CARDIOVASCULAR SYSTEM

- Composed of the heart and blood vessels

I. FUNCTION:
- HEART:
o Delivers oxygenated blood to the system
o Receives deoxygenated blood from the system
o R: delivers blood to the lungs
o L: delivers blood to the system

II. LOCATION
- located at the mediastinum
- BASE  BA23  Superiorly between 2nd and 3rd rib
- APEX  5PEX  Inferiorly at the level of the 5th rib

III. HEART TISSUE

A. PERICARDIUM
a. Parietal – outer and thicker
b. Visceral – inner and thinner
× Pericarditis: caused by infections 
inflammation  ↑fluids in pericardial
cavity
× Cardiac Tamponade: compression of the
heart caused by ↑↑↑fluids
B. MYOCARDIUM – responsible for muscle
pumping activity (to eject the blood)
× Cardiomyopathies
C. ENDOCARDIUM – innermost layer and
connected to the heart valves and
chambers (for protection)
× Valvular Heart Dysfunctions
 IV. VALVES
- FUNCTION: prevents backflow
- AV VALVE: prevents backflow from ventricle to atrium during systole
: Connected to papillary muscles in the ventricle via chordae tendinae  no contribution to closing of
the valve closure  only prevents bulging
- SL VALVE: prevents backflow from arteries to ventricle during diastole

DRILL:
1. Compression of the heart caused by pericarditis?
2. Protects the heart valves and chambers?

V. CARDIAC CYCLE
RAPID INFLOW/ ATRIAL KICK/ ISOVOLUMIC ISOVOLUMIC
DIASTASIS RAPID EJECTION
FILLING SYSTOLE CONTRACTION RELAXATION
DIASTOLE SYSTOLE
1st 1/3 passive Middle 3rd small Last 2/3 active Isovolumetric Blood is ejected ↓Blood Volume
filling amount of blood filling contraction of LV from ventricles ↓P°
N flows to the  ↑P°
ventricles LV: 80 mmHg LV: >80 mmHg Ventricles relax
RV: 8 mmHg RV: >8 mmHg

AV OPEN AV OPEN AV OPEN S1: AV CLOSE AV CLOSE AV CLOSE

Start of Diastole End of Diastole End of Systole
Start of Systole
SL CLOSE SL CLOSE SL CLOSE SL CLOSE SL OPEN S2: SL CLOSE
↑P° in the LA ↑P° in the LV ↑↑P° in the LV ↑P° in the
causes AV to open causes AV to close causes SL to open aorta/pulmonic
valves causes SL
to close
EDV=110-120 ml Period of SV=70 ml ESV=50 ml
Maximal EF= 55-75%
Ventricular P° (~60%)
= SV/EDV

70% of 60% (70

ml)=rapid ejection

30% of 60%=slow
ejection
VI. ELECTRICAL CONDUCTION OF THE HEART
A. SA NODE
- Located sup/pos-lateral wall of (R) atrium
- Slightly below the SVC
- Main pacemaker (60-100 bpm)
- Faster discharge than AV/Purkinje fibers
*Internodal Pathways – responsible for faster
conduction from SA  AV node
*Ectopic Pacemaker – anywhere outside SA

B. AV NODE
- Located at the pos wall of (R) Atrium behind
tricuspid valve
- Has intrinsic rate of (40-60 bpm)
- Delays conduction from atria  ventricles d/t
↓gap junctions = ↑resistance to conduction
of excitatory ions

C. AV BUNDLE/ BUNDLE OF HIS

- Passes down from Interventricular septum to
apex
- Branches into Left and Right Bundle Branches
- Only promotes forward flow of ions due to presence of fibrous tissue barrier

D. PURKINJE FIBERS
- Continuous to Left and Right Bundle Branches
- Has intrinsic rate of 15-40 bpm
- Distributes the impulses to the ventricles

VII. CORONARY ARTERIES

 RIGHT LEFT
RCA – RA, RV, INF WALL OF LV, 60% SA NODE LEFT MAIN – branches into:
LADA – Interventricular Septum, ANT wall, Apex
Most commonly affected in MI
PDA – POS wall LEFT CIRCUMFLEX ARTERY – LAT/INF wall, LA, 40%
– Can originate from (L) Circumflex Artery SA NODE

