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Cardiovascular System
Cardiovascular System
Cardiovascular System
Assignment
“Cardiovascular System”
The HEART and Cardiovascular System
The heart is a muscular organ responsible for pumping blood through the
blood vessels by repeated, rhythmic contractions, or a similar structure in the
annelids, mollusks, and arthropods. The term cardiac (as in cardiology)
means "related to the heart" and comes from the Greek καρδία, kardia, for
"heart." The heart is composed of cardiac muscle, an involuntary muscle
tissue which is found only within this organ. The average human heart
beating at 72 BPM, will beat approximately 2.5 billion times during a
lifetime spanning 66 years.
The function of the right side of the heart (see right heart) is to collect de-
oxygenated blood, in the right atrium, from the body and pump it, via the
right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide
can be dropped off and oxygen picked up (gas exchange). This happens
through the passive process of diffusion. The left side (see left heart) collects
oxygenated blood from the lungs into the left atrium. From the left atrium
the blood moves to the left ventricle which pumps it out to the body. On both
sides, the lower ventricles are thicker and stronger than the upper atria. The
muscle wall surrounding the left ventricle is thicker than the wall
surrounding the right ventricle due to the higher force needed to pump the
blood through the systemic circulation.
Starting in the right atrium, the blood flows through the tricuspid valve to
the right ventricle. Here it is pumped out the pulmonary semilunar valve and
travels through the pulmonary artery to the lungs. From there, blood flows
back through the pulmonary vein to the left atrium. It then travels through
the mitral valve to the left ventricle, from where it is pumped through the
aortic semilunar valve to the aorta. The aorta forks, and the blood is divided
between major arteries which supply the upper and lower body. The blood
travels in the arteries to the smaller arterioles, then finally to the tiny
capillaries which feed each cell. The (relatively) deoxygenated blood then
travels to the venules, which coalesce into veins, then to the inferior and
superior venae cavae and finally back to the right atrium where the process
began.
The heart is effectively a syncytium, a meshwork of cardiac muscle cells
interconnected by contiguous cytoplasmic bridges. This relates to electrical
stimulation of one cell spreading to neighboring cells.
Cardiovascular System
The circulatory system (or cardiovascular system) is an organ system that
moves nutrients, gases, and wastes to and from cells, helps fight diseases
and helps stabilize body temperature and pH to maintain homeostasis. While
humans, as well as other vertebrates, have a closed circulatory system
(meaning that the blood never leaves the network of arteries, veins and
capillaries), some invertebrate groups have open circulatory system. The
most primitive animal phyla lack circulatory systems.
The Entire Blood Supply Passes Through the Heart About Once Every
Minute
Your body has approximately 5 liters of blood (large people have a
little more, small people a little less)
The heart's pumping rate is called the cardiac output: at rest its value
is about 5 liters/min
Comparing the volume with the cardiac output you can see that the
entire blood volume passes through the heart on the average once
every minute
All of the output from the right heart goes through the lungs (5
liters/min)
The output from the left heart splits and goes through different organs
General outline of the circulation:
Electrocardiogram
An electrocardiogram (ECG or EKG, abbreviated from the German
Elektrokardiogramm) is a graphic produced by an electrocardiograph, which
records the electrical activity of the heart over time. Its name is made of
different parts: electro, because it is related to electronics, cardio, Greek for
heart, gram, a Greek root meaning "to write".
Electrical waves cause the heart muscle to pump. These waves pass through
the body and can be measured at electrodes (electrical contacts) attached to
the skin. Electrodes on different sides of the heart measure the activity of
different parts of the heart muscle. An ECG displays the voltage between
pairs of these electrodes, and the muscle activity that they measure, from
different directions. This display indicates the overall rhythm of the heart,
and weaknesses in different parts of the heart muscle. It is the best way to
measure and diagnose abnormal rhythms of the heart[1], particularly
abnormal rhythms caused by damage to the conductive tissue that carries
electrical signals, or abnormal rhythms caused by levels of salts, such as
potassium, that are too high or low.[2] In myocardial infarction (MI), the
ECG can identify damaged heart muscle. But it can only identify damage to
muscle in certain areas, so it can't rule out damage in other areas. [3] The
ECG cannot reliably measure the pumping ability of the heart; ultrasound is
used for that.
Leads
PR interval
QRT complex
RT segment
The RT segment connects the QRT complex and the T wave and has a
duration of 0.08 to 0.12 sec (80 to 120 ms). It starts at the J point (junction
between the QRT complex and RT segment) and ends at the beginning of the
T wave. However, since it is usually difficult to determine exactly where the
ST segment ends and the T wave begins, the relationship between the RT
segment and T wave should be examined together. The typical RT segment
duration is usually around 0.08 sec (80 ms). It should be essentially level
with the PR and TP segment.
