CARDIOVASCULAR

SYSTEM
 ANATOMY AND PHYSIOLOGY
 Consists of the heart, arteries, capillaries, and veins and may be further divided into
two subsystems of circulation:
 (1) Pulmonary circulation transports blood between the heart and lungs for exchange
of blood gases
 (2) Systemic circulation transports blood between the heart and the rest of the body.
 Heart
 Acts as a pump to propel the blood throughout the body via the circulatory vessels.
 Lies in the anterior chest within the mediastinum and is generally readily visible on a
chest radiograph.
 Right and Left atria (upper chambers) Right and Left ventricles (lower chambers).
 Lies in an oblique plane within the mediastinum; PA chest radiograph does not clearly
demonstrate all chambers of the heart.
 PA projection shows a cardiac silhouette, with two thirds of the heart lying to the left of
midline.
 Right side is composed mainly of the right atrium, and the left side is composed mainly
of the left ventricle.
 The right ventricle lays midline within the cardiac shadow and is located
anterior to the right atrium and left ventricle. The left atrium is located
midline and is the most posterior aspect of the heart.
 Therefore, it is necessary to obtain a lateral projection of the chest to best
demonstrate the right ventricle and the left atrium.
 The heart contains three tissue layers.
 Endocardium, innermost layer is smooth. The valves located within and
between the various chambers are also composed of endocardium.
 Myocardium, middle layer is muscular. The thickest layer of heart
tissue, and the cardiac muscle receives blood supply from the right and
left coronary arteries, which arise directly from the aorta, just superior to
the aortic valve. When the myocardium contracts (systole), blood is
pumped out of the heart.
 Epicardium, outermost layer, protective covering. Entire heart is
enclosed within a pericardial sac, which contains a small amount of fluid
to lubricate the heart as it contracts and relaxes, thus reducing friction
between the heart and other mediastinal structures.
 In the normal heart, RA receives deoxygenated blood from the body via the superior
and inferior vena cava. The deoxygenated blood passes through the right
atrioventricular or tricuspid valve into the right ventricle. The right ventricle
contracts during systole, thus propelling blood to the lungs through the pulmonary
valve and pulmonary trunk, which bifurcates into the right and left main pulmonary
arteries, respectively. Approximately 60% of deoxygenated blood enters the right
lung, and approximately 40% enters the left lung.
 The exchange of gases occurs at the capillary– alveolar level within the lungs, and
the now oxygenated blood is returned to the left atrium via the four pulmonary
veins.
 Oxygenated blood flows from the left atrium to the left ventricle via the left mitral
valve. The left ventricle is responsible for pumping oxygenated blood throughout the
systemic circulatory system. Oxygenated blood flows through the aortic valve into
the aorta when the left ventricle contracts.
 Cardiac Cycle
 The contraction of the myocardium is termed
systole
 The subsequent relaxation is termed diastole.
 The pacemaker of the heart is the sinoatrial (SA)
node, which is located in the upper portion of
the right atrium near the superior vena cava. An
electrical current is transmitted through the
myocardium, resulting in a heartbeat.
 Electrocardiography graphically demonstrates
this electrical activity. The elements of an
electrocardiogram (ECG) include the P wave, PR
interval, QRS complex, T wave, and QT duration.
 Circulatory Vessels
 Arteries
 blood vessels that carry blood away from the heart and are generally named for their location or
the organ they supply (e.g., splenic artery).
 They are composed of three layers.
 Outermost layer is termed the adventitia, middle layer is the media, and innermost layer is the
intima. The internal, tubular structure of the vessel is termed the lumen.
 Veins
 blood vessels that carry blood to the heart.
 They are composed of the same three layers; however, venous walls are thinner than arterial walls,
and veins contain valves at set intervals to help with blood return to the heart.
 Capillaries
 microscopic vessels that connect arteries and veins.
 They are responsible for the exchange of substances necessary for nutrient and waste transport.
 IMAGING CONSIDERATIONS
 Radiography
 Chest radiography provides information about heart shape and size. It is also excellent
for demonstrating the great vessels and vascular changes within the lung fields.
 Chest radiographs should be taken with the patient in the erect position. If a patient is
semi-recumbent or recumbent, the heart appears to be enlarged because abdominal
organs push the diaphragm and the heart up into the thoracic cavity.
 Chest radiographs obtained without a good inspiration also distort heart shape and size.
