CARDIOVASCULAR

SYSTEM
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CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

CONTENTS
DEVELOPMENT OF CARDIOVASCULAR SYSTEM ............................................................................................................ 6
ANATOMY OF CARDIOVASCULAR SYSTEM ................................................................................................................... 6
PHYSIOLOGY OF CARDIOVASCULAR SYSTEM ................................................................................................................ 7
GENERAL FEATURES OF PHYSIOLOGY OF CARDIOVASCULAR SYSTEM ..................................................................... 7
OXYGEN CONSUMPTION......................................................................................................................................... 10
MEAN ARTERIAL PRESSURE .................................................................................................................................... 10
PULSE PRESSURE ..................................................................................................................................................... 11
VASCULAR SYSTEM ..................................................................................................................................................... 11
SYNCOPE ..................................................................................................................................................................... 12
HEART SOUNDs ........................................................................................................................................................... 12
FIRST HEART SOUND ............................................................................................................................................... 12
SECOND HEART SOUND .......................................................................................................................................... 12
THIRD HEART SOUND .............................................................................................................................................. 13
FOURTH HEART SOUND .......................................................................................................................................... 13
SNAP, CLICK AND THRILL ......................................................................................................................................... 13
MURMUR ................................................................................................................................................................ 14
ARTERIAL PULSE AND JUGULAR VENOUS PULSE ........................................................................................................ 14
GENERAL FEATURES OF PULSE ................................................................................................................................ 14
PULSUS BISFERIENS ................................................................................................................................................. 15
PULSUS PARADOXUS ............................................................................................................................................... 15
PULSUS ALTERANS .................................................................................................................................................. 15
JUGULAR VENOUS PULSE ........................................................................................................................................ 15
ELECTROCARDIOGRAM ............................................................................................................................................... 16
GENERAL FEATURES OF ECG ................................................................................................................................... 16
ECG FEATURES OF HYPERKALEMIA ......................................................................................................................... 17
ECG FEATURES OF HYPOKALEMIA .......................................................................................................................... 17
ECG FEATURES OF HYPERCALCEMIA ....................................................................................................................... 17
ECG FEATURES OF HYPOCALCEMIA ........................................................................................................................ 17
ANGINA ....................................................................................................................................................................... 18
FEATURES OF ANGINA ............................................................................................................................................ 18
MANAGEMENT OF ANGINA .................................................................................................................................... 18
NITRATES ................................................................................................................................................................. 19

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CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

MYOCARDITIS.............................................................................................................................................................. 19
SUDDEN CARDIAC DEATH ........................................................................................................................................... 20
VENTRICULAR INFARCT AND HYPERTROPHY .............................................................................................................. 20
MYOCARDIAL INFARCTION ......................................................................................................................................... 20
BLOOD SUPPLY TO HEART ....................................................................................................................................... 20
FEATURES OF MI ..................................................................................................................................................... 21
MORPHOLOGY OF MI.............................................................................................................................................. 22
COMPLICATIONS OF MI .......................................................................................................................................... 23
ENZYMES IN MI ....................................................................................................................................................... 23
DIAGNOSIS IN ISCHEMIC HEART DISEASE ............................................................................................................... 24
MANAGEMENT OF MI ............................................................................................................................................. 25
THROMBOLYSIS ....................................................................................................................................................... 26
WARFARIN .............................................................................................................................................................. 26
AORTIC DISSECTION .................................................................................................................................................... 26
ARRHYTHMIAS ............................................................................................................................................................ 27
CARDIAC CONDUCTION .......................................................................................................................................... 27
GENERAL FEATURES OF ARRHYTHMIA.................................................................................................................... 29
ATRIAL FLUTTER ...................................................................................................................................................... 29
ATRIAL FIBRILLATION .............................................................................................................................................. 29
VENTRICULAR TACHYCARDIA .................................................................................................................................. 30
VENTRICULAR FIBRILLATION ................................................................................................................................... 31
MANAGEMENT OF ARRHYTHMIA ........................................................................................................................... 31
HEART BLOCK .............................................................................................................................................................. 32
VENTRICULAR PREMATURE CONTRACTION ............................................................................................................... 33
TORSADES DE POINTES ............................................................................................................................................... 33
WPW SYNDROME ....................................................................................................................................................... 34
ATHEROSCLEROSIS ...................................................................................................................................................... 34
CAUSES OF ATHEROSCLEROSIS ............................................................................................................................... 34
FEATURES OF ATHEROSCLEROSIS ........................................................................................................................... 35
MORPHOLOGY IN ATHEROSCLEROSIS .................................................................................................................... 35
DIAGNOSIS OF ATHEROSCLEROSIS .......................................................................................................................... 35
HYPOLIPIDEMIC DRUGS .......................................................................................................................................... 36
PREVENTION OF ATHEROSCLEROSIS ....................................................................................................................... 37
CARDIAC TUMOURS .................................................................................................................................................... 37
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CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