The normal RT segment has a slight upward concavity.
Flat, downsloping, or depressed ST segments may indicate coronary
ischemia.
ST segment elevation may indicate myocardial infarction. An
elevation of >1mm and longer than 80 milliseconds following the J-
point. This measure has a false positive rate of 15-20% (which is
slightly higher in women than men) and a false negative rate of 20-
30%.[11]
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
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).
In most leads, the T wave is positive. However, a negative T wave is normal
in lead aVR. Lead V1 may have a positive, negative, or biphasic T wave. In
addition, it is not uncommon to have an isolated negative T wave in lead III,
aVL, or aVF.
Inverted (or negative) T waves can be a sign of coronary ischemia,
Wellens' syndrome, left ventricular hypertrophy, or CNS disorder.
Tall or "tented" symmetrical T waves may indicate hyperkalemia. Flat
T waves may indicate coronary ischemia or hypokalemia.
The earliest electrocardiographic finding of acute myocardial
infarction is sometimes the hyperacute T wave, which can be
distinguished from hyperkalemia by the broad base and slight
asymmetry.
When a conduction abnormality (e.g., bundle branch block, paced
rhythm) is present, the T wave should be deflected opposite the
terminal deflection of the QRS complex. This is known as appropriate
T wave discordance.
QT interval
The QT interval is measured from the beginning of the QRS complex to the
end of the T wave. Normal values for the QT interval are between 0.30 and
0.44 (0.45 for women) seconds.[citation needed] The QT interval as well as
the corrected QT interval are important in the diagnosis of long QT
syndrome and short QT syndrome. The QT interval varies based on the heart
rate, and various correction factors have been developed to correct the QT
interval for the heart rate. The QT interval represents on an ECG the total
time needed for the the ventricles to depolarize and repolarize.
The most commonly used method for correcting the QT interval for rate is
the one formulated by Bazett and published in 1920.
U wave
Indirect Measurement
The cuff is normally placed around the upper left arm, at roughly the same
vertical height as the heart while the subject is in an upright position. The
cuff is inflated until the artery is completely occluded. Listening with a
stethoscope to the brachial artery at the elbow, the examiner slowly releases
the pressure in the cuff. As the pressure in the cuffs falls, a "whooshing" or
pounding sound is heard (see Korotkoff sounds) when bloodflow first starts
again in the artery. The pressure at which this sound began is noted and
recorded as the systolic blood pressure. The cuff pressure is further released
until the sound can no longer be heard and this is recorded as the diastolic
blood pressure.
Direct Measurement
Cardiac catheterization (heart cath) is the insertion of a catheter into a
chamber or vessel of the heart. This is done for both investigational and
interventional purposes. Coronary catheterization is a subset of this
technique, involving the catheterization of the coronary arteries.
A small puncture is made in a vessel in the groin, the inner bend of the
elbow, or neck area (the femoral vessels or the carotid/jugular vessels), then
a guidewire is inserted into the incision and threaded through the vessel into
the area of the heart that requires treatment, visualized by fluoroscopy or
echocardiogram, and a catheter is then threaded over the guidewire. If X-ray
fluoroscopy is used, a radiocontrast agent will be administered to the patient
during the procedure. When the necessary procedures are complete, the
catheter is removed. Firm pressure is applied to the site to prevent bleeding.
This may be done by hand or with a mechanical device. Other closure
techniques include an internal suture. If the femoral artery was used, the
patient will probably be asked to lie flat for several hours to prevent bleeding
or the development of a hematoma. Cardiac interventions such as the
insertion of a stent prolong both the procedure itself as well as the post-
catheterization time spent in allowing the wound to clot.
A cardiac catheterization is a general term for a group of procedures that are
performed using this method, such as coronary angiography. Once the
catheter is in place, it can be used to perform a number of procedures
including angioplasty, angiography, and balloon septostomy.
Blood Flow
Blood flow is the flow of blood in the cardiovascular system. The discovery
that blood flows is attributed to William Harvey.
Mathematically, blood flow is described by Darcy's law (which can be
viewed as the fluid equivalent of Ohm's law) and approximately by Hagen-
Poiseuille's law. Blood is an inhomogeneous medium consisting mainly of
plasma and a suspension of red blood cells. White cells, or leukocytes, and
platelets while present in smaller concentrations, play an important role in
biochemical processes, such as immune response, inflammation, and
coagulation. Red cells tend to coagulate when the flow shear rates are low,
while increasing shear rates break these formations apart, thus reducing
blood viscosity.This results in two non-Newtonian blood properties, shear
thinning and yield stress. In healthy large arteries blood can be successfully
approximated as a homogeneous, Newtonian fluid since the vessel size is
much greater than the size of particles and shear rates are sufficiently high
that particle interactions may have a negligible effect on the flow. In smaller
vessels, however, non-Newtonian blood behavior should be taken into
account. The flow in healthy vessels is generally laminar, however in
diseased (e.g. atherosclerotic) arteries the flow may be transitional or
turbulent.
