Cardiovascular System Normal

ANATOMY AND PHYSIOLOGY

Heart and Heart Wall Layers

Located in the left side of the mediastinum Consists of 3 Layers: EPIcardium MYOcardium ENDOcardium EPI-MYO-ENDO

 Encases and protects the heart from trauma and infection Has 2 Layers: Parietal Pericardium Tough, fibrous outer membrane Visceral Pericardium Thin, inner layer that closely adheres to the heart Pericardial Space Between PP and VP; holds 5-20 ml of pericardial fluid Lubricates pericardial surfaces and cushions the heart

Pericardial Sac

Pulmonary valve

Left atrium

Chambers

Structures of the Heart

Atria- (2) upper chambers

Thin walled Receive blood from veins Send blood to ventricles

Aortic valve

Right atrium

Mitral valve

Ventricles- (2) lower chambers

Left ventricle

Tricuspid valve Septum

Septum
Right ventricle

Thick walled Receive blood from atria Pump blood out through arteries

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Wall that divides heart 8 into right and left halves

Valves
Valves seen from above
Pulmonary valve

Pulmonary veins Tricuspid valve

Right atrium

Mitral valve

Aortic valve

Left atrium Pulmonary valve

Chordea tendinea

Between the chambers At junctions of artery and chamber

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Prevent backflow of blood Keep blood moving in one direction

Chordae tendinease

Papillary muscle

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Heart strings Cord-like tendons Connect papillary muscles to tricuspid and mitral valves Prevent inversion of valve Papillary muscles Small muscles that anchor the cords

Structures of the Heart

brachiocephalic artery right pulmonary artery right pulmonary veins left common carotid artery left subclavian artery aorta left pulmonary artery

pulmonary trunk
superior vena cava aortic valve right atrium

left pulmonary veins

left atrium (auricle) mitral valve pulmonary valve

tricuspid valve

papillary muscle

right ventricle inferior vena cava

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left ventricle
septum
11 2006 Merriam-Webster, Inc.

Chambers of the Heart

Great Vessels of the Heart

Superior and Inferior Vena Cava Pulmonary Arteries Pulmonary Veins Aorta

ATRIOVENTRICULAR VALVES
Close at the beginning of ventricular contraction Prevents blood from flowing back in the atria from the ventricles Open when the ventricle relaxes Tricuspid Valve right side of the heart Bicuspid (mitral) Valve left side of the heart

SEMILUNAR VALVES
Prevents blood from flowing back into the ventricles during relaxation Open during ventricular contraction Close when ventricles begin to relax Pulmonic Semilunar Valve Lies between RV and PA Aortic Semilunar Valve Lies between LV and Aorta

Blood Flow through the Heart

SVC &IVC Right Atrium Tricuspid Valve Right Ventricle Pulmonary Semilunar Valve

Pulmonary Veins

Left Atrium

U
N G S
oxygenation

Bicuspid / Mitral Valve

Left Ventricle

Aortic Semilunar Valve

Aorta

Pulmonary Arteries BODY

Conduction System
Generates and transmits electrical impulses that stimulate contraction of the myocardium

 Sinoatrial Node (SA Node) Main pacemaker that initiates each heartbeat Located at the junction of SVC and RA Generates electrical impulses at 60100 times per minute Controlled by the sympathetic and parasympathetic nervous system Atrioventricular Node (AV Node) Located in the lower aspect of the atrial septum Receives electrical impulses from SA node If SA node fails, AV node can initiate 40-60 bpm

Conduction System

 Bundle of His Continuation of the AV node Right and Left bundle branches
Purkinje Fibers Diffuse network of conducting strands located beneath the ventricular endocardium Spread the wave of depolarization through the ventricles Can act as a pacemaker at 20-40 bpm when higher pacemaker fail

Coronary Arteries
Supply the capillaries of myocardium with blood Right coronary artery Supplies the RA and RV, inferior portion of the LV, posterior septal wall, SA and AV nodes Left coronary artery Left anterior descending artery Supplies blood to the anterior wall of the LV and apex of the LV Circumflex artery Supplies blood to the left atrium and the lateral and posterior surfaces of the LV

 S1

Heart Sounds

S2

1st heart sound Heard as the AV valves close Heard loudest at the apex of the heart
2nd heart sound Heard when SL valves close Heard loudest at the base of the heart