VIII. LABORATORY VALUES

1. Sodium: 135 – 145 mEq/L
2. Potassium: 3.5 – 5.0 mEq/L
3. Chloride: 95 – 105 mEq/L
4. Calcium: 9-11 mg/dL
5. BUN: 10 – 20
6. Creatinine: 0.5 – 1.2 mg/dL
7. Glucose: 70 – 110/mg/dL
8. Carbon dioxide: 20 – 29 mEq/L
9. Magnesium 1.5 – 2.5 mEq/L
10. HGB (g/dL)
i. F: 12 – 16
ii. M: 13 – 18
 >10 regular exercise
 8-10 light exercise
 <8 no exercise
11. Hematocrit (%)
i. F: 37 – 48
ii. M: 45 – 52
 >25% reg/light exercise
 <25% no exercise
12. WBC: N 4.8k – 10.8k
i. >5k light/reg exercise
ii. <5k with fever no exercise
iii. <1k no exercise, mask required
13. RBC: N 4 – 6.2M/mm3
14. Platelet Count: 150k – 450k
i. >150k
 Normal activity
ii. 50 – 150k (BLS Sex Mo Me)
 Bicycling (Flat only)
 Low bench Stepping
 Swimming
 Sexual Intercourse
 MMT without restrictions
 Min-mod resistive exercise
iii. 30 – 50k (WASAbiNOps)
 Walking as tolerated
 Aquatic therapy
 Stationary Bicycle
 Arom, submax isomets
  No prolonged stretching, resistive exercise
iv. 20k – 30k (WALILINOP)
 Walking as tolerated
 Light exercise
 Light AROM as tolerated
 No PROM
v. <20k (GANAAROM)
 Guard carefully
 AAROM – AROM No antigravity
 No resistive exercise
 ADLs
vi. <10k
 Usually transfused
15. SaO2: 95-100%
16. Cholesterol: 100-200 mg/dl
17. LDL: <100 mg/dl
18. HDL: 37-80 mg/dl
19. Triglycerides: <150 mg/dl

IX. HEMODYNAMIC VALUES

A. STROKE VOLUME
- Amount of blood ejected by the ventricles per beat
- N = 70 mL
- Influenced by:
o Preload – amount of blood in the ventricle at the end-diastole (EDV)
o Afterload – force needed to generate by LV to counteract aortic pressure
o Contractility – ability of the myocardium to pump blood
- FRANK STARLING PRINCIPLE: LENGTH-TENSION RELATIONSHIP  ↑LENGTH = ↑FORCE
B. EJECTION FRACTION
- Ratio of the amount of blood ejected and the amount of blood during end-diastole
- N = 55-75% (~60%)
- EF = SV/LVEDV
C. CARDIAC OUTPUT (CO)
- Amount of blood ejected per minute
- N = 4-6 L
D. CARDIAC INDEX (CI)
- CO in relation to Body Surface Area (BSA)
- More clinically important because it measures adequacy of individual’s CO
- CI = CO/BSA
- ↓BSA = ↑tissue perfusion
E. MYOCARDIAL DEMAND (MVO2)
- ↑Demand = ↑supply (must be balanced)
- In order for the heart to ↑↑↑supply in response to greater demands, ↑↑↑CBF or Coronary Blood Flow
- MVO2 = HR x SBP
- N CBF = 225 mL

DRILL:
1. Who is more at risk of having cardiovascular problem? A man of 5 feet tall or man of 6 feet tall?
2. What supplies the interventricular septum?
 3. If the SA node became dysfunctional, will the heart stop beating? Why? Why not?
4. Responsible for faster conduction from atria to ventricles?

X. NEUROHORMONAL INFLUENCES
SYMPATHETIC PARASYMPATHETIC
Located at SA node and ventricles Located at SA node and ventricles
Stim  releases Norepinephrine at sympa nn Stim  releases Acetylcholine at vagal nn endings
endings
Nore  stimulates Beta1 Adrenergic Receptor
↑Na+ and Ca2+ permeability ↑K+ permeability = repolarize = relax
↑HR (chronotropy) ↓ rate discharge of SA
↑Contractility (inotropy) ↓ excitation of AV node
↓ HR
↓ Contractility

Vasodilation of Coronary arteries = ↑Blood FlowVasoconstriction of Coronary Arteries = ↓Blood

