KARDIOVASKULAR

ALTJE J. TULANDI, BSN

DIKLAT RS. JANTUNG DAN PEMBULUH
 What is the position of the heart within the thorax?

• Middle of the
mediastinum
• 2/3 to left of midline
• Between the two pleural
sacs
• Heart is connected to
major blood vessels &
these vessels are in
turn connected to
smaller vessels

PKKvTD
Referensi: Marea Reading, St’ Vincent Hospital Sidney Australia
• Pointed end = apex
• Anteriorally apex is in
the 5th ICS, about 7.5
– 8 cms (3 inches)
from the midline
• Base of the heart 3rd
ICS
• Major function..
• To pump blood, it acts
as a servant to the
body
2. What is the weight and size of a normal
adult heart?

• 250-400 grams (male approx. 300-350,

female 250-300 grams)

• 12 cms (5 inches) long x 9 cm (3½ inches)

wide x 6 cm thick

• Shape: about the size of a clinched fist

3. Describe the structure and function of the
fibrous pericardium (Parietal)

• Thick fibrous layer –

not attached to the
heart, but is to the
large vessels
entering & leaving
the heart, to
diaphragm & to the
inside of the sternal
wall of thorax, also
adheres to parietal
• Function – protection pleura
Surface anatomy jantung
 Anatomi sistem konduksi jantung
• Sinus node
• Internodal dan interatrial conduction
• Atrioventricular node
• Bundle His
• Bundle branch
• Serabut Purkinje
• The heart & blood
vessels form a closed
system of tubes that
carry blood to all parts
of the body

• The heart consists of

two side-by-side
pumps that force
blood through the
blood vessels
Attached to the fibrous pericardium is the
serous pericardium

• Fibrous
pericardium
• Serous
pericardium
- parietal layer
- visceral layer
• Myocardium
 4.
There are 2 layers of serous pericardium
The visceral layer or epicardium adheres
to the heart and the parietal layer
adheres the fibrous pericardium
There are a few drops of fluid between
the layers of the serous pericardium
Its main function is
lubrication
 Endocardium
(endothelial layer
covers trabeculae)

• Layers of the heart

• Fibrous pericardium
• Serous pericardium
- parietal layer (lines fibrous layer)
- visceral layer (epicardium)
• Myocardium
 Summary layers of the heart

(Porth,1998)
 Endocardium (endothelial
layer covers trabeculae)

• The edocardium is
continuous with the
tunica intima of blood
vessels.
• The endocardium is
smooth which
6. enables it to perform
its main function of
facilitating blood flow
7. What are trabeculations?
• Ridges inside the
chambers of the heart

• They are formed by

the muscle bundles
entering the
chambers
8. State the names and locations of the cardiac
valves

• 1. Mitral (LA & LV)

2 leaflets
• Tricuspid (RA & RV)
3 leaflets

(A-V valves)
• Aortic – (LV & aorta)
• Pulmonary – (RV &
PA) – 3 leaflets
The Cardiac Chambers (Thickness of its walls)

• Reservoir chambers

• Little force of
contraction needed to
pump blood to
ventricles in atrial
systole
Cardiac Chambers (cont’d)
• Pumps to low-
resistance low-
pressure pulmonary
system .. 25 mmHg

• Pumps to high-
resistance high-
pressure arterial
system
• Peak pumping
pressure.. 120 mmHg
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9. What is the major function of cardiac valves?

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To facilitate forward flow & prevent backward flow

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 10. Write one sentence about each of the following
features of the atrioventricular valves

i) Valve cusps
Fibrous connective tissue with a
covering of endothelium
ii) Chordae tendinae
Fibrous cords which are attached to the
valve cusps & enter into papillary
muscles
iii) Papillary muscles
Muscle bundles – formed from muscle
bundles, attached to chordae tendinae

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iv) Opening of AV Valves

•  pressure in atria,
secondary to venous
return  opening of AV
valves
v) Closure of A-V Valves

• Atrial systole  
ventricular
pressure 
backward flow of
blood in a circular
motion behind
valve cusps 
closure of A-V
valves
vi) Prevention of opening of the A-V valves
during ventricular systole

• As the ventricles
contract, the papillary
muscles contract and
shorten, thus pulling
the chordae tendinae
and valve cusps
downwards &
preventing herniation
back into atria

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11. i) How do the cusps of the semi-lunar valves differ from
the cusps of the A-V valves?

