Академический Документы
Профессиональный Документы
Культура Документы
Sistem
Kardiovaskuler
M. Saifur Rohman, dr SpJP(K),
PhD
Dept. of Cardiology and Vascular Medicine
Faculty of Medicine, Brawijaya University
Outline
Circulatory System
Three basic components
Heart
Serves as pump that establishes the pressure
gradient needed for blood to flow to tissues
Blood vessels
Passageways through which blood is distributed
from heart to all parts of body and back to heart
Blood
Transport medium within which materials being
transported are dissolved or suspended
Circulatory System
Pulmonary circulation
Closed loop of vessels
carrying blood between
heart and lungs
Systemic circulation
Circuit of vessels
carrying blood between
heart and other body
systems
Obliquely
Leftward
Downward
Forward
Apex of heart:
Junction of ventricles & ventricular
septum
Found at left of MCL @ 5th ICS.
Lateral
Lateral right heart
border: RA.
Lateral wall of LV &
small part of LA form
most of left heart border.
Major components
Pacemaker cells
5 10 um in length;
Sinoatrial and atrioventricular nodes
Spontaneous depolarization
Action Potential
Electrical conducting cells
Long thin cells
Atrial conducting system
Ventricular conducting system
Myocardial cells
Contractile units in the heart, most are
myocardial cells
Calcium is responsible for contractile process
after
initiation of action potential
Endocardium
Cardiac Wall
Myocardium
Muscular portion.
Composed of cardiac muscle cells.
Contractile portion.
Epicardium
Visceral layer of serous pericardium.
Completely encloses external surface of
the heart.
Pericardium
Parietal
Visceral
Pericardium
Pericardium: Fibroserous membranous sac
that encloses the heart & root of the great
vessels.
Pericardial space contains 10-20 ml of fluid.
Two Layers:
1. Fibrous pericardium
Outermost layer
2. Serous pericardium
Parietal
Visceral
Pericardium Functions
Protects heart from friction.
Lubricates moving surfaces of the
heart.
Helps hold heart in position.
Forms a protective barrier against
infection & neoplasia
Trauma to chest results in damage
to the RV.
Myocardium
Cardiac Myocyte
Myofiber: is a group of myocytes held together by
surrounding collagen connective tissue
Excess collagen, may cause LV diastolic dysfunction
(e.g. left ventricular hypertrophy)
10-20 m in diameter
50-100 m long
single central nucleus
the cell is branched, attached to adjacent cells in
an end-to-end fashion (intercalated disc)
desmosomes (proteoglycan glue)
gap junction (region of close apposition)
LA blood supply
Receives O2 blood
Lower Chambers:
Ventricles
Major pumps
Right Ventricle
Contraction propels deoxygenated blood into
pulmonary circulation via PA.
Functions in a low pressure system (20-30/0-5)
Left Ventricle
Ejects blood into systemic circulation via aorta during
ventricular systole.
Functions in a high pressure system (100-140/60-80)
Valves
Cardiac Valves:
Atrioventricular Valves
Located between atria &
ventricles
Mitral Valve
2 cusps
Located between LA &
LV
Tricupsid Valve
3 cusps
Located between RA &
RV
Atrio-Ventricular Valves
Allow unidirectional blood to flow from
atria to
ventricles during ventricular diastole
Prevent retrograde flow during systole.
Diastole: Papillary muscles relax &
valve leaflets
open.
Systole: Valve leaflets close
AV valve closure produces a sound that
constitutes the first heart sound (S1).
Semi-Lunar Valves
Location
Pulmonary valve
Between RV & PA
3 cusps or semilunar cups
Aortic valve
Located between
LV & aorta
3 cusps
Semi-Lunar Valves
Permits unidirectional blood flows from ventricle to
artery during ventricular systole
Valve opens when ventricle contracts
Pressure greater in ventricle than arterial
outflow tract and valve opens.
Prevents retrograde blood flow during ventricular
diastole.
Pressure in arterial outflow tract exceeds
pressure in ventricle & causes valve to close.
Valve closure produces sound that is S2
Papillary Muscle
Papillary Muscle
Arise from
endocardial &
myocardial surface
of ventricles.
Attach to tendinae.
Blood supply from
coronary arteries.
