CARDIOVASCULAR PHYSIOLOGY for Part II,2010/11 Set

Dr. O. Ogunlade, MBChB, M.Sc.,FWACP

Lecturer/Consultant Cardiologist, Department of Physiological Sciences, Obafemi Awolowo University, Ile-Ife.

INTRODUCTION
William Harveys description of the circulation of blood and the motive force of the heart was contained in a 72paged book titled De Motu Cordis ( On the motion of the Heart and Blood). William Harveys work published in 1628 is considered the beginning of modern physiology and cardiovascular research. A sound knowledge of the human cardiovascular physiology is essential as a solid foundation for the training of doctors, nurses, pharmacists, physiotherapists and other paramedics.

Definition of Cardiovascular Physiology

Cardiovascular physiology is the study of the function of the cardiovascular system.

Cardiovascular System(CVS)
CVS consists of the heart and the network of blood vessels in which the blood circulates. It is also referred to as the circulatory system. In human beings, the CVS exists as a closed circuit in which the blood stays within the circuit as it circulates and chemicals or other substances in the system are exchanged by diffusion. CVS in human is a closed circulatory system.

Functions of Cardiovascular System

The functions of the cardiovascular system can be categorised into two; 1. Mechanical function 2. Electrical function

Mechanical Function
Cardiovascular system serves as vehicle for the transportation of blood and its constituents across the body. Cardiovascular system generates the blood pressure that gives strength to the body generates the blood pressure that gives strength to the body.

Substances transported within the cardiovascular system include;

Blood cells e.g. erythrocytes and leucocytes Gases such as oxygen and carbon dioxide Food nutrients e.g. proteins, lipid, glucose, vitamins and minerals Fluid e.g. water Electrolytes such as sodium and potassium Hormones Cytokines Waste products e.g. urea Energy and heat

Electrical Function
The cardiovascular system generations and propagates the electrical impulses that gives life to the body. The electrical activity initiates mechanical activities. Without electrical activity, there will be no mechanical activities.

Components of Cardiovascular System

Cardiovascular system consists of the heart and vascular networks (figures 1 & 2).

Fig. 1. Heart and Great Vessels

The Heart and Its Interior

The human heart is a 4-chambered muscular organ located in the chest. It is main pump(engine) of the cardiovascular system. The chambers of the heart include; right and left atria, left and right ventricles (Figure 1and 2).

Fig.3. Heart Interior

Vascular Network
The vascular network consists of the aorta, arteries, arterioles, capillaries, venules, veins and vena cavae. The cardiovascular system has two main divisions; 1. Systemic circulation (major division) 2. Pulmonary circulation (minor division)

Divisions of Cardiovascular System

The cardiovascular system has two main divisions; 1. Systemic circulation (major division) 2. Pulmonary circulation (minor division)

Systemic Circulation
Systemic circulation involves transportation of blood and its constituents from the left side of the heart to the body tissues and back to the right side of the heart. The systemic circulation is called the major circulation and it is a high pressure driven system. The pump for the systemic circulation is the left ventricle. The feeding venous system to the systemic circulation is the pulmonary venous system.

Box.1. Systemic Circulation

left atrium left ventricle aorta arteries arterioles capillaries venules veins vena cavae right atrium

Pulmonary Circulation
Pulmonary circulation involves transportation of blood and its constituents from the right side of the heart to lung and back to the left side of the heart. It is a low pressure driven system compared with systemic circulation. The pump for the pulmonary circulation is the right ventricle. The feeding venous system to the pulmonary circulation is the systemic venous system.

