Dr.

Saima’s

Cardiovascular System
Cardiovascular system is made up of heart & blood vessels i.e. arteries, veins, capillaries. These blood
vessels distribute blood throughout the body. The capillaries are the thinnest and exchange of O2 and
CO2 at tissue levels occurs in the capillaries.

The heart is located in the chest between the lungs behind the sternum and above the diaphragm. At
the 3rd week of Gestation, the heart starts its work. So the heart is the first organ developed in human
body.

Functioning Of Heart:
The heart consists of two sides i.e. Left side and Right side. Similarly, there are four chambers in the
heart: Right Atrium, Right Ventricle, Left Atrium and Left Ventricle.

Right Atrium:
 Right Atrium has a Sinoatrial Node between the superior and inferior Vena Cava. The SA Node is
responsible for initiating impulse. Right Left
 Receives deoxygenated blood from superior vena cava and inferior Atrium Atrium
vena cava.
 Drains blood to Right Ventricle through AV (Artioventricular) valve /Tricuspid valve.

Right Ventricle: Right Left

 From Right Ventricle blood goes to Pulmonary Artery to lungs to Ventricle Ventricle
pulmonary veins and then to Left Atrium. All Arteries contain oxygenated blood expect
Pulmonary arteries.

Left Atrium:
 Receives oxygenated blood from Pulmonary Veins.
 Drains blood to Left Ventricle through Mitral Valve/Bicuspid Valve.

Left Ventricle:
 Through left Ventricle, oxygenated blood comes out through Aorta/Systemic Artery.

Septa:
There are 2 septa in the heart that do the work of separation. Right Left
Atrium Atrium
 The septum between the two Atria is called
Interatrial Septum.
 The Septum between the two Ventricles is called Right Left
Intraventricular Septum. Ventricle Ventricle
Valves:
There are four Valves in the heart.

 Tricuspid and Bicuspid Valves are responsible between the two chambers.
 Semilunar Valves:
Right Left
Pulmonary Valve (Right Side)
Atrium Atrium
Aortic Valve (Left Side)
 These valves prevent the back flow of blood.

Layers: Right Left

The heart has three layers: Ventricle Ventricle

 The outermost layer is called Pericardium.

 The middle layer is called Myocardium.
 The inner layer is called Endocardium.

Pericardium: The pericardium consists of two layers. The outer layer is Parietal/Epicardium layer &
the inner layer is Visceral layer. Between the two layers there exists a space filled with pericardial
fluid.

Myocardium: (Myo=Muscles) Myocardium is made up of muscles. These muscles contribute to the

following

 Contraction 90%
 Pacemaker: Initiates impulses.
 Conducting system: A Conducts impulse i.e. transmits impulses from one part to another.

Endocardium: Endocardium is made up of endothelial cells, the same cells that make up the blood
vessels. Endocardium is also continuous with the blood vessels.

Actions of the heart:

Chronotropic Effect: The beating of the heart is called the chronotropic effect. The normal heartbeat is
72beats/min. It can be both positive and negative. In positive chronotropic effect, the heartbeat
increases and is termed as Tachycardia (more than 100beats/min). If the effect is negative, the
heartbeat decreases and is termed as Bradycardia (less than 50beats/min).

Inotropic Effect: The effect of contraction is called inotropic effect. It can be positive and negative.

Dromotropic Effect: The speed of conduction is called dromotropic effect. It can also be negative and
positive. Dromotropic Effect is produced by Sympathetic and Parasympathetic Nervous System
(Autonomic Nervous System).

Circulation:
There are two types of circulation in the blood i.e. Systemic Circulation & Pulmonary circulation.
  Systemic Circulation starts from left Atrium and ends at right Atrium. It is a greater circulation.
 Pulmonary Circulation starts from Right Atrium and ends at Left Atrium. It is a lesser circulation.