Chordae Tendinae
Chordae Tendinae
Tendinous attachments to
tricuspid & mitral valves
Prevent eversion of
valves into atria during
systole.
String-like in appearance
and are sometimes
referred to as "heart
strings."
Heart Sounds
First heart sound or lubb
AV valves close and surrounding fluid
vibrations at systole
Second heart sound or dupp
Results from closure
of aortic and pulmonary
semilunar valves at
diastole, lasts longer
Coronary Arteries
Coronary Arteries
Originates from the
aorta just beyond the
aortic valve
Coronary blood flow to
the myocardium occurs
primarily during diastole
* To maintain adequate
blood flow through the
coronaries, mean
arterial pressure
(MAP) must be at least
60 mmHg
Coronary Arteries
Left main coronary artery
(LCA)
- Left anterior descending
artery (LAD)
>descends toward the
anterior wall & apex of LV
> supplies LV, ventricular
septum, chordae, papillary
muscle & RV
- Left circumflex artery (LCX)
> descends toward the
lateral wall of LV & apex
> supplies LA, lateral &
posterior LV surfaces
*45% supplies SA node
Coronary Arteries
Right main
coronary artery
(RCA)
- descends
toward the apex
of RV
- supplies the
RA, RV, & inferior
portions of LV
.
Coronary Arteries
RCA Supplies
SA node in 55% of hearts
AV node in 90% hearts
RA & RV heart muscle
Inferior wall of LV
Posterior 1/3 of intraventricular
septum
In 85% of hearts, RCA provides the
posterior descending branch.
Coronary Arteries
LCA
Branches into LAD & L Circumflex
Left Anterior Descending
Anterior wall of LV & anterior 2/3 septum
RBB & part of LBB
LA
Circumflex Supplies
AV node in 10% hearts
SA node in 45% hearts
Posterior surface of LV
Cardiac Veins
Return deoxygenated blood back to the
heart
Coronary Sinus: Drains into RA
Great cardiac vein
Small cardiac vein
Thesbesian Veins
Numerous small veins, present
mostly in RA & RV
Empty into chambers
Electricity
Autorhythmic cells
Do not contract
Specialized for initiating and conducting action potentials
responsible for contraction of working cells
70-80/min
40-60/min
20-40/min
Bundle of HIS
Electrical impulses conducted
to ventricles via Bundle of HIS
& purkinjie fibers
Divides into bundle branches
Right
Left
Anterior Fascicle
Posterior Fascicle
Purkinje Fibers
Impulse stimulates
ventricular myocardial cells
Inherent rate: 20-40
bpm
Action potential in
autorhythmic cells
Action Potential in
contractile cells
Electrical to mechanical
response
Excitation-contraction coupling
2
1 SA node depolarizes.
SA node
Internodal
pathways
AV node
A-V bundle
Bundle branchesPurkinje
fibers
5
4 Depolarization moves
rapidly through ventricular
conducting system to the
apex of the heart.
5 Depolarization wave
spreads upward from
the apex.
Excitation-Contraction Coupling in
Cardiac Contractile Cells
Electrocardiogram (ECG)
Record of overall spread of electrical activity through heart
Represents
Recording part of electrical activity induced in body
fluids by cardiac impulse that reaches body surface
Not direct recording of actual electrical activity of heart
Recording of overall spread of activity throughout heart
during depolarization and repolarization
Not a recording of a single action potential in a single
cell at a single point in time
Comparisons in voltage detected by electrodes at two
different points on body surface, not the actual potential
Does not record potential at all when ventricular muscle
is either completely depolarized or completely
repolarized
Electrocardiogram (ECG)
Different parts of ECG record can be
correlated to specific cardiac events
P wave: atrial
depolarization
P
The end
R
PQ or PR segment:
conduction through
AV node and A-V
bundle
QS
Atria contract.
T wave:
ventricular
Repolarization
R
T
ELECTRICAL
Repolarization
EVENTS
OF THE
CARDIAC CYCLE
QS
P Q wave
Q
ST segment
R
R wave
R
P
QS
P
Ventricles contract.
