Anatomy/Cardiovascular System

The cardiovascular system, also known as the circulatory system is a topic in Anatomy and Physiology. It was last tested in 2015 and is expected to return for the 2019 season.

Functions

 * Transportation: The cardiovascular system transports nutrients, oxygen, and hormones to the cells and metabolic wastes like carbon dioxide away from the cells.
 * Protection: Circulating throughout the blood are leukocytes (white blood cells) and other defenses against antigens.
 * Regulation: Homeostasis is maintained in the body through regulation of pH, temperature, and water content of cells.

Formulas
To determine the values for these calculations, data like blood pressure and heart rate must be measured with a sphygmomanometer. When this is being used, a doctor puts a cuff around the arm and pumps it up, exerting pressure and cutting off blood flow. As the pressure is being released, the blood starts to flow again, and doctors listen to these sounds to measure the systolic pressure and diastolic pressure. Heart rate can be measured by counting the number of beats felt in a minute and doesn't require any machinery.


 * Heart Rate (HR): Number of heartbeats per minute
 * Stroke Volume (SV): Amount of blood pumped out of the heart in one beat: Stroke Volume = End Diastolic Volume - End Systolic Volume (SV = EDV - ESV)
 * Pulse Pressure (PP): The difference between systolic pressure (SP) and diastolic pressure (DP) - Pulse Pressure = Systolic Pressure - Diastolic Pressure (PP = SP - DP)
 * Cardiac Output (CO): Amount of blood pumped out of the heart in one minute - Cardiac Output = Heart Rate x Stroke Volume (CO = HR x SV)
 * Mean Arterial Pressure (MAP): The average pressure in the arteries during one cardiac cycle - Mean Arterial Pressure = 2/3 Diastolic Pressure + 1/3 Systolic Pressure (MAP = 2/3 DP + 1/3 SP) OR Mean Arterial Pressure = Diastolic Pressure + 1/3 Pulse Pressure (MAP = DP + 1/3 PP)

The Heart


The heart is the main organ of the cardiovascular system. It is a muscular organ about the size of one's fist and weighs between 7-15 ounces. It acts as a pump and propels blood through the blood vessels. The average heart beats about 100,000 times a day, circulating about 2,000 gallons of blood through about 60,000 miles of blood vessels. An adult has, on average, 5 to 6 quarts of blood. The average adult resting heart rate is 72 bpm (beats per minute).

The heart is located in the middle of the thorax with part of it offset slightly to the left. It is underneath the sternum (breastbone) and is surrounded by the lungs. It sits on the diaphragm and is protected by the ribcage. It is inside of a sac known as the pericardium.

In general, the left side of the heart (which is located on the right side in a diagram) is the pump for the systemic circuit, which takes blood to and from the body. The right side of the heart (which is located on the left in a diagram), is the pump for the pulmonary circuit, which takes blood to and from the lungs.

The sound of the heartbeat can be described as "lubb-dupp". The first sound, or the "lubb", comes from the closing of the atrioventricular valves, which are the tricuspid and mitral (bicuspid) valves. The second sound, which is the "dupp", comes from the closing of the other two valves (semilunar valves), which are the aortic and pulmonary valves. After the dupp should be a small pause before the lubb comes again.

Inside the heart are four chambers, two superior atria (left and right) and two inferior ventricles (left and right). The atria are areas under low pressure while the ventricles are areas under high pressure. The left side of the heart is separated from the right side of the heart by a wall of muscle known as the septum. As a general rule, ventricles are more muscular than atria because they have to pump blood to another location outside of the heart. The left ventricle is the most muscular chamber of the heart. For the right ventricle, this location is the lungs while for the left ventricle, this location is the rest of the body via the aorta. There are also four valves inside the heart: the tricuspid valve, the pulmonary valve, the mitral (bicuspid) valve, and the aortic valve. The purpose of the valves is to prevent backflow of blood back into the chamber that it came from.

Main Parts in Order of Blood Flow (also includes vessels leading in and out of the heart): Superior Vena Cava/Inferior Vena Cava, right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary artery, pulmonary capillary bed (lungs), pulmonary veins, left atrium, bicuspid (mitral valve), left ventricle, aortic valve, aorta, arteries, arterioles, capillaries, venules, veins, Superior vena cava/inferior vena cava.

Parts of the Heart


Below are the specific parts of the heart in the order that blood travels.