Properties of Cardiac Muscles:

Cardiac Muscles are striated muscles. They are involuntary in function. All muscles receive calcium ions
for contraction from sarcoplasmic reticulum. In cardiac muscles, the sarcoplasmic reticulum is not as
well developed as in skeletal muscles therefore the calcium source for cardiac muscles is extracellular
fluid.

Functional Syncytium: Cardiac Muscles are interconnected by Intercalated discs. These intercalated
discs transmit signals between the fibers. Between these intercalated discs are passages called Gap
Junction. These gap junctions help in the free transmission of ions from one place to another. The parts
in intercalated disc other than the gap junction are called Desosomes. Due to functional syncytium,
when stimulus is given to one fiber, all fibers contract/relax. There are two types of syncytium:

 Atrial Syncytium
 Ventrical Syncytium.

Auto excitability: Excitability is the response of any living tissue due to stimulus. Auto excitability in
cardiac muscles produces own impulses and respond.

Action Potential: Action Potential is the first response to stimulus. Action potential in cardiac muscles is
different from action potential in skeletal and smooth muscles. The resting membrane potential of
skeletal muscles is -90mV, and the rmp of smooth muscles is -50 to -95 mV.

In cardiac muscles, the rmp is -95mV. After a stimulus is generated across the membrane, Initial
Depolarization begins. During Initial Depolarization sodium ions from extracellular fluid begins to enter
the membrane through sodium channels. This causes increase in positive sign inside the membrane.
Initial depolarization reaches upto +20mV.

The second step is Initial Repolarization. During initial repolarization, efflux of K ions takes place. Due to
this efflux, the membrane starts to regain its negative charge.

The third step in cardiac muscles is Final Depolarization. Final depolarization is also called Plateau
Phase. Plateau phase/sustained depolarization takes place due to slow influx of calcium ions. The
concentration of negativity and positivity inside and outside of the membrane is equal preventing
repolarization. The significance of plateau phase is to prevent another impulse or to prevent multiple
contractions.

The final step of action potential in cardiac muscles is Final Repolarization. During final repolarization,
calcium channels close and potassium channels open causing the efflux of potassium ions. This efflux
restores the negativity inside the membrane bringing it back to the rmp.
Conductivity: Transfer of cardiac impulse from pace-maker (SA node) to all cardiac muscle fibers is
called conductivity. The main components of the cardiac conduction system are the SA node, AV node,
bundle of His, bundle branches, and Purkinje fibers.
Cardiac contraction is the end result of action potentials that are initiated at the pace-maker cells in the
SA node. Due to functional syncytium, the atria contract simultaneously but the conduction of impulse
from the atria to ventricle is done through a conducting system. From SA node the impulse is
transmitted to AV node and then to Bundle of His.

Contractility: Cardiac contractility can be defined as the shortening (i.e., the strength of contraction) of
myocardial fibers. When stimulus is threshold or suprathreshold, the muscle gives maximum response.

 All-or-none law: The all-or-none law is the principle that the strength by which a nerve or
muscle fibre responds to a stimulus is independent of the strength of the stimulus. The
contraction will be the constant at either threshold stimulus or suprathreshold stimulus.
Whereas, the muscle gives no response is the stimulus is subthreshold.
 Refractory period: Refractory period is the period during which an already excited cardiac
muscle cannot be re-excited by anormal cardiac impulse. There are two types of refractory
period
(a) Absolute refractory period: During the absolute refractory period, the cardiac muscle
cannot be excited to generate a second action potential (no matter how intense the
stimulus). Absolute refractory period occurs in depolarization phase.
(b) Relative refractory period: There is a little bit chance that the cardiac muscles will give
response when stimulus is suprathreshold. Relative refractory period occurs in
repolarization state.