• Semi-lunar valves are

thick & fibrous
• Attached to the
outflow tracks only by
their bases
• They do not have the
supporting structures
of the A-V valves

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11. ii) What feature prevents regurgitation
of blood through the semi-lunar valves?

• Their fibrous strength

& the close union of
the closed cusps
• The aortic cusps are
thicker than the
pulmonary cusps as
they are exposed to
higher pressure

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ASSESSMENT

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12. What produces the
i) First heart
sound?

Closure of the
A-V Valves

LUBB

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ii) Second heart sound?

• Closure of the
semi-lunar
valves

• DUBB

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 13. What causes – i) A third heart sound?
• Can be a normal
finding in people up to
age 30, over, it is
considered pathologic
• Means impaired
ventricular function
• Thought to originate in
ventricle in early
diastole where there is
rapid ventricular filling
with lack of
Ken-tuc-ky distensibility of
1 2 3 ventricleS3
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 ii) What causes a fourth heart sound?
• Atrial sound –
• results from atrial
contraction during
diastolic filling, normally
atrial systole is silent, but
when ventricular filling
pressure is high, the atria
produce an extra sound
as they contract against
greater ventricular
resistance
• Ten – nes – see
• Not specific for HF, also
4 1 2
occurs in H/T, AS, CM
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Lub-dub-ta ta-lub-dub

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14. What are murmurs & what are they caused by?

• Result from abnormalities in blood flow

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 1. RA
2. RV
3. LA
4. LV
5. TV
6. MV
7. Chordae
tendinae
8. Papillary
muscles
9. Trabeculat
-ions
10. AV
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 12 PV
13 SVC
14 IVC
15 Inominate
(bracheocephalic
artery)
16 L common
carotid
17 L subclavian
18 Arch of Aorta
19 P Artery
20 P veins
21 Descending
Aorta
22 Ligamentum
arteriosium
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16. Draw a simple diagram of the conduction
system . Label each part

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 17. What is an action potential?

• Electrical changes in the cell membrane

 • ECG of the cell
• Compare ECG to
action potential
• Cells in heart are
different, e.g.
specialized
conducting cells &
cells which are for
contraction &
• Because they have
different
characteristics they
have different action
potential
appearances

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 18. Draw an action potential of
i) pacemaker cell ii) myocardial cell
automatic non-automatic

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19. What are the differences between the action potentials
you have drawn?

• Myocardial cell (Fast)

• Resting – 90 mvs
• Threshold -60 to -70
• Dependant on Na+ to
start it
• Can conduct, but not
spontaneously
depolarize
• Phase 4 constant
(flat)
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Pacemaker cell slow (automatic)

• - 40 to – 60 (i.e. less to
start with
• Got a gradual rather than
a big slope
• Not dependant on Na+ to
start it off
• Rather Ca++
• Phase 4 is unstable
• Spontaneously
depolarizes, once
threshold is reached
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 20. Define the following terms -

i) depolarization
- means that the inside i.e. the interior of
the cells becomes less negative i.e. the
change or taking away from the normal
polarity – taking away of that –ive
charge inside of the cell. The action
potential goes  20 moves from -90 mVs
in myocardial cells

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 Terms (cont’d)
ii) Repolarization
means the return of the normal charge,
i.e. return of the membrane potential
toward the original negative voltage after
depolarization

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iii) Refractory Period
• The electrical resting
period of the heart.
• Once it goes through
the phase of
depolarization it is
called the absolute
refractory period i.e. it
is insensitive to any
sort of stimulus
• As it depolarizes 
relative refractory
period

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21. What is the dominant pacemaker of the
heart & what is its intrinsic rate?

- SA node 60 – 100/min

22. Name two other possible pacemakers

& state their intrinsic rates

- AV node 40-60/min
- Purkinje fibers 20-40/min

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23. The autonomic nervous system exerts control over the
heart rate & contractility. Which division is usually
dominant?

• Parasympathetic

24. What effect would

an increase in
sympathetic activity
have on the rate &
contractility of the
heart?

Increase
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25. Why is the electrical impulse delayed at
the AV node?

