Module 5 Cardiovascular System

1 Introduction to Cardiovascular System

Cardiovascular system consists of 3 main components:
 Heart
 Blood
 Blood vessels

1.1 Anatomy of the heart

1.1.1 Typography of the heart

 Heart is a hollow, muscular organ – lies in the mediastinum – protected by sternum and ribs
 In an adult it measure +- 12cm in length / 9cm in width (at its thickest part) / 6cm at its thinnest past
 Heart situated posterior to sternum, slight left
 Weighs +-250 – 300g
 Pumps +-7000 – 9000L of blood a day
 Broad part is referred to as the Base of the heart
 More pointed part is called the Apex
o Apex usually felt between 4th and 5th ribs – about mid-clavicular line
o Apex forms part of Left Ventricle
 Heart functions as pump to supply oxygenated blood to tissue and remove deoxygenated blood and
waste products from cells

1.1.2 Chamber and valves of the heart

 Heart has 4 pumping chambers
o Upper chambers: Left and Right Atrium
o Lower Chambers: Left and Right Ventricles
 Atria:
o Thin walled muscular chambers
 Ventricles
o Much thicker muscular walls
o Left ventricle wall is thicker than the right
 left ventricle pumps against higher pressure
o Muscle of the Ventricles are known as Myocardium

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1.1.3 Muscle of the heart are made up of three layers

Endocardium Innermost layer
Myocardium The heart muscle itself
Pericardium Outermost layer

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2 Physiology of the heart

2.1 Nerve Supply
 The heart is controlled by parasympathetic nerves and the sympathetic nerves
 These nerves – part of autonomic nerve system
o Not under voluntary control but an automatic response
 Sympathetic cardiac nerve purpose
o Make the heart beat faster and stronger when needed
 Parasympathetic cardiac nerve purpose
o Is to slow the heart rate down
 Parasympathetic cardiac nerve and Parasympathetic cardiac nerve supplies interact to produce
responses appropriate to bodies needs

2.2 Great Vessels

These are
 The Pulmonary Artery
 The Aorta

2.2.1 The Pulmonary Artery

 Rises from the base of the heart
o From the opening in right ventricle
 After a short distance it divides into two branches
o Left and right pulmonary arteries
 Which supply left and right lung

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2.2.2 The Aorta

 Rises from the base of the heart
o Adjacent to pulmonary artery
o From the opening in left ventricle
 Aorta gives off important coronary arteries which supply blood to heart muscle
 Coronary arteries situated at the beginning of the aorta and are closed of the aortic valves during
ventricular contraction (systole)
 Heart therefore receives blood supply during diastole (when aortic valves close)

2.3 Conducting System

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2.4 The Heart as a pump

The heart is a hollow muscular organ filled with blood

After blood perfused various tissues of the body it returns to the right side of the heart
Blood is only able to enter the heart when the heart is relaxed
This phase of the hearts cycle as a pump is called: Diastole

2.4.1 Pressure and Flow

Heart generates pressure in order for the blood to flow in a closed system
Force exerted on the walls of blood vessels known as blood pressure
The FORCE is pulsatile therefore the PRESSURE is pulsatile
Systolic pressure (high) in arterial walls during ventricular contractions
Diastolic pressure (low) in arterial walls during ventricular relaxation

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Superior
Diastole
Vena
Right Left
Atrium Atrium

Coronary Arteries

Tricuspid Bicuspid
Valve Valve
Inferior
Vena Cava
Aorta
Pulmonary
Valve Aortic Valve

Right Left
Ventricle Ventricl

Systole
Pulmonary Vein
Pulmonary Artery

Gaseous Exchange through Capillaries

2.5 Blood flow through the heart

 Blood enters the Right atrium via Superior & Inferior Vena Cava
 Pumped into Right Ventricle through Tricuspid Valve
 From Right Ventricle through Pulmonary Valve
 From Pulmonary Valve into Pulmonary Arteries
 To the Lungs where gaseous exchange takes place
 From the Lungs via Pulmonary Veins into the Left Atrium
 Pumped into the Left Ventricle through Bicuspid/Mitral valve
 From Left Ventricle through Aortic Valve
 From Aortic Valve into the Aorta
 To the Systemic Circulation for distribution through the body

3 Circulation
Three type of circulation:
 Cardiac Circulation
 Pulmonary Circulation
 Systemic Circulation

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3.1 Cardiac Circulation

 Myocardium (heart muscle) needs continuous supply of oxygen and nutrients to function efficiently
 Right coronary artery supply blood to right ventricle and bottom part / inferior wall of left ventricle
 Left coronary artery divides into two major branches that supply the left ventricle
o +-5% of the bodies entire blood supply is pumped through coronary arteries to feed the
heart with the highest amount of oxygenated blood
 Coronary artery have the ability to dilate
o To increase supply of oxygenated blood to heart muscles when needed

