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ANATOMY AND PHYSIOLOGY OF

THE HEART
Location of the Heart
The heart is located in the chest between the lungs behind the
sternum and above the diaphragm. It is surrounded by the
pericardium. Its size is about that of a fist, and its weight is
about 250-300 g. Its center is located about 1.5 cm to the left
of the midsagittal plane. Located above the heart are the great
vessels: the superior and inferior vena cava, the pulmonary
artery and vein, as well as the aorta. The aortic arch lies behind
the heart. The esophagus and the spine lie further behind the
heart. An overall view is given in Figure 6.1 (Williams and
Warwick, 1989)..
1. Right Atrium
1. Right Coronary 2. Right Ventricle
2. Left Anterior Descending 3. Left Atrium
3. Left Circumflex 4. Left Ventricle
4. Superior Vena Cava 5. Papillary Muscles
5. Inferior Vena Cava 6. Chordae Tendineae
6. Aorta 7. Tricuspid Valve
7. Pulmonary Artery 8. Mitral Valve
8. Pulmonary Vein 9. Pulmonary Valve
Aortic Valve (Not pictured)
The heart needs its own reliable blood supply in order
to keep beating- the coronary circulation. There are
two main coronary arteries, the left and right coronary
arteries, and these branch further to form several
major branches (see image). The coronary arteries lie
in grooves (sulci) running over the surface of the
myocardium, covered over by the epicardium, and
have many branches which terminate in arterioles
supplying the vast capillary network of the
myocardium. Even though these vessels have multiple
anastomoses, significant obstruction to one or other
of the main branches will lead to ischaemia in the area
supplied by that branch.
Coronary Arteries
Because the heart is composed primarily of cardiac muscle
tissue that continuously contracts and relaxes, it must have a
constant supply of oxygen and nutrients. The coronary
arteries are the network of blood vessels that carry oxygen-
and nutrient-rich blood to the cardiac muscle tissue.
The blood leaving the left ventricle exits through the aorta, the
bodys main artery. Two coronary arteries, referred to as the
"left" and "right" coronary arteries, emerge from the
beginning of the aorta, near the top of the heart.
Arteries and Arterioles
1. Arteries are strong, elastic vessels adapted for carrying
high-pressure blood.
2. Arteries become smaller as they divide and give rise to
arterioles.
3. The wall of an artery consists of an endothelium, tunica
media, and tunica externa.
4. Arteries are capable of vasoconstriction as directed by the
sympathetic impulses; when impulses are
inhibited, vasodilation results.
Blood Pressure
A. Blood pressure is the force of blood
against the inner walls of blood vessels
anywhere in the
cardiovascular system, although the term
"blood pressure" usually refers to arterial
pressure.
Arterial Blood Pressure
1. Arterial blood pressure rises and falls following a
pattern established by the cardiac cycle.
a. During ventricular contraction, arterial pressure
is at its highest (systolic pressure).
b. When ventricles are relaxing, arterial pressure is
at its lowest (diastolic pressure).
2. The surge of blood that occurs with ventricular
contraction can be felt at certain points in the body
as a pulse.
Factors that Influence Arterial Blood Pressure
1. Arterial pressure depends on heart action, blood
volume, resistance to flow, and blood viscosity.
2. Heart Action
a. Heart action is dependent upon stroke volume
and heart rate (together called cardiac output); if
cardiac output increases, so does blood pressure.
Blood Volume
a. Blood pressure is normally directly
proportional to the volume of blood within
the cardiovascular system.
b. Blood volume varies with age, body size,
and gender.
Peripheral Resistance
a. Friction between blood and the walls of
blood vessels is a force called peripheral
resistance.
b. As peripheral resistance increases, such as
during sympathetic constriction of blood
vessels, blood pressure increases.
Blood Viscosity
a. The greater the viscosity of blood, the
greater its resistance to flowing, and the
greater the blood pressure.
Control of Blood Pressure
1. Blood pressure is determined by cardiac
output and peripheral resistance.
