SHAUN E.

BORRES, MD, FPOA

College of Physical Therapy
Riverside College Inc.
 1. Anatomy
• Heart chambers and valves
• Pericardium, Myocardium, Endocardium
• Coronary circulation
 2. Physiology
• Conduction system of the Heart
• Cardiac cycle
• Cardiac output
• Hemodynamics
• Neurohumoral influence on heart function
 Hollow muscular organ
 Pyramidal
 Lies within the
pericardium
 Connected at its base
to the great blood
vessels but otherwise
lies free within the
pericardium
 Surfaces:
• Sternocostal surface
 Anterior
 Formed mainly by the RA and RV
• Diaphragmatic surface
 Formed by RV and LV and inferior surface of RA
 Where the heart rests
 Inferior
• Posterior surface
 Base of the heart
 Formed mainly by LA
 Apex of the Heart
• Formed by LV
• Downward, forward and to the left
• 5th Left ICS
• 3 ½ inches (9 cm) from the midline
• Apex beat can be seen and palpated
 RIGHT
• Right atrium
 LEFT
• Left atrium and left ventricle
 INFERIOR
• Right Ventricle and Right Atrium
 Heart
divided by vertical septa into 4
chambers
• Right atrium
• Left atrium
• Right ventricle
• Left ventricle
 RA anterior to the LA
 RV anterior to LV
 Right Heart Chambers: Pulmonary Circuit

• Right Atrium
– Receives O2-poor
blood from body via
IVC, SVC, Coronary
sinus
• Right Ventricle
– Pumps blood to lungs
via Pulmonary
Semilunar Valve in
pulmonary trunk
 Left Heart Chambers: Systemic Circuit