RHEUMATIC FEVER ..................................................................................................................................................... 38

FEATURES OF RHEUMATIC FEVER ........................................................................................................................... 38
CRITERIA OF RHEUMATIC FEVER............................................................................................................................. 39
MORPHOLOGY OF RHEUMATIC FEVER ................................................................................................................... 39
DIAGNOSIS OF RHEUMATIC FEVER ......................................................................................................................... 40
MANAGEMENT OF RHEUMATIC FEVER .................................................................................................................. 40
CARDIOMYOPATHY ..................................................................................................................................................... 40
FEATURES OF CARDIOMYOPATHY .......................................................................................................................... 40
DILATED CARDIOMYOPATHY .................................................................................................................................. 41
RESTRICTIVE CARDIOMYOPATHY ............................................................................................................................ 41
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY ................................................................................................ 41
CONGENITAL HEART DISEASE ..................................................................................................................................... 42
FEATURES OF CONGENITAL HEART DISEASE........................................................................................................... 42
TETRALOGY OF FALLOT ........................................................................................................................................... 43
ATRIAL SEPTAL DEFECT ........................................................................................................................................... 44
VENTRICULAR SEPTAL DEFECT ................................................................................................................................ 45
PATENT DUCTUS ARTERIOSUS ................................................................................................................................ 46
TRICUSPID ATRESIA ................................................................................................................................................. 46
COARCTATION OF AORTA ....................................................................................................................................... 47
TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION ................................................................................... 48
TRANSPOSITION OF GREAT VESSELS ....................................................................................................................... 48
EISENMENGER SYNDROME ..................................................................................................................................... 49
HEART FAILURE ........................................................................................................................................................... 49
FEATURES OF HEART FAILURE ................................................................................................................................ 49
DIAGNOSIS OF HEART FAILURE ............................................................................................................................... 50
MANAGEMENT OF HEART FAILURE ........................................................................................................................ 50
CARDIAC GLYCOSIDE ................................................................................................................................................... 51
DIGOXIN .................................................................................................................................................................. 51
DIGITOXIN ............................................................................................................................................................... 52
FEATURES OF DIGITALIS TOXICITY .......................................................................................................................... 52
MANAGEMENT OF DIGITALIS TOXICITY .................................................................................................................. 53
VALVULAR HEART DISEASE ......................................................................................................................................... 53
GENERAL FEATURES OF VALVULAR DISEASES ........................................................................................................ 53
MITRAL STENOSIS ................................................................................................................................................... 53
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CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

MITRAL REGURGITATION ........................................................................................................................................ 54