Listen to heart with stethoscope: lubb-dupp lubb: start of ventricular contraction dupp: start of ventricular relaxation

 Paradoxical Splitting Abnormal splitting of S2 Caused by early closure of pulmonic valve or delay in aortic valve closure Gallops S3 and S4

Abnormal Heart Sounds

 S3 (Ventricular Gallop) Heard if ventricular wall compliance is decreased and structures in the ventricular wall vibrate CHF, valvular regurgitation Normal in individuals younger than 30 years old S4 (Atrial Gallop) Abnormal finding Resistance to ventricular filling Cardiac hypertrophy Disease Injury to the ventricular wall Quadruple Gallop Severe heart failure

 Murmurs Reflect turbulent blood flow through normal or abnormal valves Systolic murmurs Occur between S1 and S2 Diastolic murmurs Occur between S2 and S1 Pericardial Friction Rub Sign of inflammation or infection Pericarditis, cardiac tamponade

Cardiac Output
Volume of blood in liters ejected by the heart each minute 4 7 liters/minute Cardiac Output = Heart rate/ Stroke volume

Heart Rate
The FASTER the HR, the less time the heart has for filling and the cardiac output decreases Increase in HR = increase in oxygen consumption Normal HR: 60-100 bpm Sinus Tachycardia: more than 100 bpm Sinus Bradycardia: less than 60 bpm

Stroke Volume
Amount of blood ejected by the left ventricle during each systole

Preload
Degree of myocardial fiber stretch at the end of diastole and just before contraction Determined by the amount of blood returning to the heart from both the right heart and left heart

 Pressure or resistance that the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels Amount of resistance is directly related to arterial blood pressure and the diameter of blood vessels

Afterload

Autonomic Nervous System

Sympathetic Response Release of norepinephrine increase HR and peripheral vasoconstriction Stimulation occurs when decrease in BP is detected Parasympathetic Response Release of acteylcholine decreases HR Stimulation occurs when increasein BP is detected

BP Control
When BP decreases as a result of hypovolemia, sympathetic response occurs = increase HR and BP When BP increases as a result of hypervolemia, parasympathetic response occurs = decrease HR and BP Antidiuretic hormone (vasopressin) influences BP by regulating vascular volume Increase in blood volume = decrease ADH = increase in diuresis (ihi) = decrease BP Decrease in blood volume = increase ADH = decrease in diuresis (ihi) = increase BP

 Renin, a vasoconstrictor, causes BP to increase Renin converts angiotensin to angiotensin I; angiotensin I is then converted to angiotensin II in the lungs Angiotensin II stimulates release of aldosterone, which promotes sodium and water retention by the kidneys, thus, increase blood volume and BP

 Arteries Blood passes AWAY from the heart Convey highly oxygenated blood Veins Carry deoxygenated blood TO the heart Capillaries Allow exchange of fluid and nutrients between blood and interstitial spaces Lymphatics Drain the tissues and return tissue fluid to the blood

Vascular System

Blood vessels have different structures: Arteries and Arterioles

Epithelial cells of arteries/veins are surrounded by smooth muscle and connective tissue Arteries are very elastic (a property of connective tissue), to accommodate very high blood pressure leaving the heart Arterioles are less elastic and have more smooth muscle, allowing constriction/dilation

Blood vessels have different structures: Veins

Veins have thinner walls and less muscle than arteries (lower blood pressure) Valves in veins prevent the backflow of blood Blood flow is aided by muscular contractions

Types of Circulation

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Cardiovascular Circuits
Pulmonary Circuit
Lung
Pulmonary artery Right atrium Vena cava Right ventricle Pulmonary vein Left atrium Aorta

Left ventricle

Systemic Circuit
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Pulmonary Circulation
Takes place on the right side of the heart. Pumps blood low in oxygen to the lungs to pick up oxygen and return to heart

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Systemic Circulation
Takes place on left side of heart Oxygenated blood is pumped to the body cells thru the aorta and other arteries Blood low in oxygen returns to the heart
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The coronary circulation consists of the blood vessels that supply blood to, and remove blood from the heart muscle itself. Although blood fills the chambers of the heart, the muscle tissue of the heart is so thick that it requires coronary blood vessels to deliver blood deep into the myocardium.