3.2 Pulmonary Circulation

 Gaseous exchange takes place at capillary level
 Pulmonary arteries system is high pressure system
 Pulmonary venous system is low pressure system

Right Atrium – Right Ventricle – Pulmonary Arteries – Pulmonary Arterioles (smaller arteries) – Capillaries –
Pulmonary Venules (smaller veins) – Pulmonary Veins – Left Atrium – Left Ventricle

 REMEMBER: this is the only instance when venous (deoxygenated) blood is carried by atrial system
 And when arterial (oxygenated) blood is carried by venous system

3.3 Systemic Circulation

 Supplies the whole body with oxygen and nutrients
 Systemic Arterial system is a HIGH pressured system
 Systemic Venous system is a low pressured system

Left Atrium – Left Ventricle – Aorta – Systemic Arteries – Arterioles – Capillaries (body tissue) – Venules –
Veins – Right Atrium

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3.4 Cardiac Output

Cardiac Output = Stroke Volume x Heart Rate

3.4.1 Stroke Volume

Stroke volume is the volume of blood pumped out of ONE VENTRICLE in SINGLE heartbeat
Adult at rest:
+- 70ml from one ventricle and single heart beat
Heart rate 72bpm

CO (Cardiac Output)
SV (Stroke Volume)
HR (Heart Rate)

CO = SV x HR CO = 70ml x 72 bpm
CO = 5000ml CO = 5L/min
Cardiac output can be greatly increased to meet demands of exercise to around 25L/min
And in athletes – 35L/min

3.4.2 Normal Heart Rates

Adults 60 – 100 bpm
Children 80 – 100 bpm
Toddlers 100 – 120 bpm
New-borns 120 – 140 bpm

3.5 Blood Pressure

Blood pressure is measured in millimetres mercury (mmHg)
Determined by cardiac output and peripheral resistance:

Blood Pressure = Cardiac Output x Peripheral resistance

3.5.1 Peripheral Resistance

Peripheral resistance is constriction and dilation of arterioles.
Vasoconstriction causes blood pressure to rise and vasodilation causes blood pressure to fall

Normal valves:
Male pt.
Age + 100 = Systolic BP 40 + 100 = 140
Diastolic BP = 2/3 of systolic BP 90 - 100
Female pt.
Age + 90 = Systolic BP 30 + 90 = 120
Diastolic BP = 2/3 of systolic BP 80

3.6 Body fluid compartments

 Human body made up of 60% water – by weight
 I.e. man weighing 70kg – consists of +-42L of water
 Fluid is contained in “compartments”
Two main compartments:
 Extracellular Compartments (20% body weight)
 Intracellular Compartments (40% body weight)

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3.6.1 Extracellular Compartments (20% body weight)

 Extracellular means outside the cell
 Extracellular fluid is made up of
o All fluid in the blood vessels (Intravascular)
o +-4% of intravascular fluid is in the form of plasma
 Plasma is between the cells and the body tissue (Interstitial)

 14L of fluid is found in extracellular compartments

 6L of the 14L is blood

3.6.2 Intracellular Compartments (40% body weight)

 Intracellular means inside the cell
 This includes all the cells of the body
 28L of fluid
 Intracellular fluid (ICF)

3.6.3 Blood vessels

Comprises of arteries, veins and capillaries

Arteries Veins
Carry blood away from the heart Carry blood towards the heart
Usually carries oxygen rich blood except pulmonary Usually carries deoxygenated blood except for the
arteries pulmonary veins
Thick walled Thin walled
No valves Valves
Capillaries are smaller veins and arteries that connect venules and arterioles.

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3.7 Basic Composition of blood

 Blood fluid composed of
o Yellowish transparent fluid known as plasma
o And floating in the fluid are different types of cells
 There are three main types of cells
o Erythrocytes (red blood cells)
o Leucocytes (white blood cells)
o Thrombocytes (platelets)

3.7.1 Erythrocytes
 Erythrocytes contain substance called haemoglobin – able to transport oxygen
 Erythrocytes and haemoglobin combine to form oxyhaemoglobin
 Bulk of oxygen in blood is transport by oxyhaemoglobin to cells in the body
 Oxyhaemoglobin is responsible for pink colour of pt. mucous membrane
 In absence of oxygen – haemoglobin will combine with carbon dioxide to for carboxyhaemoglobin
 Carboxyhaemoglobin responsible for bluish colour of pt. mucous membrane (cyanotic pt.)

