GOOD MORNING

CARDIAC CYCLE & HEART SOUNDS

CONTENTS

Introduction Cardiovascular System Path and Blood Supply to Heart Blood Vessels, Pulse and Blood Pressure Electrocardiogram Heart Sounds Cardiac Cycle Age related changes Conclusion References

INTRODUCTION
Cardiovascular system comprises of Heart and Blood Vessels. Heart is the central pump and the blood vessels are the series of distributing and collecting tubes. The function of cardio vascular system is to supply oxygen, nutrients and other essential substances to the tissues of the body and to remove metabolic end products from the tissues.

Every heart beat consists of two major periods called systole and diastole. During systole, there is contraction of the cardiac muscle and pumping of blood from the heart. During diastole, there is relaxation of cardiac muscle and filling of blood. Thus, the cardiac cycle is defined as the succession of coordinated activities, which take place during every heart beat.

The mechanical activities of the heart during each cardiac cycle, cause the production of some sounds, which are called Heart Sounds.

Cardio Vascular System

Size of Heart

Average Size of Heart 14 cm long 9 cm wide

Location of Heart
posterior to sternum medial to lungs anterior to vertebral column base lies beneath 2nd rib apex at 5th intercostal space lies upon diaphragm

Wall of the Heart

Wall of the Heart

Heart Chambers
Right Atrium receives blood from inferior vena cava superior vena cava coronary sinus Left Atrium receives blood from pulmonary veins

Right Ventricle receives blood from right atrium

Left Ventricle receives blood from left atrium

Heart Valves

Tricuspid Valve

Pulmonary and Aortic Valve

Skeleton of Heart
fibrous rings to which the heart valves are attached

Path of Blood Through the Heart

Blood Supply to Heart

Angiogram of Coronary Arteries

Blood Vessels
arteries carry blood away from ventricles of heart arterioles receive blood from arteries carry blood to capillaries capillaries sites of exchange of substances between blood and body cells venules receive blood from capillaries veins carry blood toward ventricle of heart

Arteries and Arterioles

Artery
thick strong wall endothelial lining middle layer of smooth muscle and elastic tissue outer layer of connective tissue carries blood under relatively high pressure

Arterioles
thinner walls endothelial lining some smooth muscle tissue small amount of connective tissue helps control blood flow into a capillary

Walls of Artery and Vein

Arteriole
smallest arterioles only have a few smooth muscle fibers capillaries lack muscle fibers

Metarteriole
connects arteriole directly to venule

Capillaries
smallest diameter blood vessels extensions of inner lining of arterioles walls are endothelium only semipermeable sinusoids leaky capillaries

Capillary Network

Regulation of Capillary Blood Flow Precapillary

sphincters may close a capillary respond to needs of the cells low oxygen and nutrients cause sphincter to relax

Exchange in the water and other substances leave capillaries because of net outward pressure Capillaries at the capillaries arteriolar ends
water enters capillaries venular ends because of a net inward pressure substances move in and out along the length of the capillaries according to their respective concentration gradients

Venules and Veins

Venule thinner wall than arteriole less smooth muscle and elastic tissue than arteriole

Vein thinner wall than artery three layers to wall but middle layer is poorly developed some have flaplike valves carries blood under relatively low pressure serves as blood reservoir

Venous Valves

Characteristics of Blood Vessels

Arterial Blood Pressure

Blood Pressure force the blood exerts against the inner walls of the blood vessels

Arterial Blood Pressure rises when ventricles contract falls when ventricles relax systolic pressure maximum pressure diastolic pressure minimum

Pulse

alternate expanding and recoiling of the arterial wall that can be felt

Factors That Influence Arterial Blood Pressure

Control of Blood Pressure

Controlling cardiac output and peripheral resistance regulates blood pressure

If blood pressure rises, baroreceptors initiate the cardioinhibitory reflex, which lowers the blood pressure

Baroreceptors in the Vena Cava signal cardioaccelerator reflex and sends sympathetic impulses to the heart. Baroreceptors in Vena Cava stretched send signal to cardiac center sends sympathetic impulses to the heart Heart rate increases

Dilating arterioles helps regulate blood pressure (peripheral resistance)

Venous Blood Flow

not a direct result of heart action dependent on skeletal muscle contraction breathing venoconstriction

Central Venous Pressure

pressure in the right atrium factors that influence it alter flow of blood into the right atrium affects pressure within the peripheral veins weakly beating heart increases central venous pressure increase in central venous pressure causes blood to back up into peripheral vein

Cardiac Conduction System

Electrocardiogram

An Electrocardiogram is a test that uses sound waves to create a moving picture of the heart