Box.2. Pulmonary Circulation

right atrium right ventricle pulmonary trunk pulmonary arteries lung capillaries pulmonary veins left atrium

Fig. 4. Divisions of Cardiovascular System

CARDIAC CYCLE
The cardiac cycle refers to the sequence of events occuring within the heart from one heart beat to the other. The frequency of the cardiac cycle constitutes the heart rate. Cardiac cycle is divided into two main phases; 1. Ventricular diastole 2. Ventricular systole

VENTRICULAR DIASTOLE
Ventricular diastole refers to ventricular relaxation phase Events occurring during the diastole include; 1. Isovolumetric (isovolumic) relaxation 2. Rapid passive filling 3. Slow filling (diastasis) 4. Rapid active filling (atrial contraction)

Isovolumic Relaxation
During the period of isovolumic relaxation; 1. All valves closed 2. Ventricular volumes remain constant 3. Ventricles relax 4. Intraventricular pressures fall When intraventricular pressure falls below the atrial pressure, atrioventricular valves open to pave the way for the next phase; rapid passive filling.

Rapid Passive Filling

During the period of rapid passive filling; Ventricular pressures falls below atrial pressures Atrioventricular valves open Due to differential pressure gradients, blood flows rapidly from atrial to the ventricles. Rapid passive filling is responsible for 75-80% of ventricular filling The third heart sound (S3) occurs during this phase

Diastasis(Slow filling)
Diastasis refers to a period of slow ventricular filling following rapid passive filling It precedes the period of rapid active filling This period is not always constant as it may be absent at a very rapid heart rate

Rapid Active Filling

Rapid active filling refers to the period of atrial systole The atrial contraction during this phase contributes 20-25% of the ventricular filling The fourth heart sound (S4) occurs during this phase This phase precedes ventricular systole

VENTRICULAR SYSTOLE
Ventricular systole refers to period of ventricular contraction. The intraventricular pressures begins to rise, the atrioventricular valves close marking the beginning of ventricular systole Events occurring during ventricular systole include; 1. Isovolumetric (isovolumic) contraction 2. Ventricular ejection

Isovolumic Contraction
During the period of isovolumic contraction; 1. All the valves are closed 2. Ventricular volumes remain constant 3. Ventricles contraction results in elevation of the intraventricular pressures When the intraventricular pressures exceed the pressures in the great vessels; aorta and pulmonary trunk for the left and right ventricles respectively, the semilunar valves open paving the way to the phase of ventricular ejection

Ventricular Ejection
During the period of ventricular ejection; 1. Intraventricular pressures exceeds the pressures in the aorta and pulmonary trunk for the left and right side respectively 2. Semilunar (outflow tract) valves open 3. Blood is ejected into the aorta and pulmonary trunk on the left and right side respectively At the end of this phase the semilunar valves snap closed given rise to the second heart sound.

Heart Sounds Delineation of Cardiac Cycle

S1 Lub Ist heart sound Systole S2 Dub 2nd heart sound diastole S1 Lub Ist heart sound

Duration of Cardiac Cycle

The total duration of cardiac cycle 860ms Diastole 600ms; Systole 260ms The duration of cardiac cycle varies with the heart rate. At a very fast heart rate, the period of diastole is shortened.

Annotated Diagram of Cardiac Cycle

T N E
P

CU I R

s as

F il li n e v i

LA R D I A ST O g
Sl
(D

w
g l in ) fi l s is ta

s ia

Ra pid

O u tfl o w v a l v e s c lo s e In fl o w v a l v e s o p e n

S3

Rapid active fil

in (Atr ial contracti on g )

4 S

vo lum ic Iso ax atio n r el

A ll va lve s clo se

In fl o w v a lv e c lo o u tf lo w v s e a lv e s open

S2

S1

A ll valves close

EN

TR

IC U L

S AR SY

e E j n t r ic e c u la r t io n

a Contr

mi u l o Is o v ctio

L O T

Summary of the Events in Cardiac Cycle

States of Valves Cardiac Haemodynamic Events
Atrioventricular (inflow) valves

Semilunar (outflow) valves

Diastole

Systole

Isovolumic (isovolumetric) relaxation rapid passive Ventricular filling filling slow filling (diastasis) rapid active filling (atrial contraction) Isovolumetric(isovolumic) contraction Ventricular ejection