Flow
Stim  adrenal cortex to release catecholamine Effect on LV is MINIMAL during exercise because
epinephrine (during exercise) override by SYMPA
 XI. BORG SCALE
OLD BORG SCALE (Beauty and the Beast) NEW BORG SCALE (Nothing at All)
It starts with number 6, very very light 0.5 very very weak
9 is very light 1 is very weak
11 fairly light 2 is weak
13 somewhat hard 3 is moderate, moderate
15 hard, 15 is hard 4 is somewhat strong (repeat)
17 very hard 5 is strong
19 very very hard 7 is only very strong
10 very very strong

XII. ABI SIGNIFICANCE (SBP OF LE/ SBP OF UE)

1.4 Calcification, Calcinosis, DM, Falsely high elevated BP
1.0 – 1.3 Normal
0.91 – 0.99 Borderline
0.80 – 0.90 Mild PAOD  light compression only Intermittent Claudication
0.50 – 0.80 Moderate PAOD  light compression only; delayed Resting Claudication
wound healing
< 0.50 Severe PAOD (Critical Limb Ischemia)  CI: compression Ulceration
<0.2 Ischemic  CI: compression unlikely wound healing Gangrenous

XIII. ECG LEAD SYSTEM

ELECTROCARDIOGRAM
- Diagnostic method that provides graphic analysis of the heart’s electrical activity
- Commonly used to detect arrhythmias, heart blocks and myocardial perfusion
- Can also detect atrial and ventricular enlargement

12 LEAD ECG SYSTEM

 (TUNE OF PLEASE BE CAREFUL WITH MY HEART)
WALL INFARCT STRUCTURES AFFECTED LEADS AFFECTED
Posterior --------/LADA V1, V2
Anterior LADA V1, V2, V3, V4
Lateral LCA V5, V6, AVL, I
Inferior RCA (R coronary) II, III, AVF
Superior AVR

XIV. ECG ABNORMALITIES

A. P-WAVE: atrial depolarization

B. PR INTERVAL: conduction through AV nodes
C. QRS COMPLEX: ventricular depolarization
D. ST SEGMENT: start of ventricular repolarization
E. T-WAVE: completion of ventricular repolarization
1. SA NODE (Prob: SA discharge rate)
a. Sinus Bradycardia – Fire too slow (<60 bpm)
b. Sinus Tachycardia – Fire too fast (101-150 bpm)

2. ATRIAL CELLS (Prob: Atria; N: Ventricles so N QRS)

a. Premature Atrial Contractions
– P-wave occurred too soon
– Shortened PR interval
– Ectopic foci (instead of SA node, discharge is slightly far and nearer to AV node)
b. Atrial Flutter
– Causes rapid rate of atrial contraction
– 2-3 P-waves for every QRS
c. Atrial Fibrillation
– Caused by atrial enlargement  impaired emptying of atria
– No one can see P-waves or only fine, high frequency, very low voltage wavy record
– Rapid impulses and irregular

3. AV JUNCTION (Prob: Conduction from Atria to Ventricles)

FIRST DEGREE SECOND DGREE THIRD DEGREE

Mobitz Type I (Wenckebach) Mobitz Type II
Prolonged PR Prolonged PR interval N PR interval Mismatch of
interval: + + atrial and
Presence of block Ventricular drop beat Drop beats
 delays the (no QRS) (no QRS) ventricular
conduction from conduction
atria to ventricles *Stoke-Adams
Syndrome –
periodic fainting
Regular rhythm Irregular rhythm Irregular rhythm Regular rhythm
SAFE for exercise SAFE for exercise but NOT SAFE for NOT SAFE for
monitoring is required exercise exercise

4. VENTRICULAR CELLS (Prob: Ventricles)

a. Premature Ventricular Contractions
– No P-wave; Prolonged/ bizarre wide QRS because the conduction is from slowly conducting
muscles instead of Purkinje Fibers
– With T-wave inversion (opposite of QRS)  repolarization
– Couplet: 2 PVCs – Bigeminy: every 2nd
– V-Tach: 3 PVCs – Trigeminy: every 3rd
– V-fib: 6 PVCs – Quadrigeminy: every 4th
b. Ventricular Fibrillation
– Most fatal
– Bizarre ECG
– Cardiac impulses occur anywhere in the ventricles  small portions contract at the same
time, others are relaxed  NO COORDINATION; no enlargement of the chambers only
partial contraction  no pumping of blood
NICE TO KNOW:
A. Hypokalemia  HypUkalemia – ST DEPRESSION + U-WAVE
B. Hyperkalemia  HyperTALLemia – Tall T-wave
XV. AUSCULTATION
(TUNE OF IT’S A SMALL WORLD)
AUSCULTATE LOCATE
Aortic 2 (R) ICS 3 (L) ICS
Pulmonic 2 (L) ICS 3 (L) CC
Tricuspid 4 (L) ICS 4 (R) CC
Mitral 4 (L) ICS 5 (L) ICS
*Erb’s point 3 (L) ICS “General Murmurs”