To allow time for ventricular filling

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26. State the names & origins of the three main coronary
arteries

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KD3-SEPT.2010 (Porth, 1998)
27. Label the diagram

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28. During what phase of the cardiac cycle does
coronary filling occur?

- during diastole

29. The right ventricle is usually supplied

by…
…. RCA

30. The A-V node is supplied by..

.. Nodal artery - RCA 90% (Right dominant}
- LCx 10%

31. The sinus node is supplied by..

… RCA – sinus node
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artery
32. An inferior infarct is usually caused by an
occlusion of which coronary artery?

• Right coronary artery

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33. An anteroseptal infarct is usually caused by
occlusion of which coronary artery?

• Branch of left
anterior
descending

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34. What is meant by the term “dominance” when
used to describe coronary anatomy?

• 85-90% of population have RCA

dominance which means that the postero-
inferior aspect of the heart is supplied by
RCA
• 10-15% of population the LCx is
responsible for supply to much of the
postero-inferior left ventricular wall.
Therefore dominant In these people the
RCA is relatively small, the LCx larger

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35. Write one sentence about the venous system
of the heart

• Follow
coronary
arteries
approx. –
drain 
coronary
sinus  right
atrium

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 36. What are collateral vessels?

• Extra connections
• As in other beds, coronary circulation is comprised of
arteries, capillaries & veins
• Some veins drain directlyKD3-SEPT.2010
into ventricles.
 37. List the four characteristics of cardiac
muscle
• Automaticity – ability to initiate an impulse
• Conductivity – ability to transmit an
impulse
• Contractility – ability to contract in
response to a stimulus
• Excitability – ability to respond & initiate an
impulse
• Refractoriness – inability to respond
following depolarization

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38. Compare and contrast the structure of arteries
and veins
Arteries Veins
Adventitia White fibrous layer- White fibrous
thick –causes artery tissue - thinner
to stand open
Elastic & white As for arteries,
Media fibrous (smooth but thinner layer
muscle) allows
dilation
Endothelial layer Same in
Intima (simple squamous) arteries and
in contact with blood veins
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lumen lumen
Artery KD3-SEPT.2010
Vein
• One of my students once wrote:
• There are 3 kinds of blood vessels
• Arteries, vanes & caterpillars
• Blood flows down one leg & up the other

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 Endothelial lining
(tunica intima)
Having more
Elastic tissue than} Tunica media
•
Muscle fibres }
The aorta is a PRESSURE
REGULATOR

Fibrous coat (tunica adventitia)

AORTA
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39. How do arterioles differ in structure from
arteries?
• Mostly muscle
• Arterioles regulate the
distribution of blood to
tissues according to
demand e.g.  the
supply to voluntary
muscles during
exercise or to gut
during digestion
• Arterioles deliver
blood to capillaries
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 40. Describe the structure of capillaries
• Consist of one (single) layer of endothelial
cells
• A semi-permeable membrane allowing
free passage of gases & solutes
• In inflammatory conditions, capillary
permeability is ed, & red & white cells in
great numbers leave the capillaries

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 41. What are the main functions of -
• Arteries?
Distributary (large arteries are referred to
as elastic (conducting) & medium sized are
called muscular (distributing) arteries
• Arterioles?
Also distributary (they deliver blood to
capillaries) through constriction & dilation
they assume a key role in regulating blood
flow from arteries  capillaries…hence

important in control of B/P

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 What are the main functions (cont’d)

• Veins?
Collectors and reservoirs – reservoirs i.e.
they can expand to take a large volume of
blood – they contain valves to prevent
back flow

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 Functions (cont’d)
• Capillaries
Transport of essential materials to tissues
– removal of wastes

(Total cross-sections area is 800 times

that of aorta)

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42. What is meant by the term “haemodynamic”?
• The study of blood flow

• What determines blood flow? Pressure

difference & resistance

• Blood flows from regions of higher pressure to

regions of lower pressure. The mean (av)
pressure in aorta 100 mmHg. This pressure
continually es rapidly through the arterial
system & more slowly through the venous
system

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• Because of continuous drop in pressure,
blood flows from aorta (100 mmHg), to
arteries (100-40 mmHg) to arterioles (40-
25 mmHg) to capillaries (25-12 mmHg) to
venules (12-18 mmHg) to veins 10-
5mmHg to Vena Cavae (2 mmHg) to RA 0
mmHg