Close Open

Close Close

Close Close

Close Open

HAEMODYNAMIC CONSEQUENCES OF CARDIAC CYCLE

The major haemodynamic consequences of cardiac cycle include; 1. Volume changes within heart chambers 2. Pressure changes within the heart chambers 3. Blood flow 4. Valvular events: valve closure and openings 5. Heart sound

Wiggers Diagram
Wiggers diagram is a standard diagram in cardiovascular physiology to illustrate the haemodynamic consequences of cardiac cycle. The X-axis contains the time The Y-axis contains; 1. Blood pressure; ventricular pressure, aortic pressure and atrial pressure 2. Ventricular volume changes 3. Electrocardiogram 4. Phonocardiogram (optional)

Wiggers Diagram

HEART SOUNDS
Heart Sounds include S1, S2, S3 and S4 S1: First heart sound S2: Second heart sound S3: Third heart sound S4: Fourth heart sound

Heart Sound and Events in Cardiac Cycle

S1 occurs at the onset of systole while S2 occurs at the end of systole This implies that ventricular systole occurs between S1 and S2 S2 occurs at the onset of diastole while S1 occurs at the end of diastole This implies that ventricular diastole occurs between S2 and S1 S3 and S4 are diastolic sounds.

Heart Sounds
S1 LUB Systole S2 DUB S3 diastole S4 S1 Systole LUB S2 DUB

Ist HS
*HS = heart sound

3rd HS 2nd HS

4th HS

First Heart Sound: S1

Generated by the vibrations associated with the closure of the atrioventricular valves at the onset of ventricular systole A low pitched sound (lub) Duration : 0.10 - 0.17s, Frequency: 25-45Hz S1 has two components: M1 and T1 for mitral and tricuspid components respectively. M1 precedes T1 because closure of mitral valve precedes closure of tricuspid valve (pressure in left ventricle > pressure in the right ventricle)

Second Heart Sound: S2

Generated by the vibrations associated with the closure of semilunar valves A high pitched sound (dub) Duration: 0.12s,Frequency: 50Hz S2 has two components: A2 & P2
A2 is produced by aortic valve P2 is produced by pulmonary valve

Splitting of S2 into A2 & P2 can be heard normally during inspiration(because a decrease intrathoracic pressure during inspiration increases the time needed for pulmonary pressure to exceed right ventricular pressure)

Diastolic Heart Sounds

Diastolic heart sounds include; Third heart sound (S3) Fourth heart sound (S4) S3 and S4 occur during the period of diastole of the cardiac cycle

Third Heart Sound: S3

The third heart sound is produced by the vibrations in the ventricular wall during the rapid passive filling phase of the cardiac cycle It occurs early in ventricular diastole It is referred to as an early diastolic heart sound It is a short low pitched sound Duration: 0.07-0.10s Frequency: 1-6Hz

Conditions Associated with S3

Conditions when third heart sound is audible include; 1. Young age group 2. Pregnancy 3. Heart failure 4. Fluid overload

Fourth Heart Sound: S4

The fourth heart sound is produced during the rapid active filling phase (atrial systole) of the cardiac cycle. It is due to vibrations in the ventricular wall due to its stiffness as blood rushes into the ventricle during atrial systole S4 is also called late diastolic heart sound because it occurs in the latter period of ventricular diastole It is a short low pitched sound Duration: 0.02- 0.04s Frequency: 1-4Hz

Conditions Associated with S4

Conditions when the fourth heart sound is audible include; 1. Old age group 2. Hypertension 3. Hypertrophic cardiomyopathy 4. Acute myocardial infarction

Genesis of Heart Sounds

Heart Sound Genesis

First heart sound (S1)

Second heart sound (S2)

Third heart sound (S3)

Fourth heart sound (S4)

vibrations associated with the closure of the atrioventricular (mitral & tricuspid)valves vibrations associated with the closure of semilunar(aortic & pulmonary) valves vibrations in the ventricular wall during the rapid passive filling phase of the cardiac cycle vibrations in the ventricular wall due to its stiffness as blood rushes into the ventricle during atrial systole