Aortic R 2nd ICS

Pulmonic L 2nd ICS
Erb’s point L 3rd ICS “general murmurs”
Tricuspid L 4th-5th ICS at the sternum
Apex L 5th ICS medial to midclavicular line/apex
XVI. CONDITIONS

i. Coronary Artery Disease

- primary impairment in CAD is an imbalance of myocardial oxygen supply to meet the MVO2
- This is due to the narrowing of the lumen of the coronary arteries.
- ATHEROSCLEROSIS: hardening of the arteries
- The primary signs of CAD in women
a. Unexplained, severe episodic fatigue and weakness
b. Decrease activities of daily living
c. Substernal chest pain
d. Crushing, heavy, squeezing sensation commonly occurring during emotion or exertion
- ANGINA PECTORIS: Pain in the chest, jaw or Left arm d/t decreased oxygen supply to the heart tissues
 1-3 minutes but not longer than 3-5 minutes
 15-20 mins: after meal
 Starts 3-5 minutes after activity – “LAG TIME”
- Types of Angina
 Unstable: abrupt change in the
intensity and frequency of symptoms
(20-30mins)
 Nocturnal angina: this exertion is
usually caused by dreams
 Atypical Angina: unusual
symptoms(e.g., toothache or earache)
related to physical or emotional
exertion
 New-onset angina: angina that has
developed for the first time within the last 60 days
 Prinzmetal Angina: caused by coronary artery spasm
ii. Myocardial Infarction
- HEART ATTACK
- M/C cause – THROMBOSIS
- Attacks are most common in the MORNING
- IF CARDIAC ARREST OCCURS:
A. Call emergency
B. CPR
C. Use automated external defibrillator
- ZONES OF INFARCTION:
A. Zone of ischemia: T wave inversion
B. Zone of Injury: elevated ST segment
C. Zone of Infarction: pathological Q Waves
 - INFARCTION SITES:
A. Transmural: ST elevated MI with sharp Q wave; 75%
B. Nontransmural (subendocardial): non-ST elevated
MI with persistent ST depression; 25 %
- Sites of Coronary Artery Occlusion:
A. Inferior MI: (R) coronary artery
B. Lateral MI: circumflex artery
C. Anterior MI: (L) ant. Descending artery

iii. Pericarditis
- Inflammation of the pericardium
- Pericardial friction rub (auscultation)
- S/Sx:
A. Substernal pain
B. Pain referral to the neck, upper trapz,
Upper back, (L) supra clavicular area,(L)
Arm and (L) costal margins
C. With history of chills, fever, weakness
D. Pain aggravated by deep breathing, laughing, coughing and trunk movements
E. Pain relieved by leaning forward, sitting upright or holding breath

iv. Congestive Heart Failure

- aka CARDIAC DECOMPENSATION CARDIAC
INSUFFICIENCY
- State in which the heart is unable to pump enough
blood to meet the metabolic needs of the body
 v. Aneurysms
- an abnormal dilatation in the arterial wall, vein
of the heart
- Causes:
A. Trauma / weight lifting
B. Congenital vascular disease
C. Infection
D. Atherosclerosis
- Types:
 Thoracic aneurysm: involves the ascending, transverse, or descending portion of the aorta
 Peripheral aneurysm
 Most common site:
 Femoral artery
 Popliteal artery
 Aortic Abdominal Aneurysm (AAA)
 Most common site:
 Aorta, JUST BELOW THE KIDNEY
(IMMEDIATELY BELOW THE TAKEOFF
OF THE RENAL ARTERIES)
 (+) Pulsating mass in the abdomen with
abdominal pain and back pain

