ity of Dentistry Ie’Semester 2018-2019 | Introduction | O—_____—__—__—— The cardiovascular system is a closed loop through which blood cycles continuously throughout the life of the individual. ca The loop incorporates two structurally and functionally distinct circulations. @& The systemic circulation supplies all body organs with nutrients and carries away waste products. ca The pulmonary circulation conveys the contents of the vasculature through the lungs for exchange of CO2 and O2Heart Structure CS _ siren ntl «& Blood is propelled around the vasculature by two muscular pumps, one on each side of the heart. ce Each pump contains two chambers: one atrium and one ventricle, The left heart pumps blood through the aorta to the organs of the systemic circulation. It returns to the heart via the vena cavae ca The right side of the heart perfuses the pulmonary circulation, Blood exits the right ventricle via the pulmonary artery, passes through the lungs, and then enters the left heart via the pulmonary vein Heart Structure — (4— eae aeeiereeaiectna! Atria Atria act as holding tanks for blood collected from the venous system during ventricular contraction, c Accumulated blood is transferred to the ventricles by atrial contraction at the beginning of each cardiac cycle. @& Minimal amounts of pressure are required to push blood into the ventricles and, therefore, atrial walls contain relatively small amounts of muscle and are thin,Heart Structure 0% Ventricles Ventricles drive blood at high pressure through vast networks of vessels, made possible by chamber walls that are thick with cardiac muscle. 2 The left ventricle (LV) typically generates peak pressures of 120 mm Hg. cx The right ventricle (RV) pumps blood through a system of relatively low-resistance vessels and, therefore, its walls are less muscular than those in the LV. The RV generates peak pressures of about 20 mm Hg Heart Structure Valves & One-way valves situated between atria and ventricles ( atrioventricular [AV] valves) and between ventricles and their outlets (semilunar valves) help ensure that flow around the cardiovascular system is unidirectionalHeart Structure or Atrioventricular Valves ca The tricuspid (right side) and mitral (left side) valves allow blood to pass from atrium to ventricle and close when ventricular contraction begins. ca Chordae tendineae are filaments attached to the edges of the valve leaflets. ca The chordae work in conjunction with papillary muscles to brace the valves and prevent them from being everted by high pressures generated within the ventricles during contraction Heart Structure 4——______ Semilunar & The pulmonary (right si ight side) and aortic (left si valves prevent backflow from the ea ae into the ventricles. “sem c& The semilunar valves are subj i ; ar val ject to high she; associated with high-velocity ventricular outflo oe are thicker and more resilient than AV valve leaflets, Ss.Heart Contraction OS @ The wave of depolarization that drives myocardial contraction and cycling of the pump originates in the sinoatrial (SA) node. c& Nodal cells have an unstable membrane potential (Vm) that drifts slowly positive over time. Once Vm crosses the threshold for action potential (AP) formation, the cell spikes and a wave of excitation begins. ca The SA node comprises a group of specialized cardiac myocytes located near the superior vena cava in the wall of the right atrium. @ These myocytes have lost most of their contractile elements and their function, instead, is to generate spontaneous APs, Heart Contraction CsS— = — _ c@ Nodal cells are linked electrically via gap junctions to surrounding atrial myocytes. ca Once initiated, the wave of depolarization spreads outward in all directions with a conduction velocity of 1 m/s, taking about 100 ms to engulf both atria. Atrioventricular node ca The spreading wave of depolarization is arrested before it can reach the ventricles by a plate of cartilage and fibrous material located at the AV junction. ca The plate provides structural support for the heart valves, but it also acts as an electrical insulator. c& It takes about 80 ms for the electrical “spark” to traverse the AV node, just long enough for blood to be pushed by atrial contraction through the AV valvesHeart Contraction a ca Once the wave of excitation migrates through the AV node, the ventricular walls must be stimulated to contract in a sequence that squeezes blood upwards toward the outlets: septum —> apex — freewalls ~» base. & The pathway to the ventricles begins with the common bundle of His, a tract of specialized myocytes that emerges from the AV node and then sweeps downward into the interventricular septum ca Here it separates into left and right bundle branches, which then branch again to deliver the excitation signal to all regions of the left and right ventricles, respectively. @ High-speed Purkinje fibers (conduction velocity 2-4 m/s) carry the wave of depolarization to the contractile myocytes Heart Contraction O$——______ & Ventricular myocyt tes are similar to atrial my conducting the wave of de Bone : ucting t polarization cell via gap junctions at 1 m/s, © Excitation of both ventricles is essentially within 100 ms, although the Sean r slower mechanical events will take another 300 ms to completeCardiac Cycle oS @ The cardiac cycle consists of alternating periods of contraction (systole) and relaxation (diastole). a The cardiac cycle can be further subdivided into seven discrete phases: 3 Atrial Systole 