CARDIOVASCULAR SYSTEM

MYOCARDIAL INFRACTION
Coronary heart disease is the greatest single cause for

death in most cases in the Universe. The most frequent cause is the myocardial infarction. Therefore, it is important to understand the cardiovascular system thoroughly, so as to take subsequent prevention against the heart disease. The metabolism process of the cell needs nutrients and excretes waste products; the circulatory system provides these nutrients and removes these waste products.

Function of the HEART

HEART is the major component of Circulatory system.

Heart supplies the power required to circulate the blood throughout the body.
Hearttwo pumps in series.

RHS provides the power required to force blood through the lungs.
LHS provides the power required to force blood

throughout body via capillaries.

Simplified block diagram of the circulatory system

HEART

Cell revitalization
The aorta curves in an arch up from the heart, down

along the back bone and into the abdomen; from it other large arteries lead to the head, the digestive organs, the arms and the legs. From these arteries branch the smaller arterioles and from these, branch billions of tiny capillaries. By the time blood has reached the capillaries, it is moving slowly along channels. These channels are only about 10 microns in diameter. Here the blood discharges its load of dissolved food and oxygen to the body cells.

Functional model of the cardiovascular system

 These cells in turn deposit waste materials such as

carbon-di-oxide into the blood stream. In yielding oxygen and taking on the waste, the blood turns colour form bright red to dull red or blue.
The blood now starts back to the heart passing from

the capillaries into the venules.

The venules converge into larger veins and then into

the two largest veins just above and below the heart, known as venacava.

HEART

 The blood empties into right atrium. It is pumped into the right ventricle and then moves

out through the pulmonary artery to the lungs.

The lungs then supply the blood with fresh oxygen.
The blood passes form the lungs to the left atrium,

then is pumped into the left ventricle and passes via the aorta.
This is done for repeating the circulation process.

 This general flow throughout the body is known as the

systemic circulation; the flow to and from the lungs is known as the pulmonary circulation. The waste products contained in the blood are removed by the kidneys and liver. The average quantity of blood in a mans body is about five liters. This is completely circulated through the body in approximately one minute. 5 L/min

THE HEART: Anatomy

The heart is a hollow, cone-shaped, muscular pump located

within the mediastinum of the thorax & resting upon the diaphragm.
cm long at its maximum dimension.

The heart itself weighs less than half a kilogram, is almost about 15

The heart lies pointed downward to the chest cavity to the left of

the mid-center body line.

The heart has a covering as well as lining. Its covering, the pericardium, consists of three layers of fibrous

tissues with a small space in between, filled with a thin film of pericardial fluid.

Septum

THE HEART
The left and right sides of the heart are separated by

the septum, or dividing wall of tissue.

The entire walls of the heart are made of muscle;

within these walls are four hollow chambers, a left and right receiving chamber (atrium) and below them a left and right pumping chamber (ventricle).

The Heart Valves

The tricuspid valve regulates blood flow

between the right atrium and right ventricle. The pulmonary valve controls blood flow from the right ventricle into the pulmonary arteries. The mitral valve lets oxygen-rich blood from your lungs pass from the left atrium into the left ventricle. The aortic valve lets oxygen-rich blood pass from the left ventricle into the aorta, then to the body.

Cardiac cycle or the Mechanical activity

It is characterized by the following events. With a person in a sitting position, the heart beats (or

contracts) about 70 times per minute.

With each beat, a quantity of blood is driven through

the heart.

SYSTOLE and DIASTOLE

Between beats, the heart mechanically rests and this is

known as the period of diastole.

During diastole, the heart assumes its maximum size

and fills with oxygenated blood returning from the lungs and venous blood returning from the body.
The hearts period of mechanical activity is known as

systole.

Cardiac cycle or the Mechanical activity

The onset of systole is initiated by contraction of the

muscles surrounding the atria.

This propels additional blood into the ventricles. The ventricles then begin to contract, thereby causing a

rise in pressure within the ventricles.

This increased pressure shuts two atrioventricular valves

(Tricuspid and Bicuspid).

With further contraction, the pressure continues to rise.

Electrophysiology of the cardiac muscle cell

HEART

Systemic circulation
Once the pressure of the systemic and pulmonary

circulations are exceeded, a phase of ventricular ejection is begun. The aortic valve is forced to open. Then the blood is squeezed into aorta and thence into the systemic circulation. This blood flow leading in to the aorta can be considered as a wave, with a peak pressure about 120 mmHg (called the systolic pressure) and a low pressure about 80 mmHg (called the diastolic pressure).

Arterial blood pressure waveform

Systolic pressure

Pressure (mmHg)

Dicrotic notch-represents a reflected pulse due to slight back pressure built up as the mitral valve closes

Diastolic pressure

Time

Pulmonary circulation
Similarly, the pulmonary valve is forced open and

blood is supplied to the pulmonary circulation.

After the ventricular contents are partially ejected, the

muscles surrounding the ventricles relax and the ventricular pressure falls.
As soon as these pressures fall below the pressures

sustained in the circulatory systems, the aortic and pulmonary valves close, signaling the onset of diastole.

Electrical potentials generated with in the HEART

The muscle contraction is initiated by stimulation. The right atrium consists of a bundle of nerves known

as the Sinoartrialnode (SA node).

This type of nerve system is found nowhere else in the

body.
Its function is to start the heart beat and set its rhythm

or pace; this node is also called as cardiac pacemaker or natural pacemeaker and generate impulses at a normal rate of the heart, about 70bpm at rest.

The Conduction System

 The electrical and mechanical output from the heart is

initiated by stimulation from this node which results in contraction of the various heart muscles.
Impulses generated by the SA Node stimulate

contraction of the muscles comprising the atria.