Heart Beating: Heartbeat is defined as the pulsation of heart. The pressure change in the form
of upward and downward wave in the peripheral arteries is called pulse. The upward movement
occurs due to the contraction of ventricles whereas the downward movement occurs due to the
relaxation of ventricles. Pulse can only be felt in superficial arteries. The common pulse sites are;

 Temporal region (temporal lobe)

 Facial region (angle of jaw)
 Carotid artery (in the neck)
 Axillary artery (in the axilla i.e. the armpit)
 Brachial artery (in the forearm)
 Radial artery (originating from the base of the thumb)
 Ulnar artery (originating from the base of the little finger)
 Femoral artery (large artery in the thigh i.e. groin area)
 Popliteal artery (back of the knee) SA node generates 70-80
 Dorsalis Pedis artery (dorsal artery of foot) beats/min. AV node generates
 Posterior tibial artery (ankle) 40-50 beats/min. Purkinje
Fibres generate 35 beats/min.
Radial Artery is the most superficial artery.

The normal heart rate is 72b/min. 100b/min is termed as sinus tachycardia. Tachycardia can
either be due to physiological reasons or pathological reasons. Physiological causes of
 tachycardia can be strenuous exercise, stress, anxiety, caffeine intake etc. However
pathological causes of tachycardia can be fever, anemia, hyperthyroidism etc. During fever
the vagus nerve is inhibited which increases the heartbeat. Whereas during anemia
decrease in oxygen saturation takes place which causes the heart to pump blood rapidly.
60b/min is termed as sinus Bradycardia. Bardycardia can also be due to both physiological
and pathological reasons. Bradycardia can be physiological as in athletes or during sleep.
The pathological reasons of bradycardia can be hypothyroidism, hypothermia,
polycythemia. Polycythemia (also known as polycythaemia or polyglobulia) is a disease state
in which the hematocrit (the volume percentage of red blood cells in the blood) is elevated.

Cardiac Conduction:
Origin of Impulse:
The impulse is generated from the SA node. The SA node generates 70-80b/min and it has the fastest
rate of discharge of impulse than other components. The AV node and AV bundle generates 40-60b/min
while the Right and Left Bundle Branches and the Purkinje Fibers generate 35-40b/min.

Speed of Impulse:
Speed is inversely proportional to time. The faster an object move, the lesser time it takes to cover the
distance.
The SA node generates the impulse at 0.0s. The impulse travels from the SA node to the AV node in
0.03s. In the AV node the impulse rests for 0.09s. So from the SA node to the exit of the AV node the
impulse takes total 0.12s (0.03+0.09). The AV bundle is right below the AV node; impulse rests here for
0.04s (total 0.12+0.04=0.16s). From the AV bundle, the impulse travels to the Purkinje fibers which take
0.06-0.08s. So the total time from the SA node to the purkinje fibers is 0.16+0.06/0.08=0.22/0.24s.

From the SA node impulses also travel to the Left Atrium, this takes 0.1s but this travelling is not a part
of the conducting system. Conduction pathway includes conduction of impulse from the atria to the
ventricles.

The lowest speed of the impulse is in the AV node i.e. 0.05m/s because the impulse rests here for the
longest time. The delay that occurs in the AV node is called the AV nodal delay. This is the 0.09s delay in
the conducting pathway when the impulse reaches from the SA node to the AV node and rests in the AV
node and delays transmission of impulse to the ventricles. The cause of this delay is that the AV nodal
fibers are arranged in such a way that there are lesser gap junctions between them, causing impulse to
take more time in jumping from one fiber to another. The advantage of this delay is that it allows the
atria to fully contract, emptying whole blood into the ventricles before ventricular contraction.

The highest speed of impulse is in the Right & left Bundle Branches i.e. 4m/s. This is because the impulse
travels a large surface area in a very short time. The cause of this highest speed is due to the presence of
more gap junctions. Due to these numerous gap junctions, the impulse jumps quickly from one fiber to
another. The advantage of this high speed is that it creates effective pressure in the ventricular
chambers which enables both the ventricles to contract simultaneously.