MITRAL VALVE PROLAPSE ....................................................................................................................................... 55
AORTIC STENOSIS .................................................................................................................................................... 55
AORTIC REGURGITATION ........................................................................................................................................ 56
TRICUSPID REGURGITATION ................................................................................................................................... 56
PULMONARY STENOSIS ........................................................................................................................................... 57
ENDOCARDITIS ............................................................................................................................................................ 57
ETIOLOGY OF ENDOCARDITIS ................................................................................................................................. 57
SITE OF ENDOCARDITIS ........................................................................................................................................... 58
FEATURES OF ENDOCARDITIS ................................................................................................................................. 58
MANAGEMENT OF ENDOCARDITIS ......................................................................................................................... 59
PERICARDIAL DISEASES ............................................................................................................................................... 59
GENERAL FEATURES OF PERICARDIUM ................................................................................................................... 59
CARDIAC TAMPONADE ........................................................................................................................................... 59
PERICARDITIS .......................................................................................................................................................... 60
HYPERTENSION ........................................................................................................................................................... 61
BLOOD PRESSURE ................................................................................................................................................... 61
CAUSES OF HYPERTENSION..................................................................................................................................... 62
FEATURES OF HYPERTENSION ................................................................................................................................. 62
RENOVASCULAR HYPERTENSION ............................................................................................................................ 62
MORPHOLOGY OF HYPERTENSION ......................................................................................................................... 63
MANAGEMENT OF HYPERTENSION ........................................................................................................................ 63
VASODILATORS ....................................................................................................................................................... 64
ARTERIOLAR DILATORS ........................................................................................................................................... 64
VENOUS DILATORS .................................................................................................................................................. 64
ACE INHIBITORS ...................................................................................................................................................... 64
ARB .......................................................................................................................................................................... 65
CALCIUM CHANNEL BLOCKER ................................................................................................................................. 65
BETA BLOCKERS....................................................................................................................................................... 66
CLONIDINE .............................................................................................................................................................. 66
METHYLDOPA.......................................................................................................................................................... 67
MANAGEMENT OF HYPERTENSIVE EMERGENCY AND URGENCY ........................................................................... 67

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CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

KEY TO THIS DOCUMENT

Text in normal font Must read point.
Asked in any previous medical entrance
examinations
Text in bold font Point from Harrisons
th
text book of internal medicine 18
edition
Text in italic font Can be read if
you are thorough with above two.

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DEVELOPMENT OF CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM

DEVELOPMENT OF CARDIOVASCULAR SYSTEM

First organ formed during embryogenesis
Development of heart
Development of septal defects in fetal heart
Ectopia cordis associated with
Cardiac jelly is secreted by
Cardiac jelly contributes to the formation of
Development of heart

Development of interatrial septum

Left horn of sinus venosus forms

Interventricular septum
Membranous part of interventricular
septum
Membranous part of atrioventricular part of
interventricular septum is between
Premature closure of foramen ovale results in
Patent foramen ovale is due to failure of fusion of
Aneurysm of sinus of valsalva usually arise from
Muscular component of dorsal aorta develops from
Axial artery of Upper Limb is derived from
Most important structure involved in development of
inferior vena cava
Vitelline vein forms
Does NOT derive from vitelline vein
Left sided superior vena cava drains into
Kommerells diverticulum
Smooth portion of right atrium is derived
from

Heart
2nd to 8th week
5 8 weeks
Heart
Myocardium
Endocardium
Dorsal mesocardium forms transverse pericardial sinus,
Myosites arise from splanchnopleuric mesoderm,
Purkinje fibres develop from splanchnopleuric
mesoderm, Neural crest cells have role in development
of muscular and subpulmonary infunbibulum,
Endocaridal cushion develops from cardiac jelly
Perforation in septum primum forms
foramen secundum, foramen secundum
maintains right to left shunt, septum
secundum is situated to the right of
septum primum, septum primum closes at
day 42 of development
Coronary sinus
Muscular interventricular septum, conus
septum, AV endocardial cushion
Anterior part between RV and LV,
posterior part between RA and RV
RA and LV
Right ventricular hypertrophy
Septum primum and septum secondum
Right aortic sinus
Paraxial mesoderm
Seventh Intersegmental artery
Supracardinal vein and subcardinal vein
Hepatic vein, Inferior mesenteric vein, inferior vena
cava
Superior vena cava
Coronary sinus
Anatomical remnant of right aortic arch
Sinus venosus

ANATOMY OF CARDIOVASCULAR SYSTEM

Thinnest portion of Myocardial wall
Sinoatrial node is situated at
AV node lies at

