damaged through
disease, then the heart rate will be determined
by the lower components (the AV bundle, bundle
branches or Purkinje fibres) in the conduction
system. However, if the rate is less than about
35-40bpm, blood flow to the brain becomes
inadequate (Tortora and Derrickson 2009). In
such circumstances, the provision of an artificial
pacemaker may restore adequate perfusion
(Tortora and Derrickson 2009).
Extrinsic pathway In addition to its own natural,
intrinsic pacemaker, the heart is influenced by
the autonomic nervous system (Tortora and
Derrickson 2009). The heart is innervated by
the sympathetic and parasympathetic branches
of the autonomic nervous system. The origin of
these autonomic nerves lies in the cardiac centre
in the medulla oblongata in the brainstem (Seeley
et al 2008). The vagus nerves (parasympathetic)
mainly supply the SA and AV nodes, and atrial
myocardium (Tortora and Derrickson 2009).
Parasympathetic stimulation reduces the rate at
which the SA node fires impulses, and therefore
decreases the heart rate and strength of atrial
muscle contraction. Because of the reduction in
heart rate and stroke volume (the volume of blood
pumped from the ventricle with each contraction),
cardiac output (the total amount of blood pumped
from the ventricles in one minute) decreases.
The sympathetic branch of the autonomic
nervous system innervates the SA and AV nodes
and also the atrial and ventricular myocardium.
Sympathetic stimulation speeds up the heart rate
and the heart muscle contracts more forcefully.
As a result of the increase in heart rate and stroke
volume, cardiac output increases (Tortora and
Derrickson 2009).
Cardiac cycle
The heart starts beating from around the end
of the third week of gestation (Tortora and
Derrickson 2009). The action of the heart consists
of a series of events known as the cardiac cycle; the
adult heart beats about 100,000 times each day
(Tortora and Derrickson 2009). A cardiac cycle
consists of atrial systole and diastole followed
by ventricular systole and diastole (Tortora and
Derrickson 2009). At the end of ventricular
diastole, all chambers of the heart contain blood
that has entered during this brief period of rest,
known as complete cardiac diastole (Tortora and
Derrickson 2009).
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p35-39w9.indd 38
Atrial systole begins when the SA node fires an
electrical impulse. This impulse spreads over the
atria, causing the atrial myocardium to contract
and eject about 25mL blood from the atria into
the ventricles. This additional blood completes the
filling of the ventricles (Seeley et al 2005). Atrial
systole lasts approximately 0.1 second. On an
electrocardiogram (ECG), atrial contraction is
represented by the P wave. The atria then enter a
period of relaxation known as atrial diastole.
The impulse that has travelled across the atria
then reaches the AV node, which is now stimulated
to conduct the impulse down the AV bundle or
bundle of His and into the Purkinje fibres of the
ventricular myocardium. This stimulates the
ventricular myocardium to contract, ejecting blood
from the ventricles into the pulmonary artery
and aorta. As the ventricles begin to contract, the
increasing pressure in the ventricles causes the
valves to close, and as the pressure continues to
increase, the semi-lunar valves open. Ventricular
systole lasts approximately 0.3 second. This is
represented by the QRS complex on the ECG.
When ventricular contraction ceases, the semi-
lunar valves close and the AV valves open, thus
allowing the heart to begin to refill with blood.
This is ventricular diastole and lasts approximately
0.4 second. During this time, atrial diastole
continues. Diastole then leads into the next cardiac
cycle and is represented by the T wave on an ECG.
As stated earlier, the total volume of blood
ejected from the ventricles in one minute is
known as the cardiac output. This measurement
is expressed as litres per minute and is calculated
by multiplying the stroke volume by the number
of contractions per minute (heart rate). In a
healthy individual at rest, each ventricle ejects
approximately 70mL with each contraction
(stroke volume), at an approximate heart rate of
75bpm, giving a cardiac output of 70 x 75, which
is approximately 5,250mL/min or 5.25L/min
(Tortora and Derrickson 2009). Cardiac output
can be increased when there is greater demand
from the body for oxygen delivery and removal
of waste. During exercise, for example, the heart
rate can increase to 190bpm and the stroke
volume up to 115mL, giving a cardiac output of
approximately 22L/min (Seeley et al 2008).