Q
P
S wave
QS
(Non-invasive)
Heart Rate
Signal conduction
Heart tissue
Conditions
Isovolumic ventricular
5 relaxation: as ventricles
relax, pressure in ventricles
falls, blood flows back into
cups of semilunar valves
and snaps them closed.
Ventricular ejection:
4 as ventricular pressure
rises and exceeds
pressure in the arteries,
the semilunar valves
open and blood is
ejected.
Isovolumic ventricular
contraction: first phase of
ventricular contraction pushes
AV valves closed but does not
create enough pressure to open
semilunar valves.
Wiggers Diagram
0
Electrocardiogram
(ECG)
Time (msec)
200 300 400
100
QRS
complex
500
600
700
800
QRS
complex
Cardiac cycle
T
120
Pressure
(mm Hg)
90
Aorta
Dicrotic
notch
Left
ventricular
pressure
60
Left atrial
30 pressure
Heart
sounds
Left
ventricular
volume
(mL)
S1
EDV
135
ESV
65
Atrial
systole
Atrial systole
S2
Isovolumic
ventricular
Ventricular
systole
Ventricular
systole
Ventricular
diastole
Early
ventricular
Atrial
systole
Late
ventricular
Atrial
systole
ATRIAL SYSTOLE
The end of
diastole
ATRIAL SYSTOLE
Pressures & Volumes
The "a" wave occurs when the
atrium contracts, increasing atrial
pressure (yellow).
Blood arriving at the heart cannot
enter the atrium so it flows back
up the jugular vein, causing the
first discernible wave in the
jugular venous pulse.
Atrial pressure drops when the
atria stop contracting.
During atrial systole the atrium
contracts and tops off the volume
in the ventricle with only a small
amount of blood.
Atrial contraction is complete
before the ventricle begins to
contract.
ATRIAL SYSTOLE
ECG
ISOVOLUMETRIC
CONTRACTION
The Beginning
of systole
ISOVOLUMETRIC
CONTRACTION
Heart
The atrioventricular (AV) valves
close at the beginning of this
phase.
Electrically, ventricular systole
is defined as the interval
between the QRS complex and
the end of the T wave (the Q-T
interval).
Mechanically, ventricular
systole is defined as the
interval between the closing of
the AV valves and the opening
of the semilunar valves (aortic
and pulmonary valves).
ISOVOLUMETRIC
CONTRACTION
Pressures & Volumes
ISOVOLUMETRIC
CONTRACTION
ECG
RAPID EJECTION
RAPID EJECTION
Heart
RAPID EJECTION
Pressures & Volumes
RAPID EJECTION
ECG
No Deflections
REDUCED EJECTION
The end of
systole
REDUCED EJECTION
Heart
REDUCED EJECTION
Pressures & Volumes
After the peak in ventricular and
arterial pressures (red and
green), blood flow out of the
ventricles decreases and
ventricular volume decreases
more slowly (white).
When the pressure in the
ventricles falls below the
pressure in the arteries, blood in
the arteries begins to flow back
toward the ventricles and
causes the semilunar valves to
close. This marks the end of
ventricular systole mechanically.
REDUCED EJECTION
ECG
ISOVOLUMETRIC
RELAXATION
The
beginning of Diastole
ISOVOLUMETRIC RELAXATION
Heart
ISOVOLUMETRIC RELAXATION
Pressures & Volumes
Throughout this and the previous
two phases, the atrium in
diastole has been filling with
blood on top of the closed AV
valve, causing atrial pressure to
rise gradually (yellow).
The "v" wave is due to the back
flow of blood after it hits the
closed AV valve. It is the second
discernible wave of the jugular
venous pulse.
The pressure in the ventricles
(red) continues to drop.
Ventricular volume (white) is at a
minimum and is ready to be
filled again with blood.