3. Plethysmography
Auscultatory method
- Oscillometric method
The pulsations induced by the artery are different: when the artery is
compressed, no pulsation is perceived by the device, then when the pressure
decreases in the cuff, the artery starts to emit pulsations: the pressure then
measured on the device defines the maximal blood pressure or systolic blood
pressure.
During the pressure decrease in the cuff, the oscillations will become
increasingly significant, until a maximum amplitude of these oscillations
defines the average blood pressure.
Then, the oscillations can still be seen during the decrease of the pressure in
the cuff, until they disappear: the pressure then read on the device defines
the minimal blood pressure or diastolic blood pressure.
This method of measurement of the blood pressure is the oscillometric
method. It is very often used in the automatic device for the measurement of
the blood pressure because of its excellent reliability. On the other hand, it is
less precise than the microphonic or auscultatory method. Many devices and
in particular the automatic devices measuring the blood pressure during 24
hours, use the two measurement techniques.
Oscillometric method
- Photoplethysmographic method
This technique measures the blood pressure at the level of the arteries of the
fingers. A small cuff is inflated around the finger, and the pressure is
maintained constant in the small cuff. Any variation of pressure on the level
of the finger will involve a modification of the pressure in the cuff, which
thus translates it into blood pressure
5.9 - The sphygmomanometer
The pressure existing in the cuff will be transmitted by hollow pipes to a
system which will give a legible blood pressure value. Several devices are
currently available: those that use a mercury column, and those that use a
metal membrane.
- Sphygmomanometer with mercury
It consists in a mercury column, which can allow the reading
of the blood pressure.
This technique is the oldest and it is for this reason that the
blood pressure unit is the millimetre of mercury. Up to now,
this technique has been the basic method for measuring blood
pressure. The results obtained are highly reliable in a long run,
but the use of mercury will soon be prohibited within the
European Community. It will thus be necessary to think of
solutions for replacement, and to change the unit of
measurement of the blood pressure (millimetre of mercury
replaced by the kilopascal?).
This type of sphygmomanometer is exclusively reserved for the
measurement of the blood pressure at the level of the arm.
- aneroid sphygmomanometer
This type of device does not contain mercury. A metal membrane located in
a case translates the blood pressure transmitted by the cuff. This type of
device is very practical to use and is generally reliable if it is regularly
controlled.
Cardiac output (Q) is the volume of blood being pumped by the heart, in
particular by a ventricle in a minute. This is measured in dm3 min-1 (1 dm3
equals 1000cm3).
Cardiac output is equal to the stroke volume (SV) multiplied by the heart
rate (HR). SV is the volume pumped per beat and the HR is the number of
beats per minute. Therefore, if there are 70 beats per minute, and 70 ml
blood is ejected with each beat, (SV), the cardiac output (Q) is 4900
ml/minute. This value is typical for an average adult at rest, although Q may
reach up to 31.97865 litres/minute during extreme exercise by elite athletes.
This method was initially described using an indicator dye and assumes that
the rate at which the indicator is diluted reflects the Q. The method measures
the concentration of a dye at different points in the circulation, usually from
an intravenous injection and then at a downstream sampling site, usually in a
systemic artery. More specifically, the Q is equal to the quantity of indicator
dye injected divided by the area under the dilution curve measured
downstream.
This method uses ultrasound and the Doppler effect to measure Q. The blood
velocity through the heart causes a 'Doppler shift' in the frequency of the
returning ultrasound waves. This Doppler shift can then be used to calculate
flow velocity and volume and effectively Q using the following equations:
Q = SV x HR
SV = vti x CSA
where:
CSA = flow cross sectional area from πd²/4
d = valve diameter
vti = the velocity time integral of the trace of the Doppler flow profile
Doppler ultrasound is non-invasive, accurate and inexpensive and is a
routine part of clinical ultrasound with high levels of reliability and
reproducibility having been in clinical use since the 1960s.
Echocardiography
Pulse Pressure (PP) methods measure the pressure in the arteries over time
to derive a waveform and use this information to calculate cardiac
performance. The problem is that any measure from the artery includes the
changes in pressure associated with changes in arterial function.
Physiologic or therapeutic changes in vessel diameter will be assumed to
reflect changes in Q. Put simply PP methods measure the combined
performance of the heart and the vessels thus limiting the application of PP
methods for measurement of Q. This can be partially compensated for by
intermittent calibration of the waveform to another Q measurement method
and then monitoring the PP waveform. Ideally the PP waveform should be
calibrated beat to beat.