Coronary Circulation

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Coronary Circulation

The vessels that supply blood high in oxygen to the myocardium are known as coronary arteries.
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Hepatic Portal System

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Hepatic Portal System

The liver is the only digestive organ drained by the inferior vena cava - blood leaving the capillary beds supplied by the celiac and superior and inferior mesenteric arteries flows into the veins of the hepatic portal system - a blood vessel connecting 2 capillary beds is a portal vessel and the network is a portal system Venous blood that absorbs nutrients from the small intestine, parts of the large intestine, stomach, and pancreas flows directly to the liver - regulates levels of nutrients and amino acids 51 the circulating blood in

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Fetal Circulation

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Oxygenated blood enters the umbilical vein from the placenta

Enters ductus venosus Passes through inferior venacava Enters the right atrium Enters the foramen ovale Goes to the left atrium Passes through left ventricle Flows to ascending aorta to supply nourishment to the brain and upper extremeties Enters superior vena cava Goes to right atrium

Enters the right ventricle

Enters pulmonary artery with some blood going to the lungs to supply oxygen and nourishment
Flows to ductus arteriosus

Enters descending aorta ( some blood going to the lower extremeties)

Enters hypogastric arteries Goes back to the placenta

Special Structures in Fetal Circulation

Placenta Where gas exchange takes place during fetal life Umbilical Arteries Carry unoxygenated blood from the fetus to placenta Umbilical Vein Brings oxygenated blood coming from the placenta to the fetus Foramen Ovale Connects the left and right atrium. It pushes blood from the right atrium to the left atrium so that blood can be supplied to brain, heart and kidney

 Ductus Venosus - Carry oxygenated blood from umbilical vein to inferior venacava, bypassing fetal liver Ductus Arteriosus - Carry oxygenated blood from pulmonary artery to aorta, bypassing fetal lungs.

Diagnostic Tests and Procedures

Cardiac Enzymes

CK-MB (Creatine kinase, myocardial muscle)

Reflects cell trauma Elevation indicates myocardial damage Elevation occurs within 4-6 hours and peaks 18-24 hours following an acute ischemic attack Normal value is 0-5% of the total Total CK is 26-174 units/L Isoenzymes CK MB Cardiac muscle CK MM Skeletal muscle CK BB Brain tissue

Cardiac Enzymes Lactate dehydrogenase (LDH)

Elevation occurs 24 hours following MI and peak in 48-72 hours Normally LDH 1 is lower than LDH 2. if opposite, the pattern is flipped indicating myocardial necrosis Normal: 140-280 IU/L

Cardiac Enzymes

Troponin

Composed of 3 proteins: Troponin C Cardiac Troponin I Cardiac Troponin T Trop I: lower than 0.6 ng/mL Rises within 3 hours and persists for up to 7 days Higher than 1.5 ng/mL consistent with MI Trop T: 0-0.2 ng/mL Any rise indicate myocardial cell damage Commonly used in the Philippine setting to detect MI

Cardiac Enzymes

Myoglobin

Oxygen binding protein found in cardiac and skeletal muscle Level rises within 1 hour after cell death, peaks in 4-6 hours and returns to normal within 24-36 hours Normal: lower than 90 mcg/L Elevation could indicate MI

Other Normal Values

Creatine kinase CK Male 55-170U/L Female 30-135 U/L CK - MB (isoenzyme) 0-7 U/L Lactic dehydrogenase (LDH) LDH1 22%-36% LDH2 35%-46% LDH313%-26% LDH4 3%-10% LDH5 2%-9%

Complete Blood Count

RBC decreases in RHD and endocarditis; and increases in conditions with inadequate tissue oxxygenation WBC increases in infectious and inflammatory diseases of the heart and after MI Elevated hematocrit level can result from vascular volume depletion (hypovolemia) Decrease in Hemoglobin (hgb) and Hematocrit (hct) can indicate anemia

Red blood cell count Men 4.7-6.1 million/mm3 Women 4.2-5.4 million/mm3 Infants and children 3.8-5.5 million/mm3 Newborns 4.8-7.1 million/mm3 White blood cell count Adults and children greater than two years of age 5,000-10,000/cm3 Children less than two years 6,200-17,000/mm3 Newborns 9000-30,000/mm3 Hematocrit Men 42-52% Women 37-47% (pregnancy>33%) Children 31-43% Infants 30-40% Newborns 44-64% Hemoglobin Men 13.5-18.0 g/dl Women 12-16 g/dl (pregnancy >11 g/dl) Children 11-16 g/dl Infants 10-15 g/dl Newborns 14-24 g/dl

