CHAPTER 3: ANATOMY AND PHYSIOLOGY

Overview of the circulatory system

The circulatory system consists of the pulmonary and systemic circulations. The right side of the
heart pumps blood through vessels to the lungs and back to the left side of the heart through the
pulmonary circulation. The left side of the heart pumps blood through vessels to the body
tissues and back to the right side of the heart through the systemic circulation.

Although it is a single structure, the heart is actually two pumps in one. The right side of the
heart pumps blood to the lungs and back to the left side of the heart through vessels of the
pulmonary circulation. The left side of the heart pumps blood to all other tissues of the body and
back to the right side of the heart through vessels of the systemic circulation. The functions of
the heart are:
1. Generating blood pressure. Contractions of the heart generate blood pressure, which
forces blood through the blood vessels.
2. Routing blood. The heart separated the pulmonary and systemic circulations, which
ensures the flow of oxygen rich blood to tissues.
3. Ensuring one-way blood flow. The valves of the heart ensure a one-way flow of blood
through the heart and blood vessels.
4. Regulating blood supply. Changes in the rate and force of the heart contraction match
blood flow to the changing metabolic needs of the tissues during rest, exercise, and
changes in body position

Location of the Heart

The heart is located between the lungs in the middle of the chest, behind and slightly to the left
of the breastbone (sternum). A double-layered membrane called the pericardium surrounds the
heart like a sac. The outer layer of the pericardium surrounds the roots of the heart's major
blood vessels and is attached by ligaments to the spinal column, diaphragm, and other parts of
the body

Shape and Size of the Heart

The shape of the heart is similar to a pinecone, rather broad at the superior surface and
tapering to the apex. A typical heart is approximately the size of your fist: 12 cm in length, 8 cm
wide, and 6 cm in thickness. The weight of a female heart is approximately 250–300 grams, and
the male heart is approximately 300–350 grams. 

Chambers of the heart

The human heart consists of four chambers: 
 the upper chambers
o the right and left atria. 
 receive incoming blood
o the lower chambers
 the more muscular right and left ventricles
Circulation through the heart
Blood comes into the right atrium from the body, moves into the right ventricle and is pushed
into the pulmonary arteries in the lungs. After picking up oxygen, the blood travels back to the
heart through the pulmonary veins into the left atrium, to the left ventricle and out to the body's
tissues through the aorta.

Surface Features of the Heart

The heart has five surfaces: base (posterior), diaphragmatic (inferior), sternocostal (anterior),
and left and right pulmonary surfaces. It also has several margins: right, left, superior, and
inferior: The right margin is the small section of the right atrium that extends between the
superior and inferior vena cava.
Layers
The walls of the heart are composed of three layers:
 Epicardium - the outer layer. Is continuous with the visceral layer of the serous parietal
pericardium.
 Myocardium - the middle, muscular layer. T is involuntary striated cardiac muscle, made
up of a whole network of dividing and recombining fibers. This is the part of the heart
that allows for contraction. The amount of myocardium is different for each of the
chambers, depending on the amount of force needed in the contraction - for example,
there is a proportionally large amount of myocardium in the walls of the ventricles
(particularly the left). The myocardium contains a large number of mitochondria,
providing energy for the heart muscle.
 Endocardium - the inner layer. Forms the inner lining of the heart, and the flaps which
form the valves of the heart.
Septa of the Heart
Muscular walls, called septa or septum, divide the heart into two sides. On the right side of the
heart, the right atrium and ventricle work to pump oxygen-poor blood to the lungs. On the left
side, the left atrium and ventricle combine to pump oxygenated blood to the body. Interatrial
septum separates the two atria and the interventricular septum separates the two ventricles

Right Atrium
One of the four chambers of the heart. The right atrium receives blood low in oxygen from the
body and then empties the blood into the right ventricle.
Right ventricle
One of the four chambers of the heart. The right ventricle pumps blood low in oxygen to the
lungs. In the lungs, the blood then gets a "refill" of oxygen.

Left Atrium
The left atrium receives blood full of oxygen from the lungs and then empties the blood into the
left ventricle.

Left Ventricle
The left ventricle is an integral part of the cardiovascular system. Left ventricular contraction
forces oxygenated blood through the aortic valve to be distributed to the entire body. 