Sometimes, due to some functional abnormality, the SA node fails to generate impulses. In the absence
of the SA node, impulses are generated by the AV node and AV bundle. In case the AV node fails to
generate an impulse too, right and left bundle branches and Purkinje fibers take over. SA node
generates impulse at the fastest rate. But sometimes other components generate impulses faster than
the SA node. These components that generate impulses faster than the pacemaker are called ectopic
pacemakers. There are two causes of the activation of ectopic pacemakers;

 Blockage in the transmission of impulse in the SA node.

 Generation of abnormal foci (cells).

Effect of Autonomic Nervous System on Conducting System:

ANS consists of Sympathetic Nervous System and Parasympathetic Nervous System. Sympathetic
nervous system does the work of excitement while parasympathetic nervous system relaxes.
 Function Effect of Sympathetic Nervous Effect of Parasympathetic
System Nervous System
SA nodal discharge rate Increases Decreases
Speed of transmission of impulse Increases Decreases
Time taken in transmission of Decreases Increases
impulse
AV nodal delay Decreases Increases

Action Potential in Cardiac Pacemaker Cells:

Cells within the sinoatrial (SA) node are the primary pacemaker site within the heart. These cells are
characterized as having no true resting potential, but instead generate regular, spontaneous action
potentials.

When the membrane potential is about -60 mV, channels open that conduct slow inward Na+ ions. This
causes depolarization. These currents are called "funny" currents and abbreviated as "If". These
depolarizing currents cause the membrane potential to begin to spontaneously depolarize. This is called
Phase 4. As the membrane potential reaches about -40 mV, it initiates Phase 0. Voltage gated calcium
channels open. Opening of these channels causes rapid influx of Ca+2 ions causing further
depolarization. This is also called the depolarization phase. When the membrane potential reaches
about +10mV, voltage gated Potassium channels open. Opening of these channels causes efflux of K+
ions causing repolarization. The K+ ions move outside until the membrane potential reaches -60mV
again. This is called Phase 3. The cycle is repeated.

During depolarization, the membrane potential (Em) moves toward the equilibrium potential for Ca+2,
which is about +134 mV. During repolarization, g’Ca+2 (relative Ca+2 conductance) decreases and g’K+
(relative K+ conductance) increases, which brings Em closer toward the equilibrium potential for K+,
which is about -96 mV. Therefore, the action potential in SA nodal cells is primarily dependent upon
changes in Ca+2 and K+ conductances as summarized below:

Em = g'K+ (-96 mV) + g'Ca++ (+134 mV)

 Electrocardiography
Electric current sprays from pacemaker to the entire myocardium. Electrocardiography is the
measurement of this local electric current from adjacent tissues of the heart. ECG was discovered by a
Dutch physiologist Eunthovins William. Electrocardiogram is the graphical representation of electrical
activity of heart whereas Electrocardiograph is the instrument used to perform ECG.

ECG Paper:
ECG paper is made up of horizontal and vertical lines that are at a regular interval of 1mm. Every 5 th
horizontal and vertical line is thickened. 1mm of thin line is called a small square and 5mm of thickened
line is called a large square. 1mm on the x axis represents 0.4s of time whereas 1mm on the y axis
represents 1mV of amplitude.

ECG Leads:
ECG leads are electrodes that are attached on adjacent tissues of the heart on the skin to record ECG.
Placement of ECG leads follows the Eunthovin’s Triangle. It is an imaginary triangle guiding the placing
of leads on the skin. It places the leads between the right arm, left arm and the left foot making a
triangle in which the heart rests in the centre.