AUSCULTATORY AREAS
The main auscultatory areas are locations on the precordium where the heart sounds can best be appreciated through the use of stethoscope There are five major auscultatory areas which include; mitral area, tricuspid area, aortic area, pulmonary area and Erbs point

Locations of Main Auscultatory Areas

Mitral Area: left 5th intercostal space midclavicular line Tricuspid Area: 4th intercostal space left sternal border Aortic Area: 2nd intercostal space right sternal border Pulmonary Area: 2nd intercostal space left sternal border Erb's point: third intercostal space on the left sternal border

Apex Beat
Apex beat is the most lateral and most inferior point of maximal cardiac impulse. It is located in the left 4th or 5th intercostal space mid-clavicular line.

Heart Sounds & Auscultatory Areas

Auscultatory Area Heart Sound Mitra area M1( mitral component of S1), left-sided S3 or S4 Tricuspid area T1 (tricuspid component of S1), right-sided S3 or S4 Aortic area A2( aortic component of S2) Pulmonary area Erbs point P2( pulmonary component of S2) S2

HEART MURMURS
Murmurs are abnormal sounds from the heart due to turbulent flow of blood within the cardiac chambers or its great vessels. Murmur occurs due to abnormal flow across the heart valves or abnormal communication within the heart chambers or its great vessels

Causes of Heart Murmur-1

Valvular regurgitation(incompetence): disorder of the valve in which the valve fails to appose closely thereby permitting leakage of blood across the valve at time of closure ; mitral regurgitation-leakage of blood into the left atrium during left ventricular systole tricuspid regurgitation-leakage of blood into the right atrium during right ventricular systole aortic regurgitation-leakage of blood into the left ventricle during left ventricular diastole pulmonary regurgitation -leakage of blood into the right ventricle during right ventricular diastole

Causes of Heart Murmur-3

Valvular stenosis: narrowing of cardiac valve preventing free flow of blood across the valve. Examples include mitral, tricuspid, pulmonary and aortic valves stenoses. Septal defect: atrial or ventricular septal defect in which a defect occurs in inter-atrial or inter-ventricular septum respectively. This results in shunting of blood from the higher pressure chamber to the lower pressure chamber. Patent ductus arteriosus: patency of ductus arteriosus ( a connection between pulmonary artery and aorta in utero) after birth

Classification of Cardiac Murmur

Classification

Phase of cardiac cycle

Systolic murmur systole Diastolic murmur diastole Continuous murmur diastole and systole

Types of Murmur
Types of Subtypes of Murmur Murmur Systolic Pansystolic Valvular Disorders Mitral regurgitation Tricuspid regurgitation Aortic stenosis Pulmonary stenosis Aortic regurgitation Diastolic Early diastolic Pulmonary regurgitation Mitral stenosis Tricupid stenosis Auscultatory Areas Mitral area Tricuspid area Aortic area Pulmonary area 2nd-4th intercostal spaces , left sternal edge Mitral area Tricuspid area

Mid systolic

Mid diastolic

Murmurs Dominantly Produced by Major valvular Disorders

Heart Valves Mitral Tricuspid Major valvular disorders

Pulmonary Aortic

Regurgitation Pansystolic murmur Pansystolic murmur Early diastolic murmur Early diastolic murmur

Stenosis Mid-diastolic murmur Mid-diastolic murmur Mid-systolic murmur Mid- systolic murmur

Aids to memory about heart murmur

1. Regurgitation across an atrioventricular valve produces a pansystolic murmur 2. Stenosis of atrioventricular valve produces a middiastolic murmur 3. Regurgitation across semilunar valve produces an early diastolic murmur 4. Stenosis of semilunar valve produces a mid systolic murmur 5. A flow across a ventricular septal defect produces a pansystolic murmur 6. A flow across patent ductus arteriosus produces a continuous or machinery murmur.