Superior vena cava

The superior vena cava is a major vein in your upper body. It carries blood from your head,
neck, upper chest, and arms to the heart. Superior vena cava syndrome (SVCS) happens when
the superior vena cava is partially blocked or compressed.

Pulmonary vein
Pulmonary veins are blood vessels that carry oxygen-rich blood from your lungs to your heart.
Your pulmonary veins are part of your body's pulmonary circuit. This is a system of blood
vessels that moves blood between your heart and your lungs. This circuit also includes your
pulmonary arteries.

Aorta
The aorta is the main artery that carries blood away from your heart to the rest of your body.
The blood leaves the heart through the aortic valve. Then it travels through the aorta, making a
cane-shaped curve that allows other major arteries to deliver oxygen-rich blood to the brain,
muscles and other cells.

Pulmonary artery
The pulmonary arteries function to transport deoxygenated blood from the right side of the heart
to the lungs for oxygenation. These vessels serve as the conduit between the right side of the
heart and the lungs.

Mitral valve
The mitral valve is located between the upper left heart chamber (left atrium) and the lower left
heart chamber (left ventricle). A healthy mitral valve keeps your blood moving in the right
direction. A leaky valve doesn't close the way it should, allowing some blood to flow backward
into the left atrium.

Aortic valve
The aortic valve is one of four valves that control blood flow in the heart. It separates the lower
left heart chamber (left ventricle) and the body's main artery (aorta).

Tricuspid valve
The tricuspid valve is one of four valves in the heart. It's located between the right lower heart
chamber (right ventricle) and the right upper heart chamber (right atrium). The tricuspid valve
opens and closes to ensure that blood flows in the correct direction. It's also called the right
atrioventricular valve.

Pulmonary valve
The pulmonary valve is one of four valves that control blood flow in the heart. It's between the
lower right heart chamber (right ventricle) and the artery that delivers blood to the lungs
(pulmonary artery).
Inferior vena cava
The inferior vena cava (IVC) is the largest vein of the human body. It is located at the posterior
abdominal wall on the right side of the aorta. The IVC's function is to carry the venous blood
from the lower limbs and abdominopelvic region to the heart.

Coronary Circulation
Coronary circulation is the circulation of blood in the blood vessels that supply the heart muscle
(myocardium). Coronary arteries supply oxygenated blood to the heart muscle. Cardiac veins
then drain away the blood after it has been deoxygenated.

Coronary Arteries
Coronary arteries supply blood to the heart muscle. Like all other tissues in the body, the
heart muscle needs oxygen-rich blood to function. Also, oxygen-depleted blood must be carried
away. The coronary arteries wrap around the outside of the heart.

The left coronary artery supplies blood to the left side of the heart muscle (the left ventricle and
left atrium). The left main coronary divides into branches: The left anterior descending artery
branches off the left coronary artery and supplies blood to the front of the left side of the heart.

The right coronary artery supplies blood to the right ventricle, the right atrium, and the SA
(sinoatrial) and AV (atrioventricular) nodes, which regulate the heart rhythm. The right coronary
artery divides into smaller branches, including the right posterior descending artery and the
acute marginal artery.

Coronary Veins
Coronary veins are responsible for draining deoxygenated blood from the myocardium into the
cardiac chambers. Comprised of two venous systems, coronary veins classify into either the
greater cardiac venous system or the smaller cardiac venous system.

Cardiac Muscle
Cardiac muscle makes up the thick middle layer of the heart and is surrounded by a thin outer
layer called the epicardium or visceral pericardium and an inner endocardium.

Electrical Activity
The sinus node generates an electrical stimulus regularly, 60 to 100 times per minute under
normal conditions. The atria are then activated. The electrical stimulus travels down through the
conduction pathways and causes the heart's ventricles to contract and pump out blood.
P wave: electrical impulse coming from the sinus going to the atria (atrial
depolarization/contraction)
QRS complex: represents ventricular depolarization/contraction
T wave: represents ventricular repolarization/relaxation
U wave: represents the repolarization of the Purkinje fibers
PR interval: measures from the beginning of the P wave to the beginning QRS complex and
represents the time needed for sinus node stimulation, atrial depolarization and conduction to
the av node before ventricular depolarization
ST segment: represents early ventricular repolarization. “Place where cardiac ischemia is being
assess”
QT interval: represents the total time for ventricular depolarization and repolarization. Place
where ventricular dysrhythmia is being assess
TP interval: it is measured from the end of the T wave to the beginning of the next P wave
PP interval: it is measured from the beginning of one P wave to the beginning of the next
RR interval: it is measured from the beginning of one R wave to the beginning of the next