At least 10 posterior ribs should be visible within the lung fields on a chest radiograph.
 Conventional chest radiographs are generally obtained using a 72-inch SID to decrease
magnification of the heart to an approximate factor of 10%.
 Chest radiography is the most commonly performed procedure, and radiographers all too
often underestimate the importance of these basic radiographic principles. Well-positioned
diagnostic chest radiographs are crucial in the diagnosis and treatment of cardiovascular
disorders.

Echocardiography
 Encompasses a group of noninvasive sonographic (ultrasound) procedures that can provide
detailed information about heart anatomy, function, and vessel patency.
 Sonographic imaging may be performed using M-mode, two-dimensional (2-D) imaging,
spectral Doppler, color Doppler, or stress echocardiography.
 M-mode echocardiography uses a stationary ultrasound beam to provide an examination of
the atria, ventricles, heart valves, and aortic root, allowing evaluation of left ventricular
function. This technique allows for the recording of the rate of motion and the amplitude of
moving objects. It is also used to measure the thickness of the ventricular walls; however, it
has largely been replaced by 2-D echocardiography.
 2-D echocardiography allows for spatially correct, real-time imaging of the heart. It provides
multiple tomographic projections of the heart and great vessels in a cine-like presentation.
It is an excellent modality for visualizing the ascending and abdominal aorta in cases of
suspected aneurysm.
 Both M-mode and 2-D images are obtained by placing the transducer over the thorax at the
sternal borders, at the cardiac apex, between the ribs, or at the suprasternal notch.
 Transesophageal echocardiography (TEE), patient swallows a mobile, flexible probe containing the
transducer. With TEE, the heart’s structure can be readily visualized without interference from such
structures as skin, the rib cage, and chest muscles. It is especially helpful in imaging the aortic arch and aortic
root. Smaller transducers are placed on intravascular catheters to assess vessel anatomy and blood flow.
 Stress echocardiography combines an exercise test with an echocardiogram to check the heart’s
contraction ability and its pumping efficiency. If exercise is not possible, a drug, dobutamine, may be used to
increase cardiac output to assess how well the heart pumps during infusion.
 Doppler sonography is an adjunct, noninvasive procedure used to study the peripheral vasculature. It has
been a mainstay of vascular imaging since the 1970s and is used to determine the direction and velocity, as
well as the presence or absence, of blood flow in both arteries and veins. The Doppler Effect is the principle
that the sound coming toward you has a higher pitch than the sound going away from you.
 Nuclear Cardiology
 Myocardial perfusion scan is the most widely used procedure in nuclear cardiology. It may be performed on
patients with chest pain of an unknown origin, to evaluate coronary artery stenosis, and as a follow-up to
bypass surgery, angioplasty, or thrombolysis. Useful in detecting regions of myocardial ischemia and scarring.
A radionuclide, (technetium sestamibi or thallium) is injected through a vein. It concentrates in the areas of
the heart that have the best blood flow. Those areas lacking blood flow demonstrate filling defects, visualized
between images taken at rest and under stress. Stress may be induced by exercise on a treadmill or by the use
of pharmaceuticals such as regadenoson. Myocardial perfusion scanning is performed using SPECT.
 SPECT myocardial perfusion scans can detect significant CAD in 90% of patients. A PET unit is more sensitive
than conventional nuclear medicine cameras, and spatial resolution is superior to that of conventional
cameras. It is highly accurate for detecting CAD that interferes with blood flow to the heart muscle and can
identify injured but viable heart muscle. PET can also provide quantitative data about the distribution of the
radionuclide within the body.
 Gated cardiac blood pool scans (radionuclide ventriculograms or multiple gate acquisition scans (MUGA) )
 Evaluate ventricular function and ventricular wall motion. These images are obtained with the patient at rest and
during exercise. They are synchronized with the patient’s heartbeat using electrocardiography to image the heart
during specific phases of the cardiac cycle with the use of the radionuclide technetium-99.
 Images are obtained over a 5- to 10-minute period.
 The images are displayed in a cine-like format.
 Computed Tomography
 Noninvasive modality used to assess cardiac and vascular disease. Multidetector scanners provide the
highest image quality, and electron beam CT (EBCT) may also be used to image the heart.
 Cardiac scoring is performed without the use of a contrast agent, a scoring algorithm was developed for
evaluating the amount of calcium (hard plaques) present in the coronary arteries.