Right arm Left arm

Left foot

The number of ECG leads is 12 which include both bipolar & unipolar leads. The bipolar leads have both
negative and positive poles whereas the unipolar leads have only one active lead.
 12 leads

9 unipolar leads 3 bipolar leads

3 limb leads 6 chest leads 3 limb leads

3 Bipolar limb leads;

 Lead I
 Lead II
 Lead III

3 unipolar limb leads;

 avR
 avL
 avF

6 unipolar chest leads;

 C1
 C2
 C3
 C4
 C5
 C6
Placement of the leads:
 Lead I is placed between the left and the right arm with the negative end on the right side and
the positive being on the left.
 Lead II is placed between the right arm and the left foot with the negative end on the right arm’s
side and the positive on the left foot’s side.
 Lead III is placed between left arm and left foot with the negative end on the left arm’s side and
the positive on the left foot’s.
 avR is placed on the right arm.
 avL is placed on the left arm.
 avF is placed on the left foot’s side.
 C1 is placed on the right sternal margin at the 4 th intercoastal space.
 C2 is placed on the left sternal margin at the 5 th intercoastal space.
 C3 is placed between C2 and C4.
 C4 is placed on the left mid clavicular line at the 5 th intercoastal space.
 C5 is placed on the left anterior axillary line at the 5 th intercoastal space.
 C6 is placed on the left mid axillary line at the 5 th intercoastal space.

Components of ECG
1. Waves
2. Intervals
3. Segments

Waves
 P waves
 QRS complex
 T waves
 U waves
 Arterial T waves

P waves: Normal P wave is produced due to arterial depolarization. The amplitude of normal P wave is
0.1 to 0.2 mV and time of normal P wave is 0.1 to 0.12s.

Abnormality of P waves: “Tall P waves” are produced when amplitude increases to 0.6mV. It is due to
hypertrophic factors i.e. increasing of arterial mass. “Small P waves or absent P waves” are produced
due to SA nodal blockage (when there will be no impulse from the SA node, the P wave will be small or
absent).

QRS Complex: It is the complex of three waves. It is produced due to the ventricular depolarization i.e.
when impulse reaches from the AV node to the ventricles. The normal time for QRS complex is 0.06 to
0.08s. The normal amplitude of Q wave is 0.1mV, of R wave is 1mV (comprises of 2 large squares) and of
S wave is 0.4mV.

Abnormality of QRS complex: “Tall QRS complex” is due to ventricular hypotrophy whereas “Small QRS
complex” is due to AV bundles blockage.

T Wave: T wave is produced due to the ventricular repolarization. Its normal time is 0.15s and normal
amplitude is 0.3mV. It is produced due to the efflux of K ions so if any abnormality comes it will be due
to alteration in K ions transport.

Abnormality of T waves: Hyperkalemia is an abnormality of T waves when efflux of K ions increases.

“Tall or tented T waves” is due to hyperkalemia whereas “Short or absent T waves” is due to
hypokalemia. “Inverted T waves” is due to myocardial infarction.

U wave: U wave is produced due to slow repolarization of papillary muscles. It is not a significant wave
of ECG.

Intervals
Intervals comprise of two or move waves.

PR Interval: Interval starts from the beginning of P wave to the beginning of Q or R wave and depolarize
the atria. Its time duration is 0.16 to 0.20s. If the time duration prolongs, it is because of first degree
heart blockage (minor blockage of AV bundles or AV node).

QRS Interval: This interval starts from the beginning of Q wave to the end of S wave. Its time duration is
0.06 to 0.08s.

QT Interval: It starts from the beginning of Q wave to the end of T wave. Arterial repolarization,
ventricular repolarization along with ventricular depolarization is done here. Its time duration is 0.4s.

ST Interval: It starts at the end of S waves to the end of T waves. Ventricular repolarization is done here.
Its time duration is 0.32s.

Segments
Isoelectric line when there is no action potential or no activity in the ECG is called a segment.

PQ Segment: Isoelectric line between the end of P wave and the beginning of Q wave. It shows the AV
nodal delay. Its time duration is 0.09s.

ST Segment: Isoelectric line between the end of S wave and the beginning of T wave. It shows the
plateau phase.
“ST Segment elevation” occurs due to myocardial infarction whereas “ST Segment depression” occurs
due to angina (chest pain or discomfort when heart muscles don’t get enough oxygen rich blood).