2. The body maintains normal blood pressure
by adjusting cardiac output and peripheral
resistance.
Cardiac output depends on stroke volume and heart rate,
and a number of factors can affect these actions.
a. The volume of blood that enters the right atrium is
normally equal to the volume leaving the left ventricle.
b. If arterial pressure increases, the cardiac center of the
medulla oblongata sends parasympathetic impulses
to slow heart rate.
c. If arterial pressure drops, the medulla oblongata sends
sympathetic impulses to increase heart rate to
adjust blood pressure.
d. Other factors, such as emotional upset, exercise, and a rise
in temperature can result in increased cardiac
output and increased blood pressure.
The vasomotor center of the medulla
oblongata can adjust the sympathetic impulses
to smooth muscles in arteriole walls, adjusting
blood pressure.
a. Certain chemicals, such as carbon dioxide,
oxygen, and hydrogen ions, can also affect
peripheral resistance.
Venous Blood Flow
1. Blood flow through the venous system is
only partially the result of heart action and
instead also depends on skeletal muscle
contraction, breathing movements, and
vasoconstriction of veins.
The body's blood vessels can be divided into a pulmonary
circuit, including vessels carrying blood to the lungs and back,
and a systemic circuit made up of vessels carrying blood from
the heart to the rest of the body and back.
B. Pulmonary Circuit
1. The pulmonary circuit is made up of vessels that convey
blood from the right ventricle to the pulmonary
arteries to the lungs, alveolar capillaries, and pulmonary
veins leading from the lungs to the left atrium.
C. Systemic Circuit
1. The systemic circuit includes the aorta and its branches
leading to all body tissues as well as the system
of veins returning blood to the right atrium.
The initial segment of the left coronary artery is
called the left main coronary. This blood vessel is
approximately the width of a soda straw and is less
than an inch long. It branches into two slightly
smaller arteries: the left anterior descending coronary
artery and the left circumflex coronary artery. The
left anterior descending coronary artery is embedded
in the surface of the front side of the heart. The left
circumflex coronary artery circles around the left side
of the heart and is embedded in the surface of the
back of the heart.
Just like branches on a tree, the coronary arteries
branch into progressively smaller vessels. The larger
vessels travel along the surface of the heart; however,
the smaller branches penetrate the heart muscle. The
smallest branches, called capillaries, are so narrow
that the red blood cells must travel in single file. In
the capillaries, the red blood cells provide oxygen and
nutrients to the cardiac muscle tissue and bond with
carbon dioxide and other metabolic waste products,
taking them away from the heart for disposal through
the lungs, kidneys and liver.
When cholesterol plaque accumulates to the point of
blocking the flow of blood through a coronary artery,
the cardiac muscle tissue fed by the coronary artery
beyond the point of the blockage is deprived of
oxygen and nutrients. This area of cardiac muscle
tissue ceases to function properly. The condition
when a coronary artery becomes blocked causing
damage to the cardiac muscle tissue it serves is called
a myocardial infarction or heart attack.
Superior Vena Cava
The superior vena cava is one of the two main
veins bringing de-oxygenated blood from the
body to the heart. Veins from the head and
upper body feed into the superior vena cava,
which empties into the right atrium of the
heart.
Inferior Vena Cava
The inferior vena cava is one of the two main
veins bringing de-oxygenated blood from the
body to the heart. Veins from the legs and
lower torso feed into the inferior vena cava,
which empties into the right atrium of the
heart.
Aorta
The aorta is the largest single blood vessel in
the body. It is approximately the diameter of
your thumb. This vessel carries oxygen-rich
blood from the left ventricle to the various
parts of the body.
Pulmonary Artery
The pulmonary artery is the vessel
transporting de-oxygenated blood from the
right ventricle to the lungs. A common
misconception is that all arteries carry oxygen-
rich blood. It is more appropriate to classify
arteries as vessels carrying blood away from
the heart.