vi. Rheumatic Fever

- Streptococcal bacteria in the throat
- May lead to scarring and deformity of the heart valves
- Children: 5-15 y/o
- Most common symptoms:
 Joint pain
 Fever
vii. Endocarditis
- Inflammation of the endothelium secondary to remote
bacterial infection (skin or oral cavity)
- Damages the tricuspid, mitral and aortic valves
- Risk Factors:
 Previous valvular disease
 Injection drug users
  Postcardiac surgical patients
 Prosthetic cardiac valve
 Invasive diagnostic procedures
- S/Sx:
 Arthralgias
 Arthritis
 Low back / Sacroiliac pain
 Myalgias
 Petechiae
 Dyspnea, chest pain
 Cold and painful extremities
 Constitutional symptoms
viii. Mitral Valve Prolapse
- aka FLAPPY VALVE SYNDROME, BARLOW’S SYNDROME CLICK-MURMUR SYNDROME
- Characterized by:
 Mitral leaflet thickness with increase extensibility
 Decreased stiffness
 Decreased strength
- Listen for “CLICK” and murmurs
- Triad symptoms:
 Fatigue
 Palpitations
 Dyspnea
- MVP is not life threatening
- Regular exercise is encouraged (gradual)
ix. Arrythmia
- Are disorders of the heart rate and rhythm caused by
disturbances in the conduction system
- Arrhythmias can arise from problems in the:
1. Sinus node
2. Atrial cells
3. AV junction
4. Ventricular cells
 `

x. CARDIOVASCULAR DISORDERS
a. HTN
- An elevation of SBP, DBP or both measured on at least 2 separate occasions at least 2 weeks apart.
- CLASSIFICATION:
1. a.Primary / essential / idiopathic
2. b.Secondary
 Due to renal artery stenosis
 Oral contraceptive use
 Medications
3. Labile/Borderline

b. TIAs
- Due to temporary disruption of blood supply
to the brain
- This last from 5-20 minutes or 24 hours
- “mini-strokes”
- IMMEDIATE MEDICAL REFERAL
c. Orthostatic Hypotension
- Excessive drop of BP on assumption of erect
position
 SBP 20mmHg or more
 DBP 10 mmHg or more
 10% to 20% increase in pulse rate
- S/Sx:
- Decrease BP, Increase HR
- Lightheadedness
- Pallor & Diaphoresis
- Syncope
- Mental or visual blurring
- “RUBBERY LEGS”
 d. Peripheral Vascular Diseases
A. Arterial (Occlusive Diseases)
- Caused by:
 Thrombus, embolism or trauma to an
artery
 Arteriosclerosis Obliterans
 Thromboangitis Obliterans
 Raynaud’s disease
- S/Sx of Arterial Disease:
 Intermittent claudication
 Burning, ischemic pain at rest
 Rest pain aggravated by elevating the
extremity; relieved by hanging the foot
over the side of the bed or chair
 Decreased skin temperature
 Dry, scaly, or shiny skin
 Poor nail and hair growth
 Possible ulcerations and gangrene on
Weight bearing surfaces (e.g., toes, heel)

B. Raynaud’s Phenomenon
- Primary – idiopathic
- Secondary
 Scleroderma
 SLE
- S/Sx:
 Pallor in the digits
 Cyanotic, blue digits
 Cold, numbness, pain of digits
 Intense redness of digits

C. Venous (Occlusive) Disorders

i. Acute Venous Disorders
a. THROMBOPHLEBITIS
- Caused by thrombosis
- Acute inflammation with occlusion of veins
b. DEEP VEIN THROMBOSIS
- Thrombus formation in a deep vein in the calf, thigh or
pelvic
 ii. Chronic Venous Insufficiency
- Aka Postphlebitic syndrome
- d/t dysfunctinal valves that reduce venous return leading to venous hypertension and venous stasis
- S/Sx:
- chronic swollen limbs; thick, coarse, brownish skin around the ankles
- venous stasis ulceration
iii. Lymphedema
- An excessive accumulation of fluid in tissue spaces.
- Secondary to obstruction of the lymphatic system from:
o Trauma
o Infection
o Radiation
o Surgery (axillary, inguinal, iliac)

XVII. MEDICATIONS
 - Dec BP  S/E: HA/palp/nausea/weakness/drowsiness

- dec HR/Contractility, BP/work of heart/CA

spasm

- dec HR dec BP
- For RPE (rate of perceived exertion)
 S/E: fluid retention, HA
-S/E: persistent dry cough, skin rash, loss of taste, inc swelling of feet
and abdomnen, numbness
XVIII. CARDIAC REHABILITATION

**NOTHING FOLLOWS**