Right atrium and Left atrium

Junction of SVC and Right atrium
Interatrial septum
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PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
Fibres of AV junction
Ventricular muscle receives direct innervation from
Triangle of Koch
Boundary of Koch triangle NOT formed by
NOT a boundary of Kochs triangle
Feature of right atrium
Structures associated with internal
surface of right atrium
NOT a part of interior of Right atrium
Coronary sulcus
Anatomy of right ventricle

Right ventricle
Annulus of Vieussen around
Base of heart is related to
Area of mitral orifice in adults
Central fibrous body of heart formed by
Commonest variation in arteries arising from arch of
aorta
Sympathetic supply to heart
In angina pectoris, pain radiating down the left arm is
mediated by increased activity in afferent (sensory)
fibres contained in
Buffer nerve
Superficial cardiac plexus
Left coronary plexus
Right coronary plexus

Modified Nerve fibres

Purkinje fibres
Coronary sinus opening, Tendon of todaro, Septal
leaflet of tricuspid valve
Limbus fossa ovalis
Origin of Left Coronary artery
Coronary sinus lies between fossa ovalis and IVC
Sinus of keith, triangle of Koch, tendon of
todaro, Waterson groove
Trabeculae carnea
Between right atrium and aorta. Right
coronary artery passes through it.
Most prominent trabeculation, Crista supraventricularis
separate tricuspid valve and pulmonary valve, Apex
trabeculated, TV and PV share fibrous continuity
Conus, outflow tract
Right ventricular outflow tract
Descending aorta
4-6 cm^2
Right fibrous trigone with membranous
part of ventricular septum
Left common carotid artery arising from
brachiocephalic trunk
T1 to T5
Thoracic splanchnic nerve

Carotid sinus nerve and vagal fibres from

aortic arch
Below aortic arch
Deep cardiac plexus
Both superficial and deep cardiac plexus

PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

GENERAL FEATURES OF PHYSIOLOGY OF CARDIOVASCULAR SYSTEM
Duration of Cardiac cycle in man
During cardiac cycle
Left ventricular systole corresponds to
Minimum motion of heart during cardiac imaging
LEAST correct statement
Heart stops in Diastole in
AV valves open at the beginning of
Isometric relaxation of cardiac cycle ends with
At the end of isometric relaxation phase

0.8 seconds
Mitral and aortic valve never open at
same time
Auricular diastole
Mid diastole
During exercise systole is shortened more than diastole
Hyperkalemia
Diastole
Opening of AV valve
AV valves open

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PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
Closure of aortic valve corresponds to beginning of
Isovolumetric dilatation of ventricles is at
Aortic valve closes at the end of
During cardiac cycle, opening of aortic valve takes place
at
Maximum pressure rise in ventricles
during
Phase of cardiac cycle follows immediately
after beginning of QRS wave
Isovolumetric relaxation precedes
Initiation of opening of aortic valve occurs when
Correlate with isovolumetric contraction
Preload is associated with
Volume determining preload
End diastolic ventricular volume
End diastolic volume increases in
Intrinsic heart rate is determined by
Cardiac output in L/min divided by heart rate equals
Cardiac output in an adult is nearly
Percentage of Cardiac output concentrated by Renal
blood flow
Maximum cardiac output during pregnancy
Cardiac output is decreased in
Low cardiac output is associated with
Cardiac output decreases during
Cardiac output can be determined by
Direct fick method for estimation of cardiac output
requires
Ficks law
Scientific principle for the basis for thermodilution
method used in measurement of cardiac output by
pulmonary catheter
Most recent advance in non invasive cardiac output
monitoring
Cardiac index
Cardiac index in normal person
Cardiac index of normal person
Cardiac output in L/min divided by heart rate equals
Preload to heart depends upon
Stroke volume is decreased by
Stroke volume is decreased in
Gorlin formula
Hakki formula
Severity of shunt
Venous return
Venous return to heart from lower limb is NOT affected
by
Venous return to heart during quiet standing facilitated