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• Resistance also aids
flow of blood… when
blood leaves
capillaries, it enters
venules & veins which
are larger in diameter • Contraction of
&  offer less skeletal muscles
resistance to flow around veins helps
drive blood toward the
heart

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43. Define the following terms -

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 - blood pressure
• Refers to the pressure in arteries exerted
by the LV when it undergoes systole & the
pressure remaining in the arteries when
the ventricle is in diastole

• Systolic pressure – the pressure with the

heart’s contraction ie the highest pressure

• Diastolic pressure – the lowerest pressure

ie the pressure when the heart is relaxing
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• Pulse pressure

The difference between systolic & diastolic

pressure
• NB.. The PP indicates how much pressure the
LV is able to generate in overcoming the outflow
resistance in the aorta
• Systolic & diastolic pressures becoming closer
together is a good indication that the CO is
falling e.g. PP < 40 mmHg, the ventricle maybe
weakening  watch for clinical signs of  CO

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• Mean pressure
Average…
1/3 pulse pressure +
diastolic pressure

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44. What is the normal pressure of blood in the -

• R Atrium -0-5 mmHg • L atrium 3-12 mmHg

• R Ventricle 15-25
<5 • L ventricle 120
• Pulmonary artery 10
15-25 • Aorta 120
3-12 70

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45) Define vascular resistance

Impedance to blood flow – peripheral

resistance is offered to the passage of
blood from the arterial to venous side of
the system chiefly by partial constriction
“Tone” of smooth muscle in walls of
arterioles

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46. What factors influence resistance to
blood flow?
- vessel length
- vessel diameter
- viscosity
NB.. Any alteration in the total amount or
viscosity of blood will affect blood
pressure

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47. Which blood vessels in the systemic
circulation have the greatest influence on
resistance?

Arterioles

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48. Blood pressures in different parts of systemic circulatory system

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• Arterioles control B/P by changing their
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Pressure & Volume distribution in systemic circulation. The
graphs show the inverse relation between internal pressure
& volume in different portions of the circulatory system

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• Aorta & large arteries 120/80 mean 100
mmHg remains constant until blood
reaches arterioles – smaller diameter,
resistance ed enough to reduce mean
B/P 85 mmHg
• When blood crosses arterioles to
capillaries, resistance causes mean B/P to
fall 35 mmHg – low pressure essential for
optimum exchange of nutrients & gases in
capillary bed
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• B/P only 15 mmHg when blood begins to
return to heart, es further despite a
steady  in venous diameter
• Why?? Because many veins are collapsed
much of the time by pressure from
surrounding tissues
• Venules – 15 mmHg
• Small veins – 6 mmHg
• Large veins – 2 mmHg
• Venae cavae – 1 mmHg
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 49. What are the two mechanisms that facilitate
venous return to the heart?

• Respiration
a) Intrathoracic pressure - is always
lower than atmosphere. This negative
pressure exerts a ‘suctioning’ pull
which tends to draw column of blood
upwards
b) Descent of Diaphragm in inspiration s
intra-abdominal pressure & forces blood
upwards  veins
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 “Muscular Pump” (muscular contraction)

Contractions of skeletal muscles help to squeeze veins & move

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blood upwards
50. On diagram follow flow of oxygenated blood with a blue
arrow & deoxygenated blood with red arrow

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51. Define preload

• Refers to the filling

pressure distending
the ventricles prior to
systole
• = LVEDP i.e. the load
on the ventricle pre-
systole
• Preload  in CHF & 
by diuretics &
venodilators, such as
nitroglycerine
(Anginine)
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 • To remember
preload –
• Think of a
balloon filling with
air

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52. Define Afterload

• The force the ventricles

must overcome to eject
their volume = load after
the ventricles
• Or the resistance
imposed on the LV during
systolic contraction
• Normally represented by
aortic diastolic pressure
•  Systemic B/P
•  Arterial vasodilators eg
nitroprusside or
hydralazine
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53. What is stroke volume? What are its
determinants?
The volume of blood pumped by the
ventricle per beat
• The determinants:
- preload
- afterload
- contractility
54. What is cardiac output? What are its
determinants?
- CO is the amount of blood ejected from the
LV (or RV) into aorta (or pulmonary artery)
each minute
- determined by SV x HR
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 55. What is Frank-Starling’s Law of the heart?