3 Isovolumic ventricular contraction cs Rapid ventricular ejection 3 Reduced ventricular ejection 3 Isovolumic ventricular relaxation os Rapid ventricular filling < Reduced ventricular filling, Cardiac Cycle sg @ 1 Atrial systole: The cardiac cycle begins with atrial systole, which is initiated by atrial excitation and follows the crest of the P wave on the ECG. c& 2 Isovolumic ventricular contraction: Ventricular systole begins with mitral valve closure, which occurs during the QRS complex. It takes around 50 ms for. the ventricle to develop sufficient pressure to force te aortic valve open, during which time the myocytes are contracting, around a fixed volume of blood. This phase is, thus, known as isovolumic (also isovolumetric or isometric) contraction. ‘3 Rapid ventricular ejection: The aortic valve finally opens, and blood exits the ventricle and enters the arterial system at high velocity co 4 Reduced ventric nears completion phase ir ejection: Ejection velocity decreases as ventricular systole cel jection). ‘Aerie valve closure marks the end of thisCardiac Cycle CG —_— — ic ventri son: With the ventricle once umic ventricular relaxation: : u cl ca &: Isovoluigd vessel, there follows @ period of isovolumic relaxation. - papid ventricular filling: When, the mitral, valve: CPt. 6, Rapkd ventricular omiming in the atcium during, Se blood torward into the ventricle, The rapid passive filling phase signals the beginning of diastole. ca 7. Reduced ventricular filling: ‘The cardiac cycle ends with 7. Reafiling. This phase, which is also known as diastasis, typically disappears when FIR increases because cycle length is stortenad largely at the expense of diastole. Ventricular Pressure & Volume CS During Diastole ca By the end of diastole, the ventricle has neared SN atrial contraction forces a small additional blood bolus into the ch ae amber lumen ca The left ventricular pressure (LVP) rises to around 10-12 mm Hg. caLV end-diastolic volume (EDV) then stands at 70- 240 mLVentricular Pressure & Volume Cs During Systole @ Once LVP meets and exceeds aortic pressure, the aortic valve opens, and blood is ejected into the arterial system. 8 Pressures continue to climb even though blood is being ejected because the LV myocytes are still actively contracting. @ The rapid ejection phase accounts for 70% of total ventricular output and drives aortic pressure toward a peak of 120 mm Hg. c The ventricular myocytes now begin to repolarize, contraction wanes, and LVP falls rapidly. ca The kinetic energy imparted to blood by LV contraction continues to drive ventricular outflow for a brief period, but the rapid fall in LVP soon causes the pressure gradient across the aortic valve to reverse and the aortic valve slams shut Ventricular Pressure & Volume a ca The LV does not empty completely during systole, and end-systolic volume (ESV) is usually around 50 mL. ca Subtracting ESV from EDV gives stroke volume (SV), which defines the amount of blood transferred from the LV to the arterial system during systole. ca SV should be 60 mL ina healthy person a Dividing SV by EDV yields ejection fraction (EF), normally 55%-75%Cardiac Output g—— «CO (L/min) is calculated from the product of HR (beats/min) and SV (mL): ~@CO= HRxSV 1, Heart rate: HR is established by the sinoatrial (SA) node, the cardiac pacemaker, HR is dependent on the autonomic nervous system, which controls the rate at which the pacemaker generates a wave of excitation. Sympathetic nervous system (SNS) activation raises HR, whereas parasympathetic stimulation decreases it. Cardiac Output 9 2. Stroke volume: SV is dependent on LV 1 afterload, and contractility, ee © a. Preload: Preload refers to a load that is applied to a myocyte and establishes muscle length before contrachon begins. In the LV, preload equates with the volume of blood entering the chamber during diastole (EDV), which is dependent on enddiastolic pressure (EDP). @ b. Afterload: Afterload is the load against which a myocyte must shorten, In a healthy individual, the principal component of LV afterload is aortic pressure. ¢. Contractility: Contractility is a measure of a muscle’s ability to shorten against an afterload. In_ practice, contractility equates with sarcoplasmic free Ca2 concentration, aNormal ECG CS P wave: ca The myocardium rests between beats, and the ECG pen rests at the isoelectric line. & Excitation begins with the SA node, but the current that it generates is too small to record at the body surface. & The wave of depolarization then spreads across the atria, registering as the P wave. ca When both atria are depolarized fully, the pen returns to baseline. c A normal P wave has a duration of 80-100 ms. Normal ECG ee = QRS complex: ca The P wave is followed by a brief period of quiet during which the wave of excitation moves slowly through the AV node and crosses from atria to ventricles via the bundle of His. @ This progression does not register on the recording. @ Ventricular depolarization produces the QRS complex. @& The three components reflect excitation of the intraventricular septum (Q wave), the apex and the free walls (R wave), and finally the regions near the base (S wave). a The recording returns to baseline when the entire ventricular myocardium is depolarized. c& The entire complex lasts 60-100 msNormal ECG OS T wave: © Ventricular repolarization registers on the ECG recording as the T wave. PR interval c From start of the P wave to start of ORS complex. Time for wave of excitation to