Benefits

Accurate assessment tool that provides useful information Helps doctors determine the degree of the murmur, and assess overall health of heart Time and Cost, ECGs require a substantial amount of time and resources to perform

Drawbacks

recording of electrical changes that occur in the myocardium used to assess hearts ability to conduct impulses
P wave atrial depolarization QRS wave ventricular depolarization T wave ventricular repolarization

Composite of all action potentials of nodal and myocardial cells detected, amplified and recorded by electrodes on arms, legs and chest

P wave

SA node fires, atrial depolarization atrial systole atrial repolarization and diastole (signal obscured) AV node fires, ventricular depolarization ventricular systole ventricular repolarization

QRS complex

T wave

Normal Electrocardiogram (ECG)

Electrical Activity of Myocardium 1)atria begin to

depolarize 2) atria depolarize 3)ventricles begin to depolarize at apex; atria repolarize 4)ventricles depolarize 5) ventricles begin to repolarize at apex 6) ventricles repolarize

Clinical Application
Ventricular fibrillation
rapid, uncoordinated depolarization of ventricles

Tachycardia
rapid heartbeat

Atrial flutter
rapid rate of atrial depolarization

HEART SOUNDS

General Principles Contraction of the myocardium generates pressure changes which result in the orderly movement of blood. Blood flows from an area of high pressure to an area of low pressure, unless flow is blocked by a valve. Events on the right and left sides of the heart are the same, but pressures are lower on the right.

Heart Sounds
Lubb

first heart sound occurs during ventricular systole A-V valves closing second heart sound occurs during ventricular diastole pulmonary and aortic semilunar valves closing

Dupp

Murmur abnormal heart sound

Auscultation - listening to sounds made by body First heart sound (S1), louder and longer lubb, occurs with closure of AV valves Second heart sound (S2), softer and sharper dupp occurs with closure of semilunar valves S3 - rarely heard in people > 30

A heart which is beating normal makes two sounds, "lubb" when the valves between the atria and ventricles close, and "dupp" when the valves between the ventricles and the major arteries close.

Cardiac valves

Cardiac chambers Normal Blood Flow

A heart murmur is an abnormal, extra sound during the heartbeat cycle made by blood moving through the heart and its valves

Abnormal Blood Flow, (pulmonary valve stenosis )

Cardiovascular diagram of a normal heart sound

Lubb-dupp associated with the human heartbeat

Cardiovascular Diagram of a Early systolic murmur

Notice the extra noise in-between the lubb-dupp. This can be attributed to a heart murmur

CARDIAC CYCLE

The cardiac cycle is regulated by the cardiac center in the medulla oblongata which regulates sympathetic and parasympa-thetic input.

Major Events of Cardiac Cycle

Atrial systole Isovolumetric contraction Ventricular ejection Isovolumetric relaxation Ventricular filling

Atrial Systole/Ventricular Diastole

blood flows passively into ventricles remaining 30% of blood pushed into ventricles A-V valves open/semilunar valves close ventricles relaxed ventricular pressure increases

Ventricular Systole/Atrial diastole

A-V valves close atria relaxed blood flows into atria ventricular pressure increases and opens semilunar valves blood flows into pulmonary trunk and aorta

Rate of Cardiac Cycle

Atrial systole, 0.1 sec Ventricular systole, 0.3 sec Quiescent period, 0.4 sec Total 0.8 sec, heart rate 75 bpm

Diastole and Systole

Diastole - the time during which cardiac muscle relaxes. Systole - the time in which cardiac muscle is contracting. I - The Heart at Rest : Atrial and Ventricular Diastole

While both atria and ventricles are relaxing, the atria begin filing with blood from the veins while the ventricles have just completed a contraction As the ventricles relax the AV valves between the atria and ventricles open, and blood flows from the atria to the ventricles.

II - Completion of Ventricular Filling : Atrial Systole

The last 20% of the filling of the ventricles is accomplished when the atria contract. Atrial systole begins following depolarization of the SA node. Atrial contraction can aid filling of the ventricles in stenosis of the AV valves. The force of atrial contraction can also push blood back into the vein. This can be observed by the pulse in jugular vein of a normal person lying w/ the head and chest elevated about 30 degrees. If there is an observable jugular pulse higher on the neck of a person sitting upright, it is indication that the pressure in the atria is higher than normal.

III- Early Ventricular Contraction and the 1st Heart Sound

Ventricular Systole begins at the apex of the heart as spiral bands of muscle squeeze the blood upward toward the base. Blood pushing upward on the underside of the AV valve forces them closed so that blood cannot flow back into the atria. Vibrations following closure of the AV valves creates the 1st heart sound, the lub of lub-dup.

