III.

ANATOMY AND PHYSIOLOGY CARDIOVASCULAR SYSTEM The vascular system is a vast network of vessels through which blood circulates in the body. The major functions of the cardiovascular system- delivery of nutrients to tissues and removal of metabolic wastes- are accomplished in the capillaries. Blood leaving the capillaries follows progressively larger venules and veins on its way back to the atria. The anatomic arrangement of blood vessels allows regulation of blood vessels allows regulation of blood flow delivery can be proportional to the tissues metabolic needs. Because the volume of the blood flowing from the arteries to the capillaries is a major determinant of blood pressure control systems to include control of arteriolar diameter by the sympathetic nervous system and circulating hormones. General Blood Vessel Structure The anatomic division of blood vessels into arteries, arterioles, capillaries, venules and veins is based on the presence of three histologic layers. 1. The tunica intima (innermost layer) consists of the endothelial cells that separate the blood from extravascular spaces. 2. The tunica media (middle layer) consists of elastic connective tissue and smooth muscles. Particularly in the aorta and large arteries, the elastic tissue contributes to the shape of the arterial pressure pulse. 3. The tunica adventitia (outermost layer) consists of relatively thin layer of connective tissue that provides shape for the blood vessels. Pulmonary circulation The Pulmonary circulation is the portion of the cardiovascular system which transports oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. Oxygen deprived blood from the vena cava enters the right atrium of the heart and flows through the tricuspid valve into the right ventricle, from which it is pumped through the pulmonary semilunar valve into the pulmonary arteries which go to the lungs. Pulmonary veins return the now oxygen-rich blood to the heart, where it enters the left atrium before

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flowing through the mitral valve into the left ventricle. Then, oxygen-rich blood from the left ventricle is pumped out via the aorta, and on to the rest of the body. Systemic circulation Systemic circulation is the portion of the cardiovascular system which transports oxygenated blood away from the heart, to the rest of the body, and returns oxygen-depleted blood back to the heart. Systemic circulation is, distance-wise, much longer than pulmonary circulation, transporting blood to every part of the body. Coronary circulation The coronary circulatory system provides a blood supply to the heart. As it provides oxygenated blood to the heart, it is by definition a part of the systemic circulatory system. Heart

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The human heart, through rhythmic contraction, provides the pressure necessary to propel blood through the body. The heart pumps oxygenated blood to the body and deoxygenated blood to the lungs. In the human heart there is one atrium and one ventricle for each circulation, and with both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed into the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lungs as well as the pulmonary vein which is passed into the strong left ventricle to be pumped through the aorta to the different organs of the body. Functions of the Heart A. Electrophysiologic Properties a. Excitability The ability of the cardiac muscle cells to depolarize in response to a stimulus- excitability- is influenced by hormones, electrolytes, nutrition, oxygen supply, medications, infection, and autonomic nerve activity. b. Automaticity (Rhythmicity)

The ability of cardiac pacemaker cells to initiate an impulse spontaneously and repetitively, without external neurohormonal control is known as automacity. The sinoatrial node (SA) pacemaker cells have the highest rate of automaticity of all cardiac cells and thus govern the heart rate. SA node cell automaticity is due to changes in ionic permeability of the membrane. c. Contractility The heart muscle is composed of long, narrow cells or fibers. Cardiac muscle fibers, like striated skeletal muscles, contain myofibrils, Z bands, sarcomeres, sarcolemmas, sarcoplasm, and sarcoplasmic reticulum. Contraction results from the same sliding filament mechanism described for skeletal muscle. d. Conductivity

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Conductivity is the ability of heart muscle fibers to propagate electrical impulses along and across cell membranes. Cardiac conducton is a sequential depolarization of the following: B. Cardiac Cycle a. Atrial systole Depolarizaton of the SA node spreads through the atria, both in cell-to-cell manner and by using the internodal and interatrial pathways. Depolarization of the atrial cells (P wave of the ECG) allows calcium entry, followed by contraction and pressure generation. Contraction of the atria propels a small amount of blood into the ventricles, called the atrial kick. b. Ventricle systole Following the delay at the AV node, the wave of depolarization enters the ventricles, where it is spread rapidly by the bundle branchesand Purkinje fibers (QRS complex). Following depolarization, calcium enters, initiating the contraction of the ventricles. In the isovolumic contraction phase, the ventricles begin to contract, closing the AV valves and building up pressure within the ventricles. As the AV valve close, the first heart sound (S1) is heard. Because the aortic and pulmonic valves remained closed at this point, no blood leaves the ventricle. The ejection phase begins when pressure in the ventricles exceeds the aortic and pulmonic pressures. The semilunar valves open, and the ventricles pump blood into the systemic and pulmonary circulations. c. Ventricular diastole In early diastole, as the ventricles begin to relax, aortic and pulmonary artery pressures exceed ventricular pressures, and the semilunar valves Sinoatrial node AV node Bundle of His and bundle branches Purkinje fibers Ventricular myocardiun