traverse atria and AV node Normal ECG ws a PR Segment c& From end of P wave to start of ORS complex. Time for wave of excitation to traverse AV node QT interval © From start of QRS complex to end of T wave. Duration of myocardial excitation and recoveryVascular Distensibility OS x Blood vessels are characterized by being distensible @ This feature allows © the arteries to accommodate the pulsatile output of the heart and to average out the pressure pulsations © the veins to act as a reservoir for storing large amounts of blood 0.5 to 1.0 liter os Distensibility is represented by: cs Increase in volume / Increase in pressure x Original volume Vascular Distensibility OS ae ce Walls of the arteries are thick, thus the veins are more distensible than the arteries (eight times) ce Vascular compliance is the amount of blood that can be stored in a given vessel for each mmHg pressure increase c@ Vascular Compliance = @ Increase in Volume / Increase in Pressure Or © Distensibility x VolumeVascular Distensibility Crd as 140 s ie ‘Sympathetic stimulation fr 100 \ 80 ‘Sympathetic inhibition eo Normal volume 40 Pressure (mm Hg) Artérial system 20 Venous system © 500 1000 1500 2000 2500 3000 3500 Volume (ml) Vascular Distensibility og — ca Sympathetic control of vascular capacitance is important during hemorrhage. It can result in shifting large amounts of blood to the heart if needed. a Were it not for distensibility of the arterial system, all of this new blood would have to flow through the eripheral biood vessels almost instantaneously, only Burin cardiac systole, and no flow would occur during diastole. ca Compliance of the arterial tree normally reduces the pressure pulsations to almost no pulsations by the time the blood reaches the capillaries; therefore, tissue blood flow is mainly continuous with very little pulsationVascular Distensibility ———— (%— a ca In the healthy young adult, the pressure at the top of each pulse, called the systolic pressure, is about 120 mm Hg. At the lowest point of each pulse, called the diastolic pressure, it is about 80 mm Hg. ca The difference between these two pressures, about 40 mm Hg, is called the pulse pressure. a Two major factors affect the pulse pressure: (1) the stroke volume output of the heart and (2) the compliance (total distensibility) of the arterial tree.Vascular Distensibility OS «x A stethoscope is placed over the antecubital artery and a blood pressure cuff is inflated around the upper arm. © As long as the cuff continues to compress the arm with too little pressure to close the brachial artery, no sounds are heard from the antecubital artery with the stethoscope. @ However, when the cuff pressure is great enough to close the artery during part of the arterial pressure cycle, a sound is then heard with each pulsation. & These sounds are called Korotkoff sounds Vascular Distensibilih — C%5- @ Blood from all the systemic veins flows into the right atrium of the heart; therefore, the pressure in the right atrium is called the central venous pressure. a Right atrial pressure is regulated by a balance between (1) the ability of the heart to pump blood out of the right atrium and ventricle into the lungs and (2) the tendency for blood to flow from the peripheral veins into the right atrium, ca Some of the factors that can increase this venous return and thereby increase the right atrial pressure are (1) increased blood volume, (2) increased large vessel tone throughout the body with resultant increased peripheral venous pressures, and @) dilation of the arterioles, which decreases the peripheral resistance and allows rapid flow of blood from the arteries into the veins.Vascular Distensibility CG ct The normal right atrial pressure is about 0 mm Hg, which is equal to the atmospheric pressure around the body. ffcan increase to 20 to 30 mm Hg under very abnormal conditions, such as (1) serious heart failure or (2) after massive transfusion of blood, which greatly increases the total blood volume and causes excessive quantities of blood to attempt to flow into the heart from the peripheral vessels. ca The lower limit to the right atrial pressure is usually about ~3 to -5 mm Hg below atmospheric. pressure, which is also the pressure in the chest cavity that surrounds the heart. The right atrial pressure approaches these low values when the heart pumps with exceptional vigor or when blood flow into the eart from the peripheral vessels is greatly depressed, such as after severe hemorrhage. Vascular Distensibility ca Effect of High Right Atrial Pressure on Peripheral Venous Pressure: . Blood begins to back up in the large veins. This backup of — blood enlarges the veins, and een collapse points in the veins open up when tne rig! atrial pressure rises above +4 to +6 mm Hg. id a as the right atrial pressure rises still further, the addi ion ‘ increase causes a corresponding rise iN perip! eral venous pressure in the limbs and elsewhere.Sagita sinus Ga 40 mm Hg mmHg ZS ommHg vs Senos og a { 422 mm Hg Tt dad| fo \ fee 240 mm Hg Vascular Distensibility 5 CaeVascular Distensibility OS 8 Pressure in standing still position is 90mmHg c& Pressure due to venous pump is 20mmHg 210 to 20 percent of the blood volume can be lost from the circulatory system within the 15 to 30 minutes of standing absolutely still, which may lead to fainting as sometimes occurs when a soldier is made to stand at rigid attention . ca Blood Reservoir: % Spleen os Liver @s Abdominal veins @s Venous plexus beneath the skin