 EBCT is used examine the heart, particularly as related to coronary artery calcifications. It uses a scanning
focused x-ray beam to provide complete cardiac imaging in 50 milliseconds (ms)—fast enough to “freeze”
heart motion without the need for ECG gating.
 Contrast-enhanced CTA is approved by the U.S. FDA. Noninvasive (requiring only a
peripheral intravenous [IV] line for contrast administration) and is more cost-effective than
conventional angiography. In combination with 3-D reconstruction, it is used to image
vascular structures for organ donors, to diagnose pulmonary embolisms, to evaluate
vascular stenosis and peripheral vascular disease, and to image abdominal aortic
aneurysms, it helps the surgeon determine the necessary stent type and size in the
presurgical planning of abdominal aortic aneurysms and in the evaluation after surgery to
assess the stent’s effectiveness.
 Magnetic Resonance Imaging
 Used to evaluate many cardiac, mediastinal, and great vessel anomalies. Used to evaluate myocardial wall
thickness and chamber volumes and in diagnosing right ventricular dysplasia and highly effective in the
evaluation of viable versus nonviable myocardium.
 Most protocols involve obtaining imaging sequences and putting them into motion using a cine loop to
evaluate how well the valves of the heart are functioning.
 Contrast-enhanced MRI can demonstrate myocardial perfusion, and blood flow velocities within the heart can
be measured.
 The advantage of MRI is the production of images with high spatial resolution and, thus, higher quality images.
Information may be ECG gated to acquire the images during specific portions of the cardiac cycle.
 Valuable tool for imaging the anatomy, function, and disease of the heart and is fast becoming a “one-stop
shop” for noninvasive cardiac imaging. Evaluate aortic aneurysms, dissections, and aortic stenosis, especially
in patients who are unable to have contrast enhanced CT scans because of renal failure.
 Contrast-enhanced magnetic resonance angiography (MRA) is widely used to evaluate the vasculature from
the aorta to the brain. This technology takes only about 1 minute to acquire data and is considered
noninvasive. The larger coronary arteries may also be assessed with MRA.
 Angiography
– procedure commonly performed to evaluate cardiovascular disease. May be performed for diagnostic
purposes or for therapeutic reasons.
– Cardiac catheterization an invasive procedure specific to the heart and the great vessels. It is
performed in patients with CAD, conduction disturbances, or congenital heart disease and provides
information about heart and vessel anatomy. This provides information about the function of the
cardiac valves.
– Angiocardiography is performed by injecting the contrast material into the heart chambers and
obtaining cine images of the heart and the great vessels in motion.
– Therapeutic angiography continues to steadily increase through expanded use of interventional
procedures.
– Percutaneous transluminal coronary angioplasty (PTCA) is a therapeutic procedure commonly
performed to open stenotic coronary vessels and place a stent in a narrowed vessel to maintain its
patency.
– Thrombolysis is a procedure in which a high-intensity anticoagulant such as streptokinase is dripped
over a period of hours directly onto a clot to dissolve it.
– Transjugular intrahepatic portosystemic shunt (TIPSS) a catheter is used to connect the jugular vein
to the portal vein to reduce the flow of blood through a diseased liver.
Lymphatic
System
– a widely distributed system with multiple functions
(Fig. 9-7).
– Its role in circulation is to return excess fluid and
proteins from the tissues to the bloodstream. The
fluid carried in the lymphatic system is called
lymph.
– Lymph drains from the lower part of the body and
the upper left side into the thoracic duct, which
travels upward through the chest and empties into
the left subclavian vein near the heart. The right
lymphatic duct drains the upper right side of the
body and empties into the right subclavian vein.
– Lymphatic system also absorbs digested fats from
the small intestine. These fats are added to the
blood near the heart.
– Lymphatic system also protects the body from impurities and invading
microorganisms. Along the path of the lymphatic vessels are small masses of
lymphoid tissue, the lymph nodes.
– Their function is to filter the lymph as it passes through.
– They are concentrated in the cervical (neck), axillary (armpit), mediastinal
(chest), and inguinal (groin) regions.
– The lymph nodes and the remainder of the lymphatic system also play a role in
immunity.
– Other organs and tissues of the lymphatic system include the tonsils, located
in the throat, the thymus gland in the chest, and the spleen in the upper left
region of the abdomen
 Clinical
Aspects of the
Circulatory
System
 Atherosclerosis
– The accumulation of fatty deposits within the lining of an artery is termed atherosclerosis,
called a plaque, begins to form when a vessel receives tiny injuries, usually at a point of
branching.