These impulses also travel along conducting fibers in

the atrium to the Atrioventricular node (AV Node), stimulating the depolarization of this node.

 The AV Node is located in the lower part of the heart-

wall between the two atria on the septum, and acts as a delay line to provide timing between the action of the Atria and Ventricles. Stimulation of the AV Node causes impulses to be sent to the myocardium or muscles comprising the ventricles via the bundle of his, two bundle branches on each of the septums and the fine purkinje fibers, which arborize in the ventricular muscle.

The Conduction System

 Thus the Atria and Ventricles are functionally linked

only by the AV Node and the conduction system. The AV delay is provided so that the atrial contraction is complete the ventricular filling before the contraction of the ventricles. So, the muscular contractions necessary to maintain the hearts pumping action are initiated by depolarization and repolarization of the SA Node and then depolarization and subsequent repolarization of the AV Node.

 When the ventricles are depolarizing, the atria are

repolarizing. These depolarizations and repolarizations generate external action potentials which can be recorded at the surface of the body. These external potentials generated from within the heart are known as the electrocardiogram or ECG.

Heart Electrical Activity (ECG)

1)Depolarization of the SA node and a resulting

contraction of the muscles surrounding the atria. This results in external action potential known as P wave. 2)Immediately following this depolarization, repolarization of the atria occurs.
However, for some reason, this does not generate a pronounced action potential.

This potential is known as the TA wave and is rarely

observed in practice.

 Electrical activity produced by depolarization of the

SA node travels through fibers within the atrium to the AV node.

The time taken for this electrical stimulation to travel

form the SA node to the AV node is known as the atrioventricular conduction time and is typically between 120ms and 220ms.

 When this stimulation reaches the AV node, this node

depolarizes and the depolarization is conducted down through the bundle of His to the myocardium muscle causing ventricular depolarization.
The external action potential is referred to as QRS

complex.
Immediately following this depolarization, the cells

concerned repolarize.
This results in ventricular repolarization or the T

wave.

 Many ECG waveforms also show an additional wave

occurring after the T wave. This is designated the U wave (after potentials) and its origin is unknown.

Electrophysiology of the heart

Different waveforms for each of the specialized cells

ECG WAVEFORM

ECG parameters: Amplitude

P-wave R-wave

0.25 mv 1.60 mv

Q-wave
T-wave

25% R- wave
0.1-0.5 mv

ECG parameters: Duration

P-R interval 0.12-0.22 s

Q-T

0.35-0.44 s

S-T

0.05-0.15 s

P-wave

0.11 s

QRS

0.09-0.10 s

Detail of the QRS complex, showingventricular activation time (VAT) and amplitude

http://en.wikipedia.org/wiki/File:ECG_priciple_slow.gif

Feature

Description The interval between an R wave and the next R wave: Normal resting heart rate is between 60 and 100 bpm.

Duration

RR interval

0.6 to 1.2s

P wave

During normal atrial depolarization, the main electrical vector is directed from the SA node towards the AV node, and spreads from the 80ms rightatrium to the left atrium. This turns into the P wave on the ECG.

PR interval

The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex. The PR interval reflects the time the electrical impulse takes to travel from 120 to 200ms the sinus node through the AV node and entering the ventricles. The PR interval is, therefore, a good estimate of AV node function.

PR segment

The PR segment connects the P wave and the QRS complex. The impulse vector is from the AV node to the bundle of His to the bundle branches and then to the Purkinje fibers. This electrical activity does not produce a 50 to 120ms contraction directly and is merely traveling down towards the ventricles, and this shows up flat on the ECG. The PR interval is more clinically relevant.

QRS complex

The QRS complex reflects the rapid depolarization of the right and left ventricles. They have a large muscle mass compared to the atria, so the QRS complex usually has a much larger amplitude than the P-wave.

80 to 120ms

J-point

The point at which the QRS complex finishes and the ST segment begins, it is used to measure the degree of ST elevation or depression present.

N/A

ST segment

The ST segment connects the QRS complex and the T wave. The ST segment represents the period when the ventricles are depolarized. It is isoelectric.

80 to 120ms

T wave

The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is 160ms referred to as the absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable period).

ST interval

The ST interval is measured from the J point to the end of the T wave.

320ms

QT interval

The QT interval is measured from the beginning of the QRS complex to the end of the T wave. A prolonged QT interval is a risk factor for ventricular tachyarrhythmias and sudden death. It varies with heart rate and for clinical relevance requires a correction for this, giving the QTc.

Up to 420ms in heart rate of 60 bpm

U wave

The U wave is hypothesized to be caused by the repolarization of the interventricular septum. They normally have a low amplitude, and even more often completely absent. They always follow the T wave and also follow the same direction in amplitude. If they are too prominent, suspect hypokalemia, hypercalcemia or hyperthyroidism usually.[29]

J wave

The J wave, elevated J-point or Osborn wave appears as a late delta wave following the QRS or as a small secondary R wave. It is considered pathognomonic of h ypothermia or hypocalcemia.[30]

A Wiggers diagram, showing the cardiac cycle events occuring in the left ventricle.

 In the atrial pressure plot: wave "a" corresponds to atrial

contraction, wave "c" corresponds to an increase in pressure from the mitral valve bulging into the atrium after closure, and wave "v" corresponds to passive atrial filling. depolarization, waves "QRS" correspond to ventricular depolarization, and wave "T" corresponds to ventricular repolarization.

In the electrocardiogram: wave "P" corresponds to atrial

In the phonocardiogram: The sound labeled 1st contributes to

the S1 heart sound and is the reverberation of blood from the sudden closure of the mitral valve (left A-V valve) and the sound labeled "2nd" contributes to the S2 heart sound and is the reverberation of blood from the sudden closure of the aortic valve.