3.7.2 Leucocytes
 Leucocytes responsible for providing body with defence against invading micro-organism
 Leucocytes engulf and attempt to destroy any foreign organism

3.7.3 Thrombocytes
 Thrombocytes are very small cells
 Play important role in clotting of blood
 Mechanism called coagulation (clotting of the blood) happens / reacts when
o When blood vessel is damages - to prevent blood loss
o When blood escapes from wound – thrombocytes gather at “site”
o And together with other substances form a “plug” to close the wound

 Summary of main function of blood

o Blood transports oxygen as oxyhaemoglobin from lungs to tissue cells
o And returns carbon dioxide from cells to lungs as carboxyhaemoglobin for lung excretion
o Blood transports all nourishment to cells
o Blood transports all waste products from the tissues to certain organs e.g. kidneys, liver.
o Blood transports hormones and enzymes to their target organs.
o Blood assists in the defence of the body against micro- organism.
o Blood helps to maintain body temperature. - Plays a role in acid-base-balance

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4 Clinical Cardiac Conditions

 Many types of pain occur in the chest
 Pain may arise from structure in chest wall / within thoracic cavity
 Pain the arises when heart is deprived of oxygen is most often due to disease in arteries (coronary
arteries)
 These supply the heart with oxygen and nutrients

 During assessment of chest pain (or any pain) – pt. history is VERY important
 This to determine cause of chest pain
 Ask the flowing questions: O P Q R S T

Onset When did the pain start / begin?

Provokes What provokes the pain?
E.g. was the pt. exercising?
Quality What is the quality of pain?
Crushing / stabling / feels like someone is sitting on their chest
Radiation / Radiating Is the pain radiating?
i.e. to the jaw, arms, abdomen, back
Severity How sever is the pain?
Scale of 1 – 10? 10 being the worse the pt. has ever felt
Time How long has the pain lasted?
1 hour
And is the pain constant or does it come and go and for how long

 Then ask: S A M P L E

Signs and Symptoms Signs is something you see

Symptoms is what the pt. tells you
Allergies Ask – are you allergic to anything like medication like aspirin or food like
peanuts
Medication Are you on chronic medication or taking medication for anything like flu or
heart problems
Past medical history This question needs to include the pt. as well as the pt. family
(pt. may not have past heart problems but pt. parents or family may have
heart problems)
Last meal When was the last time the pt. ate or had something to eat
Events leading up to the What was the pt. doing before the pain started
event

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4.1 Angina Pectoris

  Angina Disease of the coronary

arteries
o Causes narrowing of the lumen (inner diameter of vessels) to the extent that blood flow
decreases
 Narrowing of the lumen is due to plaque formation

 When the pt. is at rest – narrowing is not a problem – as soon as they exert themselves emotionally or
physically – heart requires more oxygen to cope with increase load of work it has to perform to supply
exercising muscles with oxygen and nutrients
 Heart is a muscle – needs oxygen and nutrients if it needs to work harder
 As one / more coronary arteries may be narrowed – this limits blood flow through them and heart
muscle is deprived of oxygen and nutrients
o Causes pain – due to ANGINA

4.1.1 Stable Angina

Predictable after exertion with predictable location / intensity

4.1.2 Unstable Angina

Unpredictable
Changes location – intensity and duration
Greater degree of obstruction and it’s usually a sign of an AMI

4.1.3 Characteristics of Angina:

 Brought on by exertion (Stable Angina)
 Relieved rapidly by rest within a few minutes in most cases (Stable Angina)
 Pain usually occurs in central chest – behind sternum

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o Classically may radiate to neck, jaw and both arms

 Pain is typically crashing
o may be described as heavy / squeezing / pressure / someone sitting on their chest
 Also relieved in minutes by certain medication (tablets) – put under the tongue – TNT / Nitro-glycerine
(spray or tablet)

4.1.4 Management of Angina

 History (take history as fast as possible)
 ABC
 Oxygen 60% (preferred – Partial re-breather)
 Reassure pt.
 Position pt. in comfortable position (semi-fowlers / fowlers)
 Entonox (IF NO CONTRA-INDICATIONS)
 Call for assistance (if pt. does not improve) / call for back up if needed
 Transport pt.
 DON’T let pt. walk

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4.2 Myocardial Infarction (MI)

 Coronary artery (or more than one) becomes completely blocked by coronary artery disease
o E.g. Atherosclerosis, blood clot
 That part of the heart beyond site of blockage (occlusion) no longer receives blood
o Deprives heart muscle in effected area of vital oxygen and nutrients leading to cell death
o (infarction / ischemia) – cell dies due to lack of oxygen
o (myocardial) – heart muscle
o This is known as Myocardial Infarction (death of heart muscles)
 AMI (Acute Myocardial Infarction) quick onset
 Pain produce by MI is identical to angina
o However pain is more persistent
o More severe pain
o May last for several hours
o Unless relieved by pain king drugs