– Plaques gradually thicken and harden with fibrous material, cells, and other deposits,
restricting the lumen (opening) of the vessel and reducing blood flow to the tissues, a
condition known as ischemia.
– A major risk factor for the development of atherosclerosis is dyslipidemia, abnormally high
levels or imbalance in lipoproteins that are carried in the blood, especially high levels of
cholesterol-containing low-density lipoproteins (LDL).
– Other risk factors for atherosclerosis include smoking, high blood pressure, poor diet,
inactivity, stress, and family history of the disorder.
– Atherosclerosis may involve any arteries, but most of its effects are seen in the coronary
vessels of the heart, the aorta, the carotid arteries in the neck, and vessels in the brain.
 Thrombosis and Embolism
• Thrombosis – the formation of a blood clot within a vessel. The clot, called a
thrombus, interrupts blood flow to the tissues supplied by that vessel, resulting
in necrosis (tissue death).
• Embolism – Blockage of a vessel by a thrombus or other mass carried in the
bloodstream, and the mass itself is called an embolus. Usually the mass is a
blood clot that breaks loose from the wall of a vessel, but it may also be air (as
from injection or trauma), fat (as from marrow released after a bone break),
bacteria, or other solid materials.
• Often a venous thrombus will travel through the heart and then lodge in an
artery of the lungs, resulting in a life-threatening pulmonary embolism. An
embolus from a carotid artery often blocks a cerebral vessel, causing a
cerebrovascular accident (CVA), commonly called stroke.
 Aneurysm
• An arterial wall weakened by atherosclerosis,
malformation, injury, or other causes may balloon
out, forming an aneurysm.
• If an aneurysm ruptures, hemorrhage results.
• Rupture of a cerebral artery is another cause of
stroke.
• The abdominal aorta and carotid arteries are also
common sites of aneurysm.
• It may be possible to repair an aneurysm surgically
with a graft.
 Hypertension
– High blood pressure, or hypertension (HTN), is a contributing factor in all of the conditions
described above.
– hypertension is defined as a systolic pressure greater than 140 mm Hg or a diastolic
pressure greater than 90 mm Hg.
– Hypertension causes the left ventricle to enlarge (hypertrophy) as a result of increased
work. Some cases of HTN are secondary to other disorders, such as kidney malfunction or
endocrine disturbance, but most of the time the causes are unknown, a condition
described as primary or essential hypertension.
– Changes in diet and life habits are the first line of defense in controlling HTN. Drugs that are
used include diuretics to eliminate fluids, vasodilators to relax the blood vessels, and drugs
that prevent the formation or action of angiotensin, a substance in the blood that normally
acts to increase blood pressure.
 Heart
Disease
 CORONARY ARTERY DISEASE
• results from atherosclerosis of the vessels that supply blood to the heart muscle, is a leading cause of death in
industrialized countries.
• An early sign of CAD is the type of chest pain known as angina pectoris. This is a feeling of constriction around
the heart or pain that may radiate to the left arm or shoulder, usually brought on by exertion. Often there is
anxiety, diaphoresis (profuse sweating), and dyspnea (difficulty in breathing).
• CAD is treated by control of exercise and administration of nitroglycerin to dilate coronary vessels.
• Patients with severe cases of CAD may be candidates for angioplasty, surgical dilatation of the blocked vessel
by means of a catheter, technically called percutaneous transluminal coronary angioplasty (PTCA) (Fig. 9-10)
• If further intervention is required, the blocked vessel may be surgically bypassed with a vascular graft known as
a coronary artery bypass graft (CABG) (Fig. 9-10), another vessel or a piece of another vessel, usually the
saphenous vein of the leg or the left internal mammary artery, is used to carry blood from the aorta to a point
past the obstruction in a coronary vessel.
• CAD is diagnosed by electrocardiography (ECG), study of the electrical impulses given off by the heart as it
functions, stress tests, coronary angiography (imaging), echocardiography, and other tests.
• Degenerative changes in the arteries predispose a
person to thrombosis and sudden occlusion
(obstruction) of a coronary artery.
• The resultant area of myocardial necrosis is termed an
infarct (Fig. 9-12), and the process is known as
myocardial infarction (MI), the “heart attack” that may
cause sudden death.