 * Superior Vena Cava: The superior vena cava is a tube located superior to the right atrium. It brings deoxygenated blood from the upper parts of the body to the heart.
 * Inferior Vena Cava: The inferior vena cava is a tube located inferior to the right atrium. It brings deoxygenated blood from the lower parts of the body to the heart.
 * Right Atrium: The right atrium takes in deoxygenated blood from the superior and inferior vena cavae. It then pumps the blood through the tricuspid valve and into the right ventricle. The Sinoatrial (SA) node is located on the roof of the right atrium.
 * Tricuspid Valve: The tricuspid valve, located between the right atrium and the right ventricle, prevents blood flow backward from the ventricle to the atrium. It is called the tricuspid valve because it has three leaflets.
 * Right Ventricle: The right ventricle takes deoxygenated blood that has traveled through the tricuspid valve from the right atrium. It then pumps that blood through the pulmonary valve and into the pulmonary trunk.
 * Pulmonary Valve: The pulmonary valve is one of the four valves of the heart, located between the right ventricle and the pulmonary trunk. Like all valves, it prevents blood from flowing backwards. The pulmonary valve is a semilunar valve, which has three cusps.
 * Pulmonary Trunk: The pulmonary trunk takes in deoxygenated blood from the right ventricle and takes it to the pulmonary arteries.
 * Pulmonary Arteries: The pulmonary arteries are the last part of the pulmonary circuit of the heart. They take deoxygenated blood from the pulmonary trunk and the right ventricle and take it to the lungs so that gas exchange can occur. There are two pulmonary arteries, the left and the right, which take the deoxygenated blood to the left and right lungs, respectively.
 * Pulmonary Capillary Beds: The pulmonary capillary beds are located in the alveoli of the lungs. They are responsible for exchanging the carbon dioxide in the venous blood for oxygen.
 * Pulmonary Veins: After gas exchange occurs at the capillary beds of the lungs, oxygenated blood goes back to the heart via the left and right pulmonary veins. They then take the blood to the left atrium.
 * Left Atrium: The left atrium receives oxygenated blood from the left and right pulmonary veins. It then pumps the blood through the mitral valve and into the left ventricle.
 * Mitral Valve: The mitral valve is another of the four valves of the heart. It allows blood to pass from the left atrium to the left ventricle and prevents backflow back into the atrium. It is also known as the bicuspid valve because it has two leaflets.
 * Left Ventricle: The left ventricle takes in oxygenated blood from the left atrium and pumps through the aortic valve and into the aorta and then the whole body. It is the most muscular chamber of the heart due to the fact that it has to pump blood to the rest of the body.
 * Aortic Valve: The aortic valve is the last of the four valves of the heart. It allows blood to pass from the left ventricle and into the aorta. It is a semilunar valve and has three cusps.
 * Aorta: The aorta receives oxygenated blood from the left ventricle to take to the whole body. It is the largest artery of the body, about two centimeters in width. Three smaller arteries branch off of the aortic arch, which are the brachiocephalic artery, the left common carotid artery, and the left subclavian artery, which all supply oxygenated blood to the head and arms.

A helpful playlist of videos on the heart

Layers of Heart Tissue
The heart wall has three main layers: the endocardium, the myocardium, and the epicardium (listed from inside to outside).
 * Endocardium: The endocardium is the most interior layer of the heart wall. It is simple squamous epithelium and lines the inside of the heart's chambers. It is very smooth and is responsible for keeping the blood from sticking to the wall and potentially forming blood clots.
 * Myocardium: The myocardium is the next most interior layer of the heart wall. It is the middle and muscular layer, which contains the cardiac muscle tissue. It is the thickest part of the wall and makes up most of the mass of the heart wall. The function of the myocardium is to contract and pump blood throughout the heart.
 * Epicardium: The epicardium is the outermost layer. It is another name for the visceral layer of the pericardium, which is the sac that contains the heart. The epicardium is a layer of serious membrane that lubricates and protects the outside of the heart.
 * Pericardium: The pericardium is the sac that the heart is inside of. Pericardium is the name for the walls and lining of the pericardial cavity. The pericardial cavity is a fluid-filled cavity with two walls on each side. The outer layer of the pericardium is the parietal layer (made of dense, fibrous connective tissue) while the inside layer is the visceral layer. The pericardium is a serous membrane that produces serous fluid to lubricate the heart. Another purpose of the pericardium is holding the heart in position and maintaining a hollow space (pericardial cavity) for the heart to expand into.

Electrical Conduction System
The heart contains a complex electrical system in which electricity moves to the different parts of the heart to allow for muscle contraction.