Pulmonary Vein
The pulmonary vein is the vessel transporting
oxygen-rich blood from the lungs to the left
atrium. A common misconception is that all
veins carry de-oxygenated blood. It is more
appropriate to classify veins as vessels carrying
blood to the heart.
Right Atrium
The right atrium receives de-oxygenated blood from
the body through the superior vena cava (head and
upper body) and inferior vena cava (legs and lower
torso). The sinoatrial node sends an impulse that
causes the cardiac muscle tissue of the atrium to
contract in a coordinated, wave-like manner. The
tricuspid valve, which separates the right atrium from
the right ventricle, opens to allow the de-oxygenated
blood collected in the right atrium to flow into the
right ventricle.
Right Ventricle
The right ventricle receives de-oxygenated blood as
the right atrium contracts. The pulmonary valve
leading into the pulmonary artery is closed, allowing
the ventricle to fill with blood. Once the ventricles
are full, they contract. As the right ventricle contracts,
the tricuspid valve closes and the pulmonary valve
opens. The closure of the tricuspid valve prevents
blood from backing into the right atrium and the
opening of the pulmonary valve allows the blood to
flow into the pulmonary artery toward the lungs.
Left Atrium
The left atrium receives oxygenated blood
from the lungs through the pulmonary vein.
As the contraction triggered by the sinoatrial
node progresses through the atria, the blood
passes through the mitral valve into the left
ventricle.
Left Ventricle
The left ventricle receives oxygenated blood as the left atrium
contracts. The blood passes through the mitral valve into the
right ventricle. The aortic valve leading into the aorta is closed,
allowing the ventricle to fill with blood. Once the ventricles
are full, they contract. As the left ventricle contracts, the mitral
valve closes and the aortic valve opens. The closure of the
mitral valve prevents blood from backing into the left atrium
and the opening of the aortic valve allows the blood to flow
into the aorta and flow throughout the body.
Papillary Muscles
The papillary muscles attach to the lower portion of
the interior wall of the ventricles. They connect to
the chordae tendineae, which attach to the tricuspid
valve in the right ventricle and the mitral valve in the
left ventricle. The contraction of the papillary
muscles opens these valves. When the papillary
muscles relax, the valves close.
Chordae Tendineae
The chordae tendineae are tendons linking the
papillary muscles to the tricuspid valve in the right
ventricle and the mitral valve in the left ventricle. As
the papillary muscles contract and relax, the chordae
tendineae transmit the resulting increase and decrease
in tension to the respective valves, causing them to
open and close. The chordae tendineae are string-like
in appearance and are sometimes referred to as
"heart strings."
Tricuspid Valve
The tricuspid valve separates the right atrium from
the right ventricle. It opens to allow the de-
oxygenated blood collected in the right atrium to
flow into the right ventricle. It closes as the right
ventricle contracts, preventing blood from returning
to the right atrium; thereby, forcing it to exit through
the pulmonary valve into the pulmonary artery.
Mitral Value
The mitral valve separates the left atrium from
the left ventricle. It opens to allow the
oxygenated blood collected in the left atrium
to flow into the left ventricle. It closes as the
left ventricle contracts, preventing blood from
returning to the left atrium; thereby, forcing it
to exit through the aortic valve into the aorta.
Pulmonary Valve
The pulmonary valve separates the right
ventricle from the pulmonary artery. As the
ventricles contract, it opens to allow the de-
oxygenated blood collected in the right
ventricle to flow to the lungs. It closes as the
ventricles relax, preventing blood from
returning to the heart.
Aortic Valve
The aortic valve separates the left ventricle
from the aorta. As the ventricles contract, it
opens to allow the oxygenated blood collected
in the left ventricle to flow throughout the
body. It closes as the ventricles relax,
preventing blood from returning to the heart.
Starting with the Superior Vena Cava, place the following items in the correct order.
aorta
left AV valve
left atrium
left ventricle
lungs
pulmonary artery
pulmonary vein
right atrium
right ventricle
right AV valve
Cardiac Cycle
1. During the cardiac cycle, pressure within the heart
chambers rises and falls with the contraction and
relaxation of atria and ventricles.