IV - The heart pumps: Ventricular Ejection

As the ventricles contract, they generate enough pressure to open the semilunar valves and the blood is pushed into the arteries. The pressure created by ventricular contraction becomes the driving force for blood flow.

V - Ventricular Relaxation and the 2nd Heart Sound

As the ventricles begin to relax, ventricular pressure decreases. Once ventricular pressure falls below the pressure in the arteries blood starts to flow backward into the heart. This backflow fills the cusps of the semilunar valves, forcing them together into the closed position. The vibrations of the semilunar valve closure is the 2nd heart sound, the dup of lub-dup. The AV valves open once the pressure in the ventricles falls below the pressure in the atria and the cycle starts again.

ATRIAL SYSTOLE - Heart

Prior to atrial systole, blood has been flowing passively from the atrium into the ventricle through the open AV valve. During atrial systole the atrium contracts and tops off the volume in the ventricle with only a small amount of blood. Atrial contraction is complete before the ventricle begins to contract.

ATRIAL SYSTOLE Pressures & Volumes

The "a" wave occurs when the atrium contracts, increasing atrial pressure (yellow). Blood arriving at the heart cannot enter the atrium so it flows back up the jugular vein, causing the first discernible wave in the jugular venous pulse. Atrial pressure drops when the atria stop contracting. During atrial systole the atrium contracts and tops off the volume in the ventricle with only a small amount of blood. Atrial contraction is complete before the ventricle begins to contract.

ATRIAL SYSTOLE ECG

An impulse arising from the SA node results in depolarization and contraction of the atria (the right atrium contracts slightly before the left atrium). The P wave is due to this atrial depolarization. The PR segment is electrically quiet as the depolarization proceeds to the AV node. This brief pause before contraction allows the ventricles to fill completely with blood.

ATRIAL SYSTOLE Heart Sounds

A fourth heart sound (S4) is abnormal and is associated with the end of atrial emptying after atrial contraction. It occurs with hypertrophic congestive heart failure, massive pulmonary embolism, tricuspid incompetence, or cor pulmonale.

ISOVOLUMETRIC CONTRACTION The Beginning of systole

ISOVOLUMETRIC CONTRACTION Heart

The atrioventricular (AV) valves close at the beginning of this phase. Electrically, ventricular systole is defined as the interval between the QRS complex and the end of the T wave (the Q-T interval). Mechanically, ventricular systole is defined as the interval between the closing of the AV valves and the opening of the semilunar valves (aortic and pulmonary valves).

ISOVOLUMETRIC CONTRACTION Pressures & Volumes

The AV valves close when the pressure in the ventricles (red) exceeds the pressure in the atria (yellow). As the ventricles contract isovolumetrically -- their volume does not change (white) -- the pressure inside increases, approaching the pressure in the aorta and pulmonary arteries (green).

ISOVOLUMETRIC CONTRACTION ECG

The electrical impulse propagates from the AV node through the His bundle and Purkinje system to allow the ventricles to contract from the apex of the heart towards the base. The QRS complex is due to ventricular depolarization, and it marks the beginning of ventricular systole. It is so large that it masks the underlying atrial repolarization signal. the ventricles to fill completely with blood.

ISOVOLUMETRIC CONTRACTION Heart Sounds

The first heart sound (S1, "lub") is due to the closing AV valves and associated blood turbulence.

RAPID EJECTION

RAPID EJECTION Heart

The semilunar (aortic and pulmonary) valves open at the beginning of this phase.

RAPID EJECTION Pressures & Volumes

While the ventricles continue contracting, the pressure in the ventricles (red) exceeds the pressure in the aorta and pulmonary arteries (green); the semilunar valves open, blood exits the ventricles, and the volume in the ventricles decreases rapidly (white). As more blood enters the arteries, pressure there builds until the flow of blood reaches a peak. The "c" wave of atrial pressure is not normally discernible in the jugular venous pulse. Right ventricular contraction pushes the tricuspid valve into the atrium and increases atrial pressure, creating a small wave into the jugular vein. It is normally simultaneous with the carotid pulse.

RAPID EJECTION ECG

No Deflections

RAPID EJECTION Heart Sounds

None

REDUCED EJECTION The end of systole

REDUCED EJECTION Heart

At the end of this phase the semilunar (aortic and pulmonary) valves close.

REDUCED EJECTION Pressures & Volumes

After the peak in ventricular and arterial pressures (red and green), blood flow out of the ventricles decreases and ventricular volume decreases more slowly (white). When the pressure in the ventricles falls below the pressure in the arteries, blood in the arteries begins to flow back toward the ventricles and causes the semilunar valves to close. This marks the end of ventricular systole mechanically.