• Left Atrium
– Receives O2-rich blood
from 4 Pulmonary
Veins
• Left Ventricle
– Pumps blood into aorta
via Aortic Semilunar
Valve to body
Heart Chambers and Valves
 Has a main cavity and a small out-
pouching (Auricle)
 Posteriorly: wall is smooth
 Anteriorly: roughened or trabeculated by
bundles of muscle fibers (Musculi
Pectinati)
 Openings:
• SVC: upper part; no valve; returns blood from the
upper half of the body
• IVC: lower part; rudimentary valve; returns blood
from the lower half of the body
• Coronary Sinus: drains most of the blood from
the heart wall; rudimentary valve
• Right AV orifice: anterior to the IVC; guarded by
tricuspid valve
 Wallsare thicker than RA
 Shows a number of internal projecting
ridges formed of muscle bundles and are
sponge-like (trabeculae carnae)
 Trabeculae Carnae:
• Papillary muscles
 Project inward; bases attached to the wall; apices
connected by fibrous chords (chordae tendinae) to
the cusps of tricuspid valve
• Moderator band
 Ends attached to the wall and the middle is free
 Crosses the ventricular cavity from the septal to the
anterior wall
 Conveys the right branch of the AV bundle
• Prominent ridges
 Openings:
• AV orifice: communicates with the RA; guarded
by tricuspid valve.
• Pulmonary orifice: communicates with the
pulmonary trunk becoming the infundibulum;
guarded by pulmonic valve
 Consists of main cavity and left auricle
 Forms the greatest part of the base of the
heart
 Interior is smooth
 Left auricle possesses muscular ridges
 Openings:
• Pulmonary veins: 2 from each lung; no valves
• Left AV orifice: guarded by the mitral valve
 Walls 3x thicker than the RV
 Intraventricular blood pressure is 6x
higher than RV
 Circular on cut-section
 Well-developed trabeculae carnae
 2 large papillary muscles
 No moderator band
 Openings:
• AV orifice: guarded by mitral valve
• Aortic orifice: guarded by aortic valve
 Atrioventricular valves
• Prevent backflow of blood from the ventricles to
the atria during systole
• Tricuspid valve
• Mitral valve
 Semilunar valves
• Prevent backflow from the aorta and pulmonary
arteries into the ventricles during diastole
• Pulmonary valve
• Aortic valve
 Lies behind the right half of the sternum
opposite the 4th ICS
 Best heard over the right half of the lower end
of the body of the sternum
 Guards the AV orifice
 3 cusps: anterior, septal and posterior (folds of
endocardium)
 Bases attached to the fibrous ring of the
skeleton of the heart
 Free edge and ventricular surfaces attached to
the chordae tendinae
 Lies behind the left half of the sternum
opposite the 4th costal cartilage
 Best heard over the apex
 Guards the AV orifice
 Has 2 cusps: anterior and posterior
 Liesbehind the medial end of the 3rd left
costal cartilage
 Heard best over the medial end of the
second left ICS
 Guards the pulmonary orifice
 3 semilunar cusps: 1 posterior and 2
anterior
 No chordae or papillary muscles
 Sinuses: dilatations at the root of the
pulmonary trunk
 Lies behind the left half of the sternum
opposite the 3rd ICS
 Best heard over the medial end of the 2nd
right ICS
 Guards the aortic orifice
 Similar in structure to the PV
 3 cusps: 1 anterior and 2 posterior
 Aortic sinuses: bulges of the aortic wall
• Anterior: gives origin to the RCA
• Posterior: gives origin to the LCA
 Heart Wall
• Epicardium (most superficial)
– Visceral pleura
• Myocardium (middle)
– Cardiac muscle
– Contracts
• Endocardium (inner)
– Endothelium
– Lines the heart
– Creates the valves
 Inner layer of the pericardium
 A conical sac of fibrous tissue that
surrounds the heart and the roots of the
great blood vessels.
 Is the muscular wall of the heart (heart
muscle)
 It contracts to pump blood out of the
heart and then relaxes as the heart refills
with returning blood.
 Innermost layer of tissue that lines the
chambers of the heart
 Also provides protection to the valves
and heart chambers.
• Right and Left Coronary Arteries
– Branch from Ascending Aorta
– Have multiple branches along heart
• Cardiac Veins
– Coronary Sinus (largest)
– Many branches feed into sinus
 Right Coronary Artery (RCA)
• Arises from anterior aortic sinus of the
ascending aorta
• Runs forward between the pulmonary trunk and
right auricle
• Descends almost vertically to the right AV
groove giving branches to the RA and RV
• Anastomose posteriorly with the LCA
 Left Coronary Artery (LCA)
• Larger than the right
• Arises from the left posterior aortic sinus of the
ascending aorta
• Passes forward between pulmonary trunk and
left auricle
• Enters AV groove dividing into anterior
interventricular branch and a circumflex branch
 Most blood from the heart wall drains
into the coronary sinus
 Coronary sinus lies in the posterior AV
groove and is a continuation of the great
cardiac vein
 Tributaries: small cardiac vein, middle
cardiac vein and anterior cardiac vein
 Innervated via the cardiac plexus situated
below the aortic arch
 Sympathetic supply
• Arises from the cervical and upper thoracic
portions
• Postganglionic fibers terminate on the SA and
AV nodes, cardiac muscle fibers and coronary
arteries
• Results in cardiac acceleration, increased force
of contraction and coronary artery dilatation.
 Parasympathetic supply: vagus nerve
• Postganglionic parasympathetic fibers terminate
on the SA and AV nodes and coronary arteries
• Activation results in reduction in the rate and
force of contraction and coronary constriction
Circulate blood throughout
entire body for:
• Transport of oxygen to cells
• Transport of CO2 away from cells
• Transport of nutrients (glucose) to cells
• Movement of immune system
components (cells, antibodies)
• Transport of endocrine gland
secretions
Heart is pump
Arteries and veins are main tubes
(plumbing)
• Arteries Away from Heart
• Veins to Heart
Diffusion happens in capillaries
(oxygen, CO2, glucose diffuse in
or out of blood)
Systemic
Circulates blood
throughout the rest of
the body
HIGH pressure