Coagulation Studies
An increase in coagulation factors can occur during and after MI which places the client at risk for thrombophlebitis and extension of clots in the coronary arteries aPTT PT Clotting time Platelet count

 Activated Partial Thromboplastin Time (aPTT)

Measures the amount of time it takes in seconds for recalcified citrated plasma to clot after partial thrmboplastin is added to it Used to monitor heparin therapy and screen for coagulation studies Normal: 20-36 seconds If value is prolonged, initiate bleeding precautions

 Prothrombin time (PT)

Prothrombin is a vitamin K-dependent protein produced by the liver necessary for clot formation Measures the amount of time it takes in seconds for clot formation Monitor warfarin therapy, vitamin K deficiency, DIC Normal: PT value within 2 seconds of the control (plus or minus) PT 9.6 11.8 seconds MALE PT 9.5 11.3 seconds FEMALE Diet high in green leafy vegetables can increase vitamin K, which shortens the PT PT longer than 30 seconds: bleeding precaution

 Clotting time Time required for the interaction of all factors involved in the clotting process Normal: 8-15 minutes Platelet count Normal: 150,000 400,000 cells/ mm If lower: bleeding precaution

Lipid Assessment
Total cholesterol: less than 200 mg/dL Triglycerides: less than 200 mg/dL high density lipoprotein (HDL): 3070 mg/dL Good cholesterol low density lipoprotein (LDL): less than 130 mg/dL Elevated lipid assessment increases the risk of coronary artery disease

http://images.medscape.com/pi/editorial/cmecircle/2004/3598/images/libby/slide005.gif

Copyright 2005 Dr. Salme Taagepera, All rights reserved.

Bad v. Good cholesterol!

Electrolytes
Sodium 135-145 mEq/L Potassium 3.5 5 mEq/L Calcium 8.6 10 mg/dL or 4 5 mEq/L Magnesium 1.6 2.6 mg/dL Phosphorus 2.7 4.5 mg/dL

 Potassium Hypokalemia: cardiac instability, dysrhythmias T wave inversion, U wave, ST depression Hyperkalemia: ventricular dysrhythmias Tall peaked T waves, prolonged PR intervals, flat P waves

 Sodium Decreases with the use of diuretics Increases in heart failure, indicating water excess Calcium Hypocalcemia: ventricular dysrhythmias, cardiac arrest Hypercalcemia: AV block, tachy/bradycardia, cardiac arrest

 Phosphorus Should be interpreted with calcium levels because kidneys retain or excrete one electrolyte in an inverse relationship Magnesium Low: ventricular tachycardia and fibrillation; tall T waves, depressed ST segments High: muscle weakness, hypotension and bradycardia, prolonged PR, widened QRS

 Blood Urea Nitrogen Elevated in heart disorders that adversely affect renal circulation such as heart failure and cardiogenic shock Normal: 8-25 mg/dL Blood Glucose Elevated in acute cardiac episodes Normal FBS: 70-110 mg/dL

B-type natriuretic peptide (BNP)

Released in response to ventricular and atrial stretch Marker for CHF Normal: should be lower than 100 pg/mL The higher the level, the more severe CHF is

Chest X-ray
Done to determine the size, silhouette and position of the heart Remove jewelry

Echocardiography (ECG)
Noninvasive test that records the electrical activity of the heart Useful for detecting cardiac dysrhythmias, location and extent of MI and evaluation of cardiac medications Client should lie still, breathe normally No electrical shock can occur

Holter Monitoring
ECG tracing over a period of 24 hours or more as the client performs ADLs Client wears a Holter monitor Avoid tub baths and showering

Echocardiography
Noninvasive Based on the principle of ultrasound Evaluates structural and functional changes of the heart Client should lie still and breathe normally

Exercise testing (Stress test)

Studies the heart during activity and evaluates coronary artery disease Treadmill testing is the most commonly used If the client is unable to tolerate exercise, IV infusion of dipyridamole (Persantine), dobutamine or adenosine is given to dilate the coronary arteries Can be invasive if used with radionuclide testing