2. When the atria fill, pressure in the atria is greater
than that of the ventricles, which forces the A-V valves
open.
3. Pressure inside atria rises further as they contract,
forcing the remaining blood into the ventricles.
4. When ventricles contract, pressure inside them
increases sharply, causing A-V valves to close and the
aortic and pulmonary valves to open.
a. As the ventricles contract, papillary muscles contract,
pulling on chordae tendinae and preventing the backflow
of blood through the A-V valves.
Heart Sounds
1. Heart sounds are due to vibrations in heart
tissues as blood rapidly changes velocity within
the heart.
2. Heart sounds can be described as a "lub-
dup" sound.
3. The first sound (lub) occurs as ventricles
contract and A-V valves are closing.
4. The second sound (dup) occurs as ventricles
relax and aortic and pulmonary valves are
closing.
Conduction system
Specialised myocardial cells depolarize more
rapidly than other myocardial cells.
Small cardiac nerves, arteries, and veins lie
close to this conducting cells providing
neurohumoral substances which modulate
cardiac impulse generation and conduction.
Supplying and removing metabolic materials
Regulation of the Cardiac Cycle
1. The amount of blood pumped at any one time must
adjust to the current needs of the body (more is
needed during strenuous exercise).
2. The S-A node is innervated by branches of the
sympathetic and parasympathetic divisions, so the CNS
controls heart rate.
a. Sympathetic impulses speed up and parasympathetic
impulses slow down heart rate.
3. The cardiac control center of the medulla oblongata
maintains a balance between the sympathetic and
parasympathetic divisions of the nervous system.
4. Impulses from cerebrum or hypothalamus may also
influence heart rate, as do body temperature and the
concentrations of certain ions.
Cell to cell conduction
SA node to AV node
The P wave represents atrial depolarisation- there is little
muscle in the atrium so the deflection is small.
The Q wave represents depolarisation at the bundle of His;
again, this is small as there is little muscle there.
The R wave represents the main spread of depolarisation,
from the inside out, through the base of the ventricles. This
involves large ammounts of muscle so the deflection is large.
The S wave shows the subsequent depolarisation of the rest
of the ventricles upwards from the base of the ventricles.
The T wave represents repolarisation of the myocardium
after systole is complete. This is a relatively slow process-
hence the smooth curved deflection.
Step 1
The first step is to determine the
RATE, which can be eyeballed by the
following technique. Locate the QRS
(the big spike) complex that is closest
to a dark vertical line. Then count
either forward or backwards to the next
QRS complex. For each dark vertical
line you pass, select the next number
off the mnemonic "300-150-100-75-60-
50" to estimate the rate in beats per
minute (BPM).).

In other words if you pass 2 lines before the


next QRS, the heart rate (HR) would be less
than 150. Remember that this is merely an
estimate. You should use real measurements to
determine the exact HR (for precise
measurement: each large box represents
200msec and small boxes represent 40msec). As
an example of using the mnemonic, in the
segment of the EKG below, start at the QRS
that lines up with the vertical line at "0". Now
counting back each vertical line to the previous
EKG "300-150-100" we notice the HR to be
slightly less than 100 (probably around 90-95)
Step 2
Next we need to determine the RHYTHM both
its source and its regularity. The prime concern is
whether the source of the rhythm is the SA node
(sino-atrial) or an ectopic pacemaker. To
determine whether the source of the rhythm is
"sinus" or an ectopic rhythm, you need to look at
the relationship of the P-wave, if present, to the
QRS-complex. If there is a P wave before each
QRS and the P is in the same direction as the
QRS, the rhythm can be said to be sinus. For
instance note in the EKG segment below that
there is a P-wave before each QRS (highlighted in
blue) and that it is pointing up as is the QRS
segment.

Also look at the quality and quantity of P-


waves before each QRS. There should only be
one P-wave before each QRS. The P-wave
should be in only one direction, and not
biphasic (except for leads V1 and V2). It
should also be closer than 200ms to the QRS.