Pulmonary
Circulates blood
through the lungs to
oxygenate blood
LOW pressure
 Contracts rhythmically at 60-100
beats/min
 Atria contracts first together followed by
the ventricles
 Slight delay in passage of impulse from
the atria to the ventricles
 Consists of:
• Sino-atrial node
• Atrioventricular node
• Atrioventricular bundle (right and left branches)
• Subendocardial plexus of Purkinje fibers
• Sinus node (aka Sinoatrial or SA node)
• Site where the contraction of the heart muscle is initiated
• Pacemaker
• Small but forms the full-thickness of the myocardium of
the RA
• Once initiated, impulse spreads through the atrial
myocardium reaching the AV node
• Controls the beat of the heart because its rate of
rhythmical discharge is faster than that of any other part
of the heart.
• A-V node
• Situated in the lower part of the atrial septum just above
the attachment of the septal cusp of the tricuspid valve
• Impulse from the atria is delayed before passing into the
ventricles

• A-V bundle
• Conducts impulse from atria to the ventricles
• Descends behind the septal cusp of the tricuspid valve to
reach the membranous part of the ventricular septum
• It is the only muscular connection between the
myocardium of the atria and the ventricles
• Right bundle branch
• Passes down the right side of the ventricular septum to
reach the moderator band
• Becomes continuous with the fibers of Purkinje plexus of
the RV
• Left bundle branch
• Pierces the septum and passes down on its left side
beneath the endocardium
• Divides into 2 branches and eventually becomes
continuous with the fibers of the Purkinje plexus of the
LV
Electrocardiogram (ECG) can trace conduction
of electrical signals through the heart
Aberrant ECG patterns indicate damage
• Series of changes that take place within as it fills with
blood and empties
• Events that occur from the beginning of one heartbeat
to the beginning of the next
• Each cycle is initiated by spontaneous generation of an
action potential in the sinus node
• Delay of >0.1 sec during passage of the cardiac impulse
from the atria to the ventricles
Consists of:

• Diastole
• Period of relaxation
• Heart fills with blood
• Systole
• Period of contraction
• Heart empties with blood
Coordination of chamber contraction, relaxation
 Relationship of the Electrocardiogram to the Cardiac Cycle

P wave is caused by spread of depolarization through the atria, and

this is followed by atrial contraction

QRS waves appear as a result of electrical depolarization of the

ventricles, which initiates contraction of the
ventricles
Ventricular T wave represents the stage of repolarization of the
ventricles when the ventricular muscle fibers begin to relax
 Blood normally flows continually from the
great veins into the atria
 80% of the blood flows directly through
the atria into the ventricles even before
the atria contract
 Atrial contraction causes additional 20%
filling of the ventricles.
 Functions of the Ventricles as Pumps
Filling of the Ventricles.
 During ventricular systole, large amounts of blood
accumulate in the right and left atria because of the
closed A-V valves.
 Therefore, as soon as systole is over and the ventricular
pressures fall again to their low diastolic values, the
moderately increased pressures in the atria
immediately push the A-V valves open and allow blood
to flow rapidly into the ventricles.
 This is called the period of rapid filling of the ventricles
(lasts for about the first third of diastole)
 Emptying of the Ventricles During
Systole
Period of Isovolumic (Isometric) Contraction.
 Immediately after ventricular contraction begins, the
pressure rises abruptly causing the A-V valves to close.
 Then an additional 0.02 to 0.03 second is required for
the ventricle to build up sufficient pressure to push the
semilunar valves open against the pressures in the aorta
and pulmonary artery.
 Therefore, during this period, contraction is occurring,
but there is no emptying.
 This is called the period of isovolumic or isometric
contraction, meaning that tension is increasing in the
muscle but little or no shortening of the muscle fibers is
occurring
Period of Ejection.
 When the left ventricular pressure rises slightly above
80 mm Hg, the pressures push the semilunar valves
open.
 Immediately, blood begins to pour out of the ventricles,
with about 70% of the blood emptying occurring during
the first third of the period of ejection and the remaining
30% emptying during the next two thirds.
 Therefore, the first third is called the period of rapid
ejection, and the last two thirds, the period of slow
ejection.
Period of Isovolumic (Isometric) Relaxation.
 At the end of systole, ventricular relaxation begins
allowing both the right and left intraventricular pressures
to decrease rapidly.
 The elevated pressures in the distended large arteries
immediately push blood back toward the ventricles,
which snaps the aortic and pulmonary valves closed.
 For another 0.03 to 0.06 second, the ventricular muscle
continues to relax giving rise to the period of isovolumic
or isometric relaxation.
 End-Diastolic Volume, End-Systolic Volume, and
Stroke Volume Output.