• The more the heart is stretched during

diastole – the greater the S.V. & C.O.
(within physiological limits)

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56. Draw in purple what would happen if myocardial contractility is
increased & in blue if it is decreased

• The normal heart *  contractility *  contractility

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Afterload affects the speed & extent of shortening,
in the absence of pathological change the aortic
pressure constitutes the afterload

•  afterload   S.V. & C.O.

•  afterload   S.V. & C.O.

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57. Complete the following flow diagram to
illustrate the cardiac cycle. Include the
following components –
- Electrical events
(depolarization/repolarization)
- Mechanical events (contraction/relaxation)
- Pressure differences
(increased/decreased pressure)
- Audible events (heart sounds)

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58

delay AV node

• Closure AV valves S1
depolarization vent


ventricular contraction
repolarization

 aortic & PA pressure

Closure of semi-lunar valves
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Important to have some understanding of the sequence of
events & “chain reaction” involved

• Firstly
• 70% of ventricular filling
occurs during diastole by
passive movement of
blood due to pressure
caused by constant
venous return

• PVs & S & IVC constantly

delivering blood to L & R
atria
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 As noted
• An electrical impulse
is initiated by sinus
node (P wave)
• Depolarization of
atrial muscle follows
&
• Then contraction of
the atria
• Thus completing
ventricular filling

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 • The impulse is slightly
delayed at the A-V
node to allow time for
this filling to occur

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 • The ventricular
pressure now
exceeds the atrial
pressure
• Which causes closure
of the AV valves & S1

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 • The  pressure in the
ventricles
mechanically results
in increased tension
of the muscular
ventricular walls;
• It also causes the
semi-lunar valves to
open

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 • And blood is ejected
from right & left
ventricles to
• Ventricular pulmonary artery &
depolarization (QRS) aorta respectively
causes contraction of
ventricles

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• There is a fall in
ventricular pressure &
obviously a rise in
pulmonary artery &
aortic pressures
• The ventricular
muscles relaxes &
pressure of blood
causes closure of
semi-lunar valves &
S2
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• During relaxation the muscle cells return to
their resting state, i.e. repolarization takes
place
• This causes the T wave on the ECG

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• Arterial pressure = cardiac output x total
peripheral resistance ie. Cardiac output &
total peripheral resistance are the
determinants of blood pressure. There
are many regulatory mechanisms
59. Briefly describe the role of each of the
following in the regulation of blood
pressure -
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• The vasomotor centre
• – located in the medulla – controls the
amount of vasoconstriction and
vasodilatation of the blood vessels

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 -Baroreceptors
• Pressure sensitive
nerve receptors
• Located in the arch of
aorta & the carotid
sinuses
•  stretch of receptors
  action potentials
 vasomotor centre
  B/P &  stretch
gives the opposite
result

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 Pressure (stretched baroreceptors)

Medualla
Depressor response

Blood Vessels -  vasoconstriction

-  venomotor tone
Heart -  rate
-  contractile strength

  pressure
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 pressure ( stretch of receptors)

medulla
pressor reflex

Blood vessels -  vasoconstriction

-  venomotor tone
Heart -  rate
-  contractile strength

  pressure
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 Renal Regulators
• Renin/Angiotensin System
 B.P  juxtaglomerular cells release
RENIN  acts on plasma proteins

Enzyme from lungs  Angiotensin 1

Angiotensin 11
(potent vasoconstrictor)

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Renin/Angiotensin System (cont’d)
• Angiotensin also
i) Acts directly on kidneys 
 secretion of salt & H2O

ii) Stimulates adrenal cortex to release

Aldosterone   secretion of Na+ + H2O
  blood volume    B.P.

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Renin-Angiotensin system
•  B/P   renin

• Renin acts on a plasma

protein  angiotensin1
converting enzyme from
the lung  angiotensin II
produces
vasoconstriction &  salt
& water retention through
direct action on kidneys &
through  aldosterone
secretion by adrenal
cortex
•   B/P
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 ADH
• (Chemicals)  B/P   release of ADH
from posterior pituitary gland
• ADH  vasoconstriction   B/P 
acts on kidneys to   excretion of H2O2

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