Isovolumetric relaxation
Closing of Semilunar valves
Protodiastole
End of isovolumetric contraction
Isovolumetric contraction
Isovolumetric contraction
Ventricular ejection
Ventricular pressure is more than aortic pressure
Both valves are open
Isotonic contraction with shortening of
muscle fiber
End diastolic volume of ventricles
130 ml
Decreasing venous compliance
IV administration of atropine, atenolol
Mean stroke volume
5 litres
25%
32 weeks
Rapid arrhythmia
Arrhythmia
Standing from lying position
Ficks principle, ECHO, Thermodilution
O2 content of arterial blood, O2 consumption per unit
time, O2 content of blood from right ventricle
Passive osmosis along concentration gradient only
Stewart Hamilton priniciple

Electrical impedance cardiography technology

cardiac output/body surface area
3.2 (2.6 4.2)
3.2 l/min/m^2
Mean stroke volume
Stroke Volume
Increasing heart rate
Arrhythmia
Area of flow across valve
Aortic valve area
Pulmonary blood flow/systemic blood flow (Qp/Qs)
(mean systemic filling pressure right atrial
pressure)/resistance to venous return
Arterial pressure
Calf muscle contraction during standing, valves in

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PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
by
When a person changes from standing to lying down
position
Supine to upright position
Shift from supine to upright NOT occur
Coronary blood flow
Amount of coronary blood flow
Coronary blood flow in left coronary artery is maximum
during
Coronary blood flow stops during
Blood pressure during exercise is increased in
Reflex noradrenergic discharge during fall in blood
pressure causes vasodilatation in
Most important metabolic factor affecting coronary
blood flow
Cardiac oxygen demand
Myocardial oxygen demand

Myocardial oxygen consumption

Myocardial oxygen demand correlate with
Oxygen utilization by ventricular muscles at rest
Negative G
Aviator subjected to negative G
Baroreceptor
Baroreceptors are mostly sensitive to
Discharge from baroreceptors causes inhibition of
Baroreceptor stimulation produce
Ligature tied proximal to baroreceptors (below carotid
sinus)
Means of studying acute physiological
response to arterial baroreceptor
unloading
Vasomotor centre of medulla
Inhibition of Vasomotor centre causes
Pressure on carotid sinus cause
On cutting or severing sinus nerve in dog, cause
Clamping of carotid arteries below (proximal) carotid
sinus likely to produce
Effect of bilateral Carotid compression above Carotid
Sinus
Single most important factor in control of autonomic
contractility of heart
Features of sympathetic stimulation of heart
Sympathetic stimulation

perforators, sleeves of deep fascia

Venous return to heart rises immediately
Decrease in central venous pressure, Rise in heart rate,
Decrease in cardiac output, Decrease in stroke volume
Rise in central venous pressure
Directly related to perfusion pressure and inversely
related to resistance
250 ml/min
Ventricular diastole
Isometric contraction
Coronary circulation
Coronary circulation
Hypoxia
Has a constant relation to external work done by heart
Correlates with heart rate, Constant relation to external
cardiac work, Depends of preload, afterload,
intramyocardial tension, myocardial muscle mass
Directly proportional to mean arterial pressure
Heart rate
10 ml/100 gm/ min
Cardiac output increases, Cerebral artery pressure
increases, Blood centrifuged towards head, Red out
Cerebral arterial pressure rises
Nucleus tractus solitarius
Systolic blood pressure
Rostral ventrolateral medulla
Decreased heart rate and BP, Decreased cardiac
contractility
Hypertension and tachycardia
Sinoaortic denervation (lowers body
negative pressure)
Acts along with cardiovagal centre to maintain blood
pressure
Decrease in BP
Reflex bradycardia
Increase in mean blood pressure
Increase in blood pressure and increase in heart rate
(stimulates vasomotor center sympathetic response)
Stimulates vagal parasympathetic center
Sympathetic stimulation
Increased contractility, increased heart rate, increased
conduction velocity
Increased HR, BP, total peripheral resistance, Decreased

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PHYSIOLOGY OF CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEM

Sympathetic stimulation does NOT cause

cAMP specific phosphodiesterase inhibitor
on contractility of isolated strips of rabbit
heart
Human heart
Features suggesting denervation