End-diastolic Volume
- During diastole, normal filling of the ventricles
increases the volume of each ventricle to about 110-
120 mL
Stroke Volume Output
- As the ventricles empty during systole, the volume
decreases about 70 mL
End-systolic Volume
- The remaining volume in each ventricle, about 40 to
50 mL after systole
Ejection Fraction
- The fraction of the end-diastolic volume that is
ejected
 Cardiac Output
- Total volume of blood pumped by the ventricle per minute
 Concepts of Preload and Afterload

Preload
- degree of tension on the muscle when it
begins to contract
- is usually considered to be the end-diastolic
pressure when the ventricle has become
filled.
Afterload
- load against which the muscle exerts its
contractile force
- is the pressure in the artery leading from the
ventricle
 Intrinsic Regulation of Heart Pumping
(Frank-Starling Mechanism)

- intrinsic ability of the heart to adapt to increasing volumes

of
inflowing blood
- means that the greater the heart muscle is stretched during
filling, the greater is the force of contraction and the greater
the quantity of blood pumped into the aorta
- Within physiologic limits, the heart pumps all the blood that
returns to it by the way of the veins.
 Heart Sounds: Lub*-Dub**
• “Lub” : Tricuspid and
Mitral valves closing

• “Dub” : Semilunar
(Pulmonic & Aortic)
valves closing
 Heart
receives visceral
motor innervation
• Sympathetic (speeds up)
• Parasympathetic (slows
down)
Neurohumoral Regulation of the Cardiac Cycle

Mechanisms of Excitation of the Heart by the Sympathetic

Nerves.
 Arises from cervical and upper thoracic portions
 Secretes norepinephrine
 Strong sympathetic stimulation can increase the HR in
young adult humans from the normal rate of 70 bpm up to
180 to 200 and, rarely, even 250 bpm
 Increases the force of heart contraction to as much as
double normal
 Thereby increasing the volume of blood pumped and
increasing the ejection pressure
Neurohumoral Regulation of the Cardiac Cycle

Parasympathetic (Vagal) Stimulation of the Heart

 From medulla oblongata (vagus nerve)
• Nerve branches to S-A and A-V nodes
• Secretes acetylcholine (slows rate)
• Vagal fibers are distributed mainly to the atria
and not much to the ventricles
• Parasympathetic activity
• increase (slow heart rate)
• decrease (increase heart rate)
 Baroreceptors detect changes in blood
pressure

 Rising pressure stretches receptors

vagus nerve parasympathetic system

 Increased temperature increases heart rate

• Heat increases the permeability of the cardiac muscle
membrane to ions that control heart rate, resulting in
acceleration of the self-excitation process.
Ions and heart rate:
• Effect of Potassium ion:
 Excess potassium in the ECF causes the
heart to become dilated and flaccid and
also slows the heart rate
 Decreases the resting membrane
potential in the cardiac muscle fibers
 As the membrane potential decreases,
the intensity of the action potential also
decreases, which makes contraction of
the heart progressively weaker
 Ions and heart rate:
• Effect of Calcium Ions
 An excess of calcium ions causes effects
almost exactly opposite to those of potassium
ions (spastic contraction)
 This is caused by a direct effect of calcium
ions to initiate the cardiac contractile process
 Conversely, deficiency of calcium ions causes
cardiac flaccidity
 Fortunately, however, calcium ion levels in the
blood normally are regulated within a very
narrow range.
 Therefore, cardiac effects of abnormal calcium
concentrations are seldom of clinical concern