4.2.1 Characteristics of MI:

 Chest pain – sub-sternal, radiating to neck and left arm (and right arm sometimes)
 May occur at rest
 NOT relieved by rest or medication
 May last for hours
 Cold and clammy skin and pale grey complexion
 Sweating
o Pt. becomes hypoxic
 Nausea and sometimes vomiting
 Dyspnea
 Dizziness and feeling faint
 If severe, cardiogenic shock may be present
 Pulse varies from normal to weak, rapid and irregular
 Feeling of impending doom (pt. will tell you they are dying)

4.2.2 Management of MI
 History (take history as fast as possible)
 ABC
 Oxygen 60% (preferred – Partial re-breather)
 Reassure pt.
 Position pt. in comfortable position (semi-fowlers / fowlers)
 Entonox (IF NO CONTRA-INDICATIONS)
 Call for assistance (if pt. does not improve) / call for back up if needed
 Transport pt. rapid without sirens
 DON’T let pt. walk

Differences between Angina and MI

Angina MI
Brought on by exertion May occur at rest (any time)
Relieved rapidly by rest or medication NOT relieved by medication or rest
Pain tends to be crushing Feeling of impending doom
May last short while (come and go) May last for hours

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4.3 Congestive cardiac failure (CCF)

 Occurs when heart is unable to pump fast / hard enough to completely empty its chambers
o Cause the blood to “back up” into systemic / pulmonary circulation

4.3.1 Left heart failure

 Left heart most easily damaged
o Left pumps harder against resistance
 Blood backs up in lungs and causes pulmonary oedema
 Dyspnea occurs – result of decreased oxygen
 Pt. becomes tachypnoeic (above 24 breathes p/min) to try and increase oxygen levels
 Hyper resonant / rales on the chest (can be heard)
 Haemoptysis (Pt. may cough up pink frothy sputum)
 May have decreased level of consciousness

4.3.2 Right heart failure

 Usually occurs after left heart failure
o After fluid has backup to lungs
o Right lung has to work hard to pump blood into lungs
o Eventually becomes too weak to cope with demand
 Blood starts to back up in vessels supplying deoxygenated blood to heart
 Jugular veins are distended and peripheral oedema is present

4.3.3 Characteristics of CCF:

 Dyspnea (result of fluid in alveoli)
 Pt. in sitting position (due to dyspnea)
 Distress / agitated – hypoxia (due to poor cardiac output)
 Peripheral oedema / Sacral oedema (Swollen legs and or sacrum)
o Result of fluid accumulating in tissues

4.3.4 Management of MI
 History (take history as fast as possible)
 ABC
 Oxygen 60% (preferred – Partial re-breather)
 Reassure pt.
 Position pt. in comfortable position (semi-fowlers / fowlers)
 Call for assistance (if pt. does not improve) / call for back up if needed
 Transport pt. rapid without sirens
 DON’T let pt. walk

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4.4 Cardiac Tamponade

Cardiac Tamponade caused by:
 Severe blow to the chest
 Disease i.e. tuberculosis
 Penetrating injury to heart i.e. stabbed heart

4.4.1 Mechanism
 Pericardial sac fills with blood
o Inhibiting mechanical action of heart as result of inward pressure
 This reduces volume-carrying capacity of cambers and inhibits electrical activity
 When caused by disease / contusion - pulmonary oedema may result
 When caused by stab wound – pulmonary oedema does not usually develop
o As blood escapes by entrance wound
 Cardiac arrest results
 When result of trauma – onset is rapid – normally lethal
 When result of disease – onset usually slower and can be treated

4.4.2 Characteristics of CCF:

 Bruising / penetrating injury in chest (acute)
 Dyspnea
 Tachycardia
 Reduced blood pressure
 Chest pain
 Severe anxiety
 Reduced GSC
 Hypoxia
 Becks triad
o Muffled heart sounds
o Distended neck veins (due to backup of liquids)
o Reduced level between systolic and diastolic BP

4.4.3 Management of MI
 ABC
 Oxygen 60% (preferred – Partial re-breather)
 Reassure pt.
 Position pt. in shock position
o Trendelenburg – and monitor closely
 Vital signs
 History
 Cover pt. with space blanket
 Call for back ASAP
 Monitor vital signs continuously
 Transport pt. rapid without sirens
 DON’T let pt. walk

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