The shape of the P-wave should also be gently
rounded and not peaked.
The cardiac action potential has five
phases
The standard model used to understand the cardiac action
potential is the action potential of the ventricular myocyte.
The action potential has 5 phases (numbered 0-4). Phase 4 is
the resting membrane potential, and describes the membrane
potential when the cell is not being stimulated.
Once the cell is electrically stimulated (typically by an electric
current from an adjacent cell), it begins a sequence of actions
involving the influx and efflux of multiple cations and anions
that together produce the action potential of the cell,
propagating the electrical stimulation to the cells that lie
adjacent to it. In this fashion, an electrical stimulation is
conducted from one cell to all the cells that are adjacent to it,
to all the cells of the heart.
Phase 4
Phase 4 is the resting membrane potential. This is the period that the cell
remains in until it is stimulated by an external electrical stimulus (typically
an adjacent cell). This phase of the action potential is associated with
diastole of the chamber of the heart.
Certain cells of the heart have the ability to undergo spontaneous
depolarization, in which an action potential is generated without any
influence from nearby cells. This is also known as automaticity. The cells
that can undergo spontaneous depolarization the fastest are the primary
pacemaker cells of the heart, and set the heart rate. Usually, these are cells
in the SA node of the heart. Electrical activity that originates from the SA
node is propagated to the rest of the heart. The fastest conduction of the
electrical activity is via the electrical conduction system of the heart.
In cases of heart block, in which the activity of the primary pacemaker
does not propagate to the rest of the heart, a latent pacemaker (also
known as an escape pacemaker) will undergo spontaneous depolarization
and create an action potential.
The mechanism of automaticity involves the so-called pacemaker channels
of the HCN family, Hyperpolarization-gated, Cyclic Nucleotide-gated
channels. These poorly selective cation channels conduct more current as
the membrane potential becomes more negative, or hyperpolarized. They
conduct both potassium and sodium. The activity of these channels in the
SA node cells causes the membrane potential to slowly become more
positive (depolarized) until, eventually, calcium channels are activated and
an action potential is initiated.
Phase 0
Phase 0 is the rapid depolarization phase. The slope
of phase 0 represents the maximum rate of
depolarization of the cell and is known as Vmax.
This phase is due to the opening of the fast Na+
channels causing a rapid increase in the membrane
conductance to Na+ (GNa) and thus a rapid influx
of Na+ ions (INa) into the cell; a Na+ current.
The ability of the cell to open the fast Na+ channels during
phase 0 is related to the membrane potential at the moment
of excitation. If the membrane potential is at its baseline
(about -85 mV), all the fast Na+ channels are closed, and
excitation will open them all, causing a large influx of Na+
ions. If, however, the membrane potential is less negative,
some of the fast Na+ channels will be in an inactivated state
insensitive to opening, thus causing a lesser response to
excitation of the cell membrane and a lower Vmax. For this
reason, if the resting membrane potential becomes too
positive, the cell may not be excitable, and conduction through
the heart may be delayed, increasing the risk for arrhythmias.
The fast Na+ channel
The fast sodium channel can be modeled as being controlled by a number
of gates. Each gate (or gating variable) can attain a value between 1 (fully
open) and 0 (fully closed). The product of all the gates denotes the
percentage of channels available to conduct Na+. Following the model of
Hodgkin and Huxley, the sodium channel contains three gates: m, h, and j.
In the resting state, the m gate is closed (zero) and the h and j gates are
open (one). Hence, the product denoting the percentage of conducting
channels is also zero. Upon electrical stimulation of the cell, the m gate
opens quickly while simultaneously the h and j gates close more slowly. For
a brief period of time, all gates are open (i.e. non-zero) and Na+ can enter
the cell following its electrochemical gradient. If, as above, the resting
membrane potential is too positive, the h or j gates may be considerably
less than one, such that the product of m, h and j becomes too small upon
depolarization.