Structure of Cardiac Muscle

The individual cardiac muscle cell (cardiomyocyte) is a tubular structure composed of chains of
myofibrils, which are rod-like units within the cell. The myofibrils consist of repeating sections of
sarcomeres, which are the fundamental contractile units of the muscle cells.
Conduction System of the Heart
the network of nodes (groups of cells that can be either nerve or muscle tissue), specialized
cells and electrical signals that keep your heart beating. Two types of cells control your
heartbeat: Conducting cells carry the electric signals.

Specialized conducting components of the heart include the sinoatrial node, the internodal
pathways, the atrioventricular node, the atrioventricular bundle, the right and left bundle
branches, and the Purkinje fibers.

Sinoatrial (SA) Node

The SA (sinoatrial) node generates an electrical signal that causes the upper heart chambers
(atria) to contract. The signal then passes through the AV (atrioventricular) node to the lower
heart chambers (ventricles), causing them to contract, or pump. The SA node is considered the
pacemaker of the heart.
 (1) The sinoatrial (SA) node and the remainder of the conduction system are at rest. (2) The SA
node initiates the action potential, which sweeps across the atria. (3) After reaching the
atrioventricular node, there is a delay of approximately 100 ms that allows the atria to complete
pumping blood before the impulse is transmitted to the atrioventricular bundle. (4) Following the
delay, the impulse travels through the atrioventricular bundle and bundle branches to the
Purkinje fibers, and also reaches the right papillary muscle via the moderator band. (5) The
impulse spreads to the contractile fibers of the ventricle. (6) Ventricular contraction begins.

Atrioventricular (AV) Node

The atrioventricular node (AVN) is a complex structure that performs a variety of functions in the
heart. The AVN is primarily an electrical gatekeeper between the atria and ventricles and
introduces a delay between atrial and ventricular excitation, allowing for efficient ventricular
filling.

Atrioventricular Bundle (Bundle of His)

The bundle of His is a group of fibers that carry electrical impulses through the center of the
heart. If these signals are blocked, you will have problems with your heartbeat. Watch this video
about: Cardiac conduction system. The His bundle electrography is part of an electrophysiology
study (EPS).

Bundle Branches
The bundle branches, or Tawara branches, are offshoots of the bundle of His in the heart's
ventricle. They play an integral role in the electrical conduction system of the heart by
transmitting cardiac action potentials from the bundle of His to the Purkinje fibers.
Purkinje Fibers
Purkinje fibers or Purkinje cardiomyocytes are part of the whole complex of the cardiac
conduction system, which is today classified as specific heart muscle tissue responsible for the
generation of the heart impulses.

The Pancreas
The pancreas is a long, slender organ, most of which is located posterior to the bottom half of
the stomach. Although it is primarily an exocrine gland, secreting a variety of digestive enzymes,
the pancreas also has endocrine cells. Its pancreatic islets—clusters of cells formerly known as
the islets of Langerhans—secrete the hormones glucagon, insulin, somatostatin, and pancreatic
polypeptide (PP).

Cells and Secretions of the Pancreatic Islets

The pancreatic islets each contain four varieties of cells:
 The alpha cell produces the hormone glucagon and makes up approximately 20 percent
of each islet. Low blood glucose levels stimulate the release of glucagon.
 The beta cell produces the hormone insulin and makes up approximately 75 percent of
each islet. Elevated blood glucose levels stimulate the release of insulin.
 The delta cell accounts for four percent of the islet cells and secretes the peptide
hormone somatostatin. Recall that somatostatin is also released by the hypothalamus,
stomach and intestines. An inhibiting hormone, pancreatic somatostatin inhibits the
release of both glucagon and insulin.
 The pancreatic polypeptide cell (PP cell) accounts for about one percent of islet cells
and secretes the pancreatic polypeptide hormone. It is thought to play a role in appetite,
as well as in the regulation of pancreatic exocrine and endocrine secretions. Pancreatic
polypeptide released following a meal may reduce further food consumption; however, it
is also released in response to fasting.