Disorders of the heart
There are a range of cardiac disorders and while
it is not possible to cover them all, this article
outlines some of the most common conditions
related to the anatomy and physiology discussed.
In coronary artery disease, the patient’s
arteries become narrowed by atheromatous
26/10/2012 11:30
 plaques or thrombus formation. This reduces
blood supply to the myocardium and results in
disease. Arterosclerosis is the most common
form of coronary artery disease. The patient may
experience angina, which is a classic symptom
that indicates a lack of blood and oxygen supply
to the cardiac tissues (ischaemia).
Myocardial infarction is caused by prolonged
ischaemia, leading to irreversible damage
(necrosis) to the myocardium (McCance and
Huether 2006). Lifestyle factors have a major
role to play in the development or the prevention
of ischaemic heart disease. Factors that can
be moderated to reduce the risk of this disease
include smoking, alcohol consumption, diet,
sedentary lifestyle, stress and obesity. Other
factors include diabetes, gender and a family
history of the disease (Jones 2006).
Where damage to the myocardium is significant,
this can impair the contractility of the heart.
The effects of this will depend on the extent
and location of the area of damage. This may
result in heart failure, which is used to describe
several types of cardiac dysfunction that result
in inadequate perfusion of tissues (McCance
and Huether 2006). Where damage is restricted
primarily to the left ventricle, the patient may
develop left ventricular failure. If both ventricles
are compromised, then the patient may experience
bilateral heart failure or congestive cardiac failure.
Heart failure can also be caused by hypertension,
diseases of the heart valves and cardiomyopathy
(Farley et al 2011).
Damage to the conduction system of the heart
may result in changes to heart rhythm (arrhythmias).
For example, the patient may experience
tachycardia, bradycardia or an irregular heart beat
such as atrial or ventricular fibrillation. This may
result from ischaemic heart disease, hypertension,
hyperthyroidism, or abnormal potassium levels
(Tortora and Derrickson 2009). Arrhythmias can
be triggered by several factors, including caffeine,
nicotine, alcohol, cocaine and substances that
contain caffeine or other stimulants (Tortora and
Derrickson 2009). Treatment is aimed at restoring
heart rate and rhythm to normal parameters,
therefore ensuring effective cardiac output.
Conclusion
The nurse has an important role in assessing
and monitoring the cardiovascular system,
detecting potential life-threatening changes
and initiating prompt treatment. It is therefore
imperative that all nurses use their knowledge
of the cardiovascular system to anticipate any
changes that may have negative effects on patient
wellbeing. This will allow the healthcare team to
take timely and appropriate action to minimise
any risks and/or disability NS
POINTS FOR PRACTICE
Describe different ways to assess the cardiovascular system and give
the rationale for each of these actions.
Using your knowledge of local resources, prepare a guide for your
colleagues to assist them in helping a patient to stop smoking.
Consider a patient with acute left ventricular failure. What measures
might the nurse use to improve gas exchange?
Cardiac arrest may result from coronary heart disease or damage to the
conduction system. List the actions that would be taken in your clinical
area in response to a cardiac arrest.
GLOSSARY
Action potential
Changes in the membrane potential (the electrical gradient) occurring across
the cell membrane that involve depolarisation following repolarisation.
Cardiac output
The total volume of blood expelled by the ventricles in one minute. This is
equal to the stroke volume multiplied by the heart rate.
Diastole
The phase of relaxation of the heart muscle during the cardiac cycle.
Stroke volume
The volume of blood ejected by the ventricle with each contraction.
Syncytium
An arrangement of cardiac muscle cells where the cytoplasm of one cell
is continuous with that of adjoining cells.
Systole
The phase of contraction of the heart muscle during the cardiac cycle.

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