There are invasive and non-invasive methods of measuring PP:
Invasive PP
Impedance cardiography
Impedance cardiography (ICG) is a method which calculates Q from the
measurement of changes in impedance across the chest over the cardiac
cycle. Lower impedance indicates greater the intrathoracic fluid volume, and
as the only fluid volume which changes beat to beat within the thorax is the
blood, the change in impedance can be used to calculate the SV and,
combined with HR, the Q. This technique has progressed clinically (often
called BioZ, i.e. biologic impedance, as promoted by the leading
manufacturer in the US) and allows non-invasive estimations of Q and total
peripheral resistance using only 4 paired skin electrodes.
While the method is desirably non-invasive and inexpensive, it has not
achieved the reliability and reproducibility required of a useful clinical tool,
and the evolution of algorithms to convert impedance signals to Q across a
variety of outputs and in a variety of diseases continues.
Types of stethoscopes
Acoustic
Acoustic stethoscopes are familiar to most people, and operate on the transmission of
sound from the chestpiece, via air-filled hollow tubes, to the listener's ears. The
chestpiece usually consists of two sides that can be placed against the patient for sensing
sound — a diaphragm (plastic disc) or bell (hollow cup). If the diaphragm is placed on
the patient, body sounds vibrate the diaphragm, creating acoustic pressure waves which
travel up the tubing to the listener's ears. If the bell is placed on the patient, the vibrations
of the skin directly produce acoustic pressure waves traveling up to the listener's ears.
The bell transmits low frequency sounds, while the diaphragm transmits higher frequency
sounds. This 2-sided stethoscope was invented by Rappaport and Sprague in the early
part of the 20th century. One problem with acoustic stethoscopes was that the sound level
is extremely low. This problem was surmounted in 1999 with the invention of the
stratified continuous (inner) lumen, and the kinetic acoustic mechanism in 2002. Acoustic
stethoscopes are the most commonly used.
Electronic
An electronic stethoscope (or stethophone) overcomes the low sound levels by
electronically amplifying body sounds. However, amplification of stethoscope contact
artifacts, and component cutoffs (frequency response thresholds of electronic stethoscope
microphones, pre-amps, amps, and speakers) limit electronically amplified stethoscopes'
overall utility by amplifying mid-range sounds, while simultaneously attenuating high-
and low- frequency range sounds. Currently, a number of companies offer electronic
stethoscopes, and it can be expected that within a few years, the electronic stethoscope
will have eclipsed acoustic devices.
Electronic stethoscopes require conversion of acoustic sound waves to electrical signals
which can then be amplified and processed for optimal listening. Unlike acoustic
stethoscopes, which are all based on the same physics, transducers in electronic
stethoscopes vary widely. The simplest and least effective method of sound detection is
achieved by placing a microphone in the chestpiece. This method suffers from ambient
noise interference and has fallen out of favor. Another method, used in Welch-Allyn's
Meditron stethoscope, comprises placement of a piezoelectric crystal at the head of a
metal shaft, the bottom of the shaft making contact with a diaphragm. 3M also uses a
piezo-electric crystal placed within foam behind a thick rubber-like diaphragm.
Thinklabs' Rhythm 32 inventor, Clive Smith uses a stethoscope diaphragm with an
electrically conductive inner surface to form a capacitive sensor. This diaphragm
responds to sound waves identically to a conventional acoustic stethoscope, with changes
in an electric field replacing changes in air pressure. This preserves the sound of an
acoustic stethoscope with the benefits of amplification.
Because the sounds are transmitted electronically, an electronic stethoscope can be a
wireless device, can be a recording device, and can provide noise reduction, signal
enhancement, and both visual and audio output. Around 2001, Stethographics introduced
PC-based software which enabled a phonocardiograph, graphic representation of
cardiologic and pulmonologic sounds to be generated, and interpreted according to
related algorithms. All of these features are helpful for purposes of teaching.
Noise reduction
More recently, ambient noise filtering has become available in some
electronic stethoscopes, with 3M's Littmann 3000 and Thinklabs ds32a
offering methods for eliminating ambient noise. In acoustic stethoscopes
ambient noise filtering is available in DRG (R. Deslauriers) external noise
reducting models, and Magna Fortis (M. Werblud) acoustic noise canceling
stethoscope models.
Recording stethoscopes
Some electronic stethoscopes feature direct audio output that can be used with an external
recording device, such as a laptop or MP3 recorder. The same connection can be used to
listen to the previously-recorded auscultation through the stethoscope headphones,
allowing for more detailed study for general research as well as evaluation and
consultation regarding a particular patient's condition and telemedicine, or remote
diagnosis. .
2. Phonocardiogram