Regulation of Blood Glucose Levels by Insulin and Glucagon

Glucose is utilized in cellular respiration as a fuel for cells of the body. The body derives glucose
from the breakdown of the carbohydrate-containing foods and drinks we consume. Glucose not
immediately taken up by cells for fuel can be stored by the liver and muscles as glycogen, or
converted to triglycerides and stored in the adipose tissue. Hormones regulate both the storage
and the utilization of glucose as required. Receptors located in the pancreas sense blood
glucose levels, and subsequently the pancreatic cells secrete glucagon or insulin to maintain
appropriate blood glucose.
Average Glucose Levels
 Normal <117 mg/dl
Prediabetic 117-137 mg/dl
Diabetic >137 mg/dl
140 mg/dl
154 mg/dl
169 mg/dl
183 mg/dl
197 mg/dl
212 mg/dl
226 mg/dl
240 mg/dl

Glucagon
Receptors in the pancreas can sense the decline in blood glucose levels, such as during
periods of fasting or during prolonged labor or exercise. In response, the alpha cells of the
pancreas secrete the hormone glucagon, which has several effects:
 Glucagon stimulates the liver to convert its stores of glycogen back into glucose. This
response is known as glycogenolysis. The glucose is then released into the circulation
for use by cells throughout the body.
 Glucagon stimulates the liver to take up amino acids from the blood and convert them
into glucose. This response is known as gluconeogenesis.
 Glucagon stimulates lipolysis, the breakdown of stored triglycerides into free fatty acids
and glycerol. Some of the free glycerol released into the bloodstream travels to the liver,
which converts the glycerol into glucose. This is also a form of gluconeogenesis.
Taken together, these actions increase blood glucose levels. The activity of glucagon is
regulated through a negative feedback mechanism; rising blood glucose levels inhibit further
glucagon production and secretion.

Insulin
The primary function of insulin is to facilitate the uptake of glucose into body cells. Red blood
cells, as well as cells of the brain, liver, kidneys, and the lining of the small intestine, do not have
insulin receptors on their cell membranes and do not require insulin for glucose uptake.
Although all other body cells do require insulin if they are to take glucose from the bloodstream,
skeletal muscle cells and adipose cells are the primary targets of insulin.

The presence of food in the intestine triggers the release of gastrointestinal tract hormones such
as glucose-dependent insulinotropic peptide (previously known as gastric inhibitory peptide).
This is in turn the initial trigger for insulin production and secretion by the beta cells of the
pancreas. Once nutrient absorption occurs, the resulting surge in blood glucose levels further
stimulates insulin secretion.

Precisely how insulin facilitates glucose uptake is not entirely clear. However, insulin appears to
activate a tyrosine kinase receptor, triggering the phosphorylation of many substrates within the
cell. These multiple biochemical reactions converge to support the movement of intracellular
vesicles containing facilitative glucose transporters to the cell membrane. In the absence of
insulin, these transport proteins are normally recycled slowly between the cell membrane and
cell interior. Insulin triggers the rapid movement of a pool of glucose transporter vesicles to the
cell membrane, where they fuse and expose the glucose transporters to the extracellular fluid.
The transporters then move glucose by facilitated diffusion into the cell interior.

Insulin also reduces blood glucose levels by stimulating glycolysis, the metabolism of glucose
for generation of ATP. Moreover, it stimulates the liver to convert excess glucose into glycogen
for storage, and it inhibits enzymes involved in glycogenolysis and gluconeogenesis. Finally,
insulin promotes triglyceride and protein synthesis. The secretion of insulin is regulated through
a negative feedback mechanism. As blood glucose levels decrease, further insulin release is
inhibited.
Hormones of the Pancreas
Associated hormones Chemical class Effect 
Insulin (beta cells) Protein  Reduces blood glucose levels
Glucagon (alpha cells) Protein Increases blood glucose levels
Somatostatin (delta cells) Protein Inhibits insulin and glucagon release
Pancreatic polypeptide (PP cells) Protein Role in appetite