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close. The valve closure causes the second heart sound (S2). The AV valves remain closed, and no blood moves in and out of the ventricles. As the ventricles continue to relax, pressure in the ventricles falls below that of the atria, and the AV valves open, allowing blood that has been pooling in the atria to flow into the ventricles. When the ventricles have filled passively, the cardiac cycle is ready to begin again. Arterial Pressure Arterial Pressure is the pressure of blood against arterial walls. Systolic pressure is the maximum pressure of the blood exerted against the artery walls when the heart contracts (normally 100 to 140 mmHg). Diastolic pressure is the force of blood against the artery walls during the hearts relaxation phase (60 to 90 mmHg). Blood pressure is expressed as systolic pressure/diastolic pressure. Changes in sympathetic and parasympathetic activity occur in response to messages sent from sensory receptors in various parts of the body. Important receptors in cardiovascular reflexes include (1) arterial baroreceptors, (2) stretch sensitive cardiopulmonary receptors of the atria and veins, and (3) chemoreceptors. These receptors are sensitive to changes in the blood pressure. When these changes occur, they transmit impulses to the CNS which stimulate either sympathetic or parasympathetic response, particularly to the kidney, to enhance salt and water retention/excretion. ENDOCRINE SYSTEM In physiology, the endocrine system is a system of glands, each of which secretes a type of hormone into the bloodstream to regulate the body. The endocrine system is an information signal system like the nervous system. Hormones regulate many functions of an organism, including mood, growth and development, tissue function, and metabolism. The endocrine system is made up of a series of ductless glands that produce chemicals called hormones. A number of glands that signal each other in sequence are usually referred to as an axis, for example, the hypothalamic-pituitary-adrenal axis. Typical endocrine glands are the pituitary, thyroid, and adrenal glands. Features of endocrine glands are, in general, their ductless nature, their vascularity, and usually the presence of intracellular vacuoles or granules storing their hormones. In contrast, exocrine glands, such as salivary glands, sweat

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glands, and glands within the gastrointestinal tract, tend to be much less vascular and have ducts or a hollow lumen. In addition to the specialized endocrine organs mentioned above, many other organs that are part of other body systems, such as the kidney, liver, heart and gonads have secondary endocrine functions. For example the kidney secretes endocrine hormones such as erythropoietin and renin. The endocrine organ to be considered in this case presentation is the pancreas. Since the patient have Diabetes mellitus II, the following will then be focused on the organs related to it.

Major endocrine glands. (Male on the left, female on the right.) 1. Pineal gland 2. Pituitary gland 3. Thyroid gland 5. Adrenal gland 6. Pancreas 7. Ovary 8. Testis. Note: the Thymus (labelled 4.) is not an endocrine gland.

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Pancreatic Islets The pancreas, located close to the stomach in the abdominal cavity, is a mixed gland. Probably the best-hidden endocrine glands in the body are the pancreatic islets, formerly called the islets of Langerhans. These little masses of hormone producing tissue are scattered among the enzyme producing acinar tissue of the pancreas. The pancreas are more than a million islets, separated by exocrine cells, each of these tiny clumps of cells busily manufactures its hormones and works like an organ within an organ. Two important hormones produced by the islet cells are insulin and glucagon. High levels of glucose in the blood stimulate the release of insulin from beta cells of the islets. Insulin acts on just about all body cells and increases their ability to transport glucose across their plasma membranes. Once inside the cells, glucose is oxidized for energy or converted to glycogen or fat for storage. These activities are also speeded up by insulin. Since insulin sweeps the glucose out of the blood, its effect is said to be hypoglycemic. As blood glucose levels fall, the stimulus for insulin release ends- another classic case of negative feedback control. Many hormones have hyperglycaemic effects (glucagon, glucocorticoids, and epinephrine, to name a few), but insulin is the only hormone that decreases the blood glucose levels. Insulin is absolutely necessary for the use of glucose by the body cells. Without it, essentially no glucose can get into the cells to be used. Glucagon acts as an antagonist of insulin; that is, it helps to regulate blood glucose levels but in a way opposite to that of insulin. Its release by the alpha cells is stimulated by low blood levels of glucose. Its action is basically hyperglycaemic. Its primary target organ is the liver, which stimulates to break down stored glycogen to glucose and to release the glucose into the blood.

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