Client Education
Adequate rest night before procedure Eat a light meal 1-2 hours Avoid smoking, alcohol and caffeine Meds withheld prior the procedure: Theophylline 12 hours Beta blockers and calcium channel blockers 24 hrs POST: Avoid hot bath 1-2 hours after

Digital Subtraction Angiography

Combine x ray with fluoroscopy for visualization of the cardiovascular system Contrast medium (dye) is injected Assess allergies to seafood, iodine Pre-medicate with antihistamine and steroids to avoid untoward reactions POST Monitor VS and injection site for bleeding

Magnetic Resonance Imaging (MRI)

Produces images of the heart and great vessels through interaction of magnetic fields Provides info on chamber size, thickness, valves and blood flow through great vessels and coronary arteries CONTRA: Pacemaker and other implanted items Metallic objects Claustrophobia

Cardiac Catheterization
Invasive test involving insertion of a catheter into the heart and surrounding vessels Femoral vein: entry point

 Consent Assess allergies to dye Seafood, iodine Withhold solid food 6-8 hours and liquid 4 hours to prevent vomiting and aspiration Document clients height and weight Baseline VS and peripheral pulses Local anesthetic before catheter insertion Need to lie still on a hard table for 2 hours Client may feel a warm, flushed sensation, a desire to cough and palpitations as the dye is injected

PRE

 Prepare the insertion site by shaving and cleaning with antiseptic solution Insert IV line as prescribed Withhold Metformin 48hrs prior

 Monitor VS and cardiac rhythm at least every 30 minutes for 2 hours initially If chest pain occurs, notify the physician Monitor extremity of insertion site at least every 30 minutes for 2 hours Peripheral pulses Color Warmth Sensation Notify physician Extremity is cool, pale, cyanotic, loss of peripheral pulse, hematoma

POST

 Keep the leg (insertion site) extended and straight 4-6 hours to prevent arterial occlusion Strict bed rest 6-12 hours; may turn side to side Encourage fluid intake to promote renal excretion of dye

Central Venous Pressure

CVP: pressure under which blood is returned to the SVC and RA Normal CVP: 3-8 mmHg Elevated: increase in blood volume due to sodium and water retention, renal failure, excess IV fluids Decreased: hypovolemia, hemorrhage, severe vasodilation with blood pooling in the extremities

 Client should be in supine, HOB 45 degrees Activity increases intrathoracic pressure (false high result) Zero point of the transducer should be at the level of the right atrium Midaxillary line at the 4th intercostal space

Therapeutic Management

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Invasive, nonsurgical technique One or more arteries are dilated with a balloon catheter to open the vessel lumen and improve arterial blood flow Client can experience re-occlusion after the procedure Complications:
Arterial rupture Immobilization of plaque Spasm MI

PRE
NPO post midnight Informed consent, allergy assessment, hold metformin Prepare the groin area with antiseptic soap and shave Assess VS and peripheral pulses Instruct client to report chest pain during balloon inflation

POST
Monitor VS, pulses Keep the leg (insertion site) extended and straight 6-8 hours Bed rest Administer anticoagulants (heparin) to prevent thrombus formation Increase OFI to excrete dye

 Percutaneous coronary intervention stenting.flv 3D stent animation

Angioplasty
Laser probe is inserted to the affected artery Heat from the laser vaporizes the plaque Similar care as PTCA

Coronary Artery Stents

Used in conjunction with PTCA To provide a supportive scaffold to eliminate the risk of acute coronary vessel closure and to improve long term patency of the vessel Balloon catheter bearing the stent is inserted into the coronary artery and positioned at the site of occlusion Balloon inflation deploys the stent When placed in the coronary artery, stent reopens the blocked artery

PRE and POST

Similar with PTCA Client is placed on antiplatelet therapy for several months after the procedure because of acute thrombosis Clopidogrel (Plavix) Aspirin Bleeding precaution

Atherectomy
Removes plaque from a coronary artery by the use of a cutting chamber on the inserted catheter or a rotating blade that pulverizes the plaque Used to improve blood flow to ischemic limbs in individuals with peripheral arterial disease Care similar to PTCA

Coronary Artery Bypass Graft

Occluded arteries are bypassed with clients own blood vessels Saphenous veins, internal mammary artery may be used to bypass Performed when client does not respond to medical management or when vessels are severely occluded

 Heart bypass.flv Beating heart surgery.flv