Denervated heart has

In a patient with transplanted heart, reason for
increased cardiac output during exercise
Plateau phase of myocardial action potential is due to
Factors increasing length of ventricular cardiac muscle
fibres
Left ventricle performs more than right due to
difference in
Ejection fraction (left ventricle)
Normal left ventricular ejection fraction
Pressure in right atrium
Right Ventricular Systolic Pressure
Right ventricular diastolic pressure
A 0.5 litre blood loss in 30 minutes will lead to
A patient with increased BP and decreased heart rate is
likely to have
Bradycardia can occur in
Drug linked with increased cardiac mortality
When blood flow stops the pressure is given by
Main site of Peripheral vascular resistance
Splanchnic circulation
Shape of arterial pulse is influenced by

venous capacitance
Increase in venous capacitance
Increases contractility

Heart rate increases with parasympathetic denervation

Unregulated firing of individual muscle fibres, presence
of positive sharp waves, spontaneous firing of motor
units
More heart rate
Epinephrine from medulla
Influx of Ca++
Increased venous tone, Increased total blood volume,
Increased negative intrathoracic pressure
Arterial pressure
Stroke volume/end diastolic volume
65%
Less than 6 mm Hg
25 mm Hg
0 12 mm Hg
Slight increase in heart rate and normal BP
Increased ICT, Brain tumor, Head trauma
Myxoedema, during convalescence, complete heart
block
Rofecoxib
Mean Circulatory filling pressure
Precapillary arterioles
25-30% of total circulation
Arterial wall expansion

OXYGEN CONSUMPTION
Whole body
Liver
Skeletal muscle
Brain
Rest of muscle
Heart muscle
Kidney
Skin

250 ml/min
51 ml/min
50 ml/min
49 ml/min
44 ml/min
29 ml/min
18 ml/min
12 ml/min

MEAN ARTERIAL PRESSURE

Mean arterial pressure

Diastolic + one third of pulse pressure

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VASCULAR SYSTEM

CARDIOVASCULAR SYSTEM
Peripheral resistance
Mean arterial pressure

Mean arterial pressure as it remains constant

(SBP + 2DBP)/3

PULSE PRESSURE
Pulse pressure lowest in arterial system in
Pulse pressure
Pulse pressure is increased by
Varying pulse pressure with Normal rhythm
Wide pulse pressure NOT seen in

Capillaries
Systolic pressure - diastolic pressure
Decrease in arterial compliance
Left ventricular failure
Congestive heart failure

VASCULAR SYSTEM
Circulation

Mareys law is
Law relating distending pressure and tension in a vessel
wall
Law related to wall tension
Laplace law for a cylinder
Laplace law has NO role in
50% reduction in arterial diameter causes
Velocity of blood in aorta
Velocity of blood is inversely proportional to
Reservoirs of blood in cardiovascular
system
Velocity of blood is maximum in
Flow is laminar in small vessels because
Which increase turbulence in blood flow
Blood flow
Local control of blood flow NOT seen in
Which is NOT increased during exercise
Storage pool of blood
Blood supply in splanchnic vessels decrease due to
In a younger subject whose aorta has high elastin
content
Maximum difference of BP occurs between
Classical finding in AV fistula
Capillaries

Capillaries
Capillaries

Pulsatile flow affects gene transcription, Increased

viscosity increases mean blood pressure, Hematocrit
does NOT markedly change peripheral resistance,
Pulsatile flow is recommended
Relationship with heart rate and blood pressure
Law of Laplace
Laplace law
P = T/r
Liver
Reduction in flow 16 times
22 cm/sec
Cross sectional area
Venules
Large veins
Effective velocity in small vessels is less
Increase diameter of blood vessel
Liver > kidney > brain > heart
Skin
Peripheral Vascular resistance
Vein
Venoconstriction with decreased blood flow
Diastolic pressure is maintained, pulse pressure is
narrow
Femoral artery and femoral vein
Sinus tachycardia
Greatest cross sectional area, Contains 5% blood,
Contains less blood than veins, Have single layer of cells
bounding the lumen, Site of gaseous exchange, Lined by
endothelium
Larger quantity of blood than veins, site of gaseous
exchange, lined by endothelium
Greatest cross sectional area, less blood than veins,

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