REDUCED EJECTION ECG

The T wave is due to ventricular repolarization. The end of the T wave marks the end of ventricular systole electrically.

REDUCED EJECTION Heart Sounds

None

ISOVOLUMETRIC RELAXATION The beginning of Diastole

ISOVOLUMETRIC RELAXATION Heart

At the beginning of this phase the AV valves are closed.

ISOVOLUMETRIC RELAXATION Pressures & Volumes

Throughout this and the previous two phases, the atrium in diastole has been filling with blood on top of the closed AV valve, causing atrial pressure to rise gradually (yellow). The "v" wave is due to the back flow of blood after it hits the closed AV valve. It is the second discernible wave of the jugular venous pulse. The pressure in the ventricles (red) continues to drop. Ventricular volume (white) is at a minimum and is ready to be filled again with blood.

ISOVOLUMETRIC RELAXATION ECG

No Deflections

ISOVOLUMETRIC RELAXATION Heart Sounds

The second heart sound (S2, "dup") occurs when the semilunar (aortic and pulmonary) valves close. S2 is normally split because the aortic valve closes slightly earlier than the pulmonary valve.

RAPID VENTRICULAR FILLING

RAPID VENTRICULAR FILLING Heart

Once the AV valves open, blood that has accumulated in the atria flows rapidly into the ventricles.

RAPID VENTRICULAR FILLING Pressures & Volumes

Ventricular volume (white) increases rapidly as blood flows from the atria into the ventricles.

RAPID VENTRICULAR FILLING ECG

No Deflections

RAPID VENTRICULAR FILLING Heart Sounds

A third heart sound (S3) is usually abnormal and is due to rapid passive ventricular filling. It occurs in dilated congestive heart failure, severe hypertension, myocardial infarction, or mitral incompetence.

REDUCED VENTRICULAR FILLING (Diastasis)

REDUCED VENTRICULAR FILLING Heart

Rest of blood that has accumulated in the atria flows slowly into the ventricles.

REDUCED VENTRICULAR FILLING Pressures & Volumes

Ventricular volume (white) increases more slowly now. The ventricles continue to fill with blood until they are nearly full.

REDUCED VENTRICULAR FILLING ECG

No Deflections

REDUCED VENTRICULAR FILLING Heart Sounds

None

Hypertension

Arterial pressure is too high Sometimes cause is unknown, or is secondary to disease Variety of causes/ risk factors are sedentary lifestyle smoking obesity diet (excess sodium; cholesterol; calories in general) stress arteriosclerosis genetic factors

Consequences

heart has to work harder; left ventricle enlarges atherosclerosis may affect coronary arteries as well (which have to work harder anyway) deficient blood supply to other parts of body damage to blood vessels heart failure

Treatment

Quit smoking; adjust diet; exercise Drug therapies- strategies differ

Reduce heart rate calcium channel blockers reduce calcium flow into heart muscle and therefore heart rate, relax smooth muscle lining coronary arteries beta blockers (reduce stimulation by sympathetic nervous system)

Vasodilators (such as nitroglycerin) open up blood vessels (reduce resistance) If heart is actually failing, digitalis increases efficiency of heart muscle Anti-hypertensive drugs may be taken in combination

Age related changes

cholesterol deposition in blood vessels heart enlargement death of cardiac muscle cells increase in fibrous connective tissue of the heart increase in adipose tissue of the heart increase in blood pressure decrease in resting heart rate

Coronary artery disease results when coronary arteries cannot deliver blood adequately Usual cause: plaques in arterial walls Angina pectoris (pain) results when body is not receiving adequate oxygen Myocardial infarction (heart attack) results when blood supply to heart is completely blocked; muscle dies

Conclusion
To clinicians heart sounds provide important information about the normal function of the heart and assist in diagnosing cardiac abnormalities. Any abnormal heart sounds and certain murmurs are important indicators of specific cardiac abnormalities. Hence, the integrated function of heart and blood vessel constitute an important , basic part of routine clinical examination and practice.

References

Understanding Human anatomy & Physiology : Sylvia Maden 2 nd Edition Textbook of Medical Physiology : Guyton & Hall 9th Edition Anatomy & Physiology : Seeley, Stephens, Tate 2nd Edition Essentials of Medical Physiology : K Sembulingam Physiology : Berne, Levy 3rd edition Stanley Salmons. Text book of Grays Anatomy [P.L Williams] 38th edition Cunninghams manual of practical anatomy (vol. 2 Abdomen & Thorax) www.google.com www.ghorayeb.com www.ask.com

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