• Symptoms of MI include pain over the heart (precordial
pain) or upper part of the abdomen (epigastric pain)
that may extend to the jaw or arms, pallor (paleness),
diaphoresis, nausea, and dyspnea. There may be a
burning sensation similar to indigestion or heartburn.
• MI is diagnosed by electrocardiography, by
measurement of certain enzymes (CK, LDH, AST)
released into the blood from the damaged heart muscle
and by a variety of other methods.
 ARRHYTHMIA
– Any irregularity of heart rhythm, such as a higher- or lower-than-
average heart rate, extra beats, or an alteration in the pattern of the
beat.
– Bradycardia is a slower-than-average rate, and tachycardia is a
higher-than-average rate.
– Tachyarrhythmia is any disturbance of the heart rate is abnormally
increased.
– Bradyarrhythmia is any disturbance of the heart rate in which the
heart rate is abnormally slowed.
 HEART FAILURE
• The general term heart failure refers to any condition in which the heart fails
to empty effectively.
• The resulting increased pressure in the venous system leads to edema, often
in the lungs (pulmonary edema), and justifies the description congestive
heart failure (CHF).
• Other symptoms of congestive heart failure are cyanosis, dyspnea, and
syncope. Heart failure is one cause of shock, a severe disturbance in the
circulatory system resulting in inadequate delivery of blood to the tissues.
Heart failure is treated with rest, drugs to strengthen heart contractions,
diuretics to eliminate fluid, and restriction of salt in the diet.
 CONGENITAL HEART DISEASE
• any defect that is present at birth.
• The most common type of congenital heart
defect is a hole in the septum (wall) that
separates the atria or the ventricles. The
result of a septal defect is that blood is
shunted from the left to the right side of the
heart and goes back to the lungs instead of
out to the body. The heart has to work harder
to meet the body’s need for oxygen.
Symptoms of septal defect include cyanosis
(leading to the description “blue baby”),
syncope (faint), and clubbing of the fingers.
Most such congenital defects can be
corrected surgically.
 CONGENITAL HEART DISEASE
– Another type of congenital defect is
malformation of a heart valve.
– Failure of a valve to open or close properly is
evidenced by a murmur, an abnormal sound
heard as the heart cycles.
– Still other congenital defects result from
failure of fetal modifications to convert to
their adult form at birth.
– Inpatent ductus arteriosus(Fig. 9-15), a vessel
present in the fetus to bypass the lungs fails
to close at birth. Blood can then flow from
the aorta to the pulmonary artery and return
to the lungs.
 RHEUMATIC HEART DISEASE
• infection with a specific type of streptococcus sets up an immune reaction that ultimately damages the heart
valves.
• The infection usually begins as a “strep throat,” and most often it is the mitral valve that is involved. Scar
tissue fuses the leaflets of the valve, causing a narrowing or stenosis that interferes with proper function.
• People with rheumatic heart disease are subject to repeated infections of the valves and must take
antibiotics prophylactically (preventively) before any type of surgery and before even minor invasive
procedures such as dental cleaning.
• Severe cases of rheumatic heart disease may require surgical correction or even valve replacement.
• The incidence of rheumatic heart disease has declined with the use of antibiotics.
 Disorders of the Veins
– A breakdown in the valves of the veins in combination with a chronic dilatation of these
vessels results in varicose veins. These appear twisted and swollen under the skin, most
commonly in the legs.
– Contributing factors include heredity, obesity, prolonged standing, and pregnancy, which
increases pressure in the pelvic veins.
– This condition can impede blood flow and lead to edema, thrombosis, hemorrhage, or
ulceration.
– Treatment includes the wearing of elastic stockings and, in some cases, surgical removal of
the varicosities, after which collateral circulation is established.
– Varicose vein in the rectum or anal canal is referred to as a hemorrhoid.
– Phlebitisis any inflammation of the veins and may be caused by infection, injury, poor
circulation, or damage to valves in the veins.
 Lymphatic Disorders
– Changes in the lymphatic system often are related to infection and
may consist of inflammation and enlargement of the nodes, called
lymphadenitis, or inflammation of the vessels, called lymphangiitis.
– Obstruction of lymphatic vessels because of surgical excision or
infection results in tissue swelling, or lymphedema.
– Any neoplastic disease involving lymph nodes is termed lymphoma.
These neoplastic disorders affect the white cells found in the
lymphatic system.