ISOVOLUMETRIC RELAXATION
ECG
No Deflections
RAPID VENTRICULAR
FILLING
No Deflections
REDUCED VENTRICULAR
FILLING
(Diastasis)
REDUCED VENTRICULAR
FILLING
Heart
REDUCED VENTRICULAR
FILLING Pressures & Volumes
REDUCED VENTRICULAR
FILLING
ECG
No Deflections
Regulation of Cardiac
Output
Figure 18.23
Stroke volume
Strength of
cardiac contractio
End-diastolic
volume
Venous return
Pre-Load
The stretch or volume
Measured by CVP & PA pressures
Increase in pre-load has following effects:
the volume of blood returning to ventricles
Stretches myocardial fibers, causing a more
forceful subsequent ventricular contraction
SV and thus CO
Ventricular work
Myocardial oxygen consumption
After Load
Amount of resistance to blood flow out
of the ventricles into the aorta
The initial resistance that the
ventricles must overcome in order to
open the semi-lunar valves & propel
blood into the systemic and pulmonary
circulatory systems
Contractility
The ability of a muscle
fiber to shorten
Hearts ability to
squeeze blood out &
change shape from full to
empty
Neurologic Control of
Heart
Autonomic Nervous System
Influences
Contractility
Depolarization &
repolarization
Rate of conductivity
Sympathetic Nervous
System
Alpha
Beta
Dopaminergic
Neurologic Control of
Heart
Chemoreceptors
Sensitive to changes in pO2/pCO2/pH
Cause changes in HR & RR
Baroreceptors
Stretch receptors in aortic arch &
heart
Respond to pressure & volume
changes
Systemic Vasculature
Major Function
Supply tissues with blood, nutrients
& hormones
Remove metabolic wastes
Blood flow to tissues
Controlled via chemical reactions &
nerves that dilate or constrict
vessels
Vascular System
Provide conduits for blood to travel
from the heart to nourish the body
Carry cellular wastes to the excretory
organs
Allow lymphatic flow to drain tissue
fluid back to the circulation
Return blood to the heart for
recirculation
Major Components
Arteries
Strong, compliant, elastic-walled vessels that
carry blood AWAY from the heart & distribute
to capillary beds.
High pressure circuit
Stretch during systole & recoil during diastole.
3 layers
Intima
Media
Adventita
Arterial
System
Delivers blood to
various tissues
for nourishment
Transport of
cellular wastes
Contribute to
thermal
regulation
Arterial System
Blood pressure
- force of blood exerted against the vessel
walls
= CO x peripheral vascular resistance
- regulated by:
> autonomic nervous system (ANS)
> kidneys (renin-angiotensin-aldosterone)
> endocrine system (catecholamines,
kinins, serotonin, histamine)
Arterioles
Contain smooth muscle
Major vessels which control arterial pressure
Innervated by sympathetic nerve fibers
Stimulation causes vascular constriction
Blood Pressure
Systolic:
- amount of pressure/force generated by LV to
distribute blood into the aorta w/ each contraction
of the heart
- 90 135 mmHg (120)
- affected by CO and arterial distention
Diastolic:
- amount of pressure/force sustained by the
arteries during the relaxation phase of the heart
- ability of the heart to rest while filling with blood
- affected by peripheral vascular resistance
- 60 85 mmHg (80)
Regulation of BP
Autonomic Nervous System
- Baroreceptors (arch of aorta & origin of
internal carotid arteries)
> stimulated when arterial walls are
stretched by increased BP
> inhibit vasomotor center (pons &
medulla
or brainstem)
- Chemoreceptors (bifurcation of carotid
arteries & aortic arch)
> sensitive to hypoxemia, hypercapnia
Venous System
Stores 60% total volume of blood in the circulatory
system.
Venules
Receive blood from capillaries
Serve as storage vessels
Veins
Storage vessels
Conduct blood back to heart in a low pressure
system
Venous pump (valves)
Venous
System
Series of veins
located adjacent to
arterial system
Veins collect blood
from the capillaries
& terminal arterioles
Acts as reservoir for
blood
Low-pressure,
collapsible system
that work against
effects of gravity
Capillaries
Diffusion & exchange
Oxygen/CO2/solutes:
blood & tissues
Fluid: plasma &
interstitium
Lack smooth muscle
Lumen diameter
passively controlled
by changes in pre &
post-capillary
resistance
Capillaries
Capillary wall is permeable to all substances in
plasma & tissue fluid, except plasma proteins
Plasma proteins cause colloid osmotic pressure.
Fluid movement due to hydrostatic pressure.
Hydrostatic pressure pushes fluid out of the
capillaries. Oncotic pressure balances this by
maintaining fluid inside the capillaries.
Terima Kasih