Parts of Electrical Conduction in the Heart
The image on the right shows the heart's electrical system with numbers in the approximate order that electricity travels (electricity travels through some parts at the same time). The labels for the numbers are as followed:
 * 1) Sinoatrial Node: Also known as the SA node, the sinoatrial node is located on the roof of the right atrium. It is the natural pacemaker of the heart.
 * 2) Intra-atrial Pathway: The intra-atrial pathway carries electricity from the sinoatrial node on the roof of the right atrium to the left atrium. This pathway leads to the Bachmann's bundle, which is a band of cardiac muscle in the left atrium which controls contraction of the left atrium.
 * 3) Internodal Pathway: The internodal pathway carries electricity from the sinoatrial node on the roof of the right atrium to the atrioventricular (AV) node located between the atria and the ventricles.
 * 4) Atrioventricular Node: Also known as the AV node, the atrioventricular node is the backup pacemaker. It is located in the interatrial septum. Its function is to slow conduction of electricity between the atria and the ventricles so blood can fill up in the ventricles and so that they do not contract at the same time.
 * 5) Bundle of His: The bundle of His is the last part of atrial conduction. It is made up of myocardial cells and is located in the ventricular wall (interventricular septum) and allows the electricity to move from the AV node and into the bundle branches in the ventricles.
 * 6) Right Bundle Branch: The right bundle branch comes off of the Bundle of His. It is one of the two branches that come off of it, with the other branch being the left bundle branch. The right bundle branch carries electricity to the right ventricle.
 * 7) Purkinje Fibers: The Purkinje fibers are located in the subendocardium layer of the heart tissue, which is the innermost layer. They distribute electrical energy to the myocardium, which is the layer of muscular tissue.
 * 8) Left Bundle Branch: The left bundle branch comes off of the Bundle of His and is the second of the two branches that come off of it. This bundle branch carries electricity to the left ventricle.

Electrocardiograms
Abbreviated EKG or ECG, an electrocardiogram is a depiction of the electrical conduction of the heart. It is taken by a machine known as an electrocardiograph. When an electrocardiogram is being taken with a traditional 12 lead electrocardiograph, 10 electrodes are placed on the limbs and chest of the person. This allows for the electrical conduction of the heart to be measured from 12 different perspectives. The machine is usually run for about 10 seconds. An EKG can help cardiologists diagnose cardiovascular disorders by detecting irregular heartbeat patterns (arrhythmias) and finding any possible areas of heart muscle damage. It may also be useful in monitoring the effects of certain medications.

Reading an Electrocardiogram



 * P Wave: The P wave, shown by the first small bump in the electrocardiogram, marks the beginning of the heartbeat. When the electrical impulse is first sent from the sinoatrial node in the right atrium, it travels to the atrioventricular node and atrial muscle. The P wave is then generated by the activation of the muscle in the atria (atrial depolarization). Its duration should not be longer than .11 seconds.
 * QRS Complex: The QRS complex is made up of the Q, R, and S waves, and is shown by a small peak below the baseline (Q wave), a large peak upward (R wave), and a peak slightly below the baseline again (S wave). After the electrical impulse reaches the AV node, it travels through the bundle of His, then the bundle branches, and then the Purkinje fibers to finally get to the ventricular muscle. When the septum is activated, the Q wave is generated. Next the ventricular free walls (both left and right) get activated, generating the R wave. Lastly, a few small areas which didn't get the electrical impulse before finally get it, generating the S wave. All in all, the QRS complex shows ventricular depolarization, and shouldn't last longer than .1 seconds.
 * T Wave: The T wave is the last bump for one beat on an ECG. It should be larger than the bump that is the P wave. It indicates ventricular repolarization, or relaxation of the ventricles.
 * ST Segment: The ST segment is the line between the S wave and the T wave. In a normal EKG, this segment should be mostly a straight line along the baseline. If the line goes up, or is elevated, more than 1mm, it indicates early ventricular repolarization, which is irregular and can lead to other cardiovascular problems.
 * PR Interval: The PR interval is the time between the P wave and the R wave. It indicates the conduction time of the atrioventricular node, or the length of time it takes for the impulse to go through the AV node to the bundle of His. The normal duration time is .12 to .20 seconds.
 * QT Interval: The QT Interval is the measure between the Q wave and the T wave. It measures the total time between ventricular depolarization and repolarization. The time for this measure is dependent on the heart rate, but the normal duration is .32-.4 seconds for a heart rate between 65-90bpm.

Mechanics of the Cardiac Cycle


The cardiac cycle is the sequence of events that occur in a single heartbeat and consists of two main parts: systole (ventricular contraction) and diastole (ventricular relaxation) of the atria and the ventricles.

Blood Vessel
All three types, arteries, veins, capillaries, and also arterioles and venules. You will need to know their structure, their functions, and how they are alike and different. There are three layers to all vessels except for capillaries, which have one epithelial cell thick walls to let nutrients and other materials to go through.

a. Arteries and Arterioles. These blood vessels carry blood away from the heart. For the most part, they carry oxygen rich, "red" blood, but there is one exception. The pulmonary arteries carry oxygen poor, "blue" blood away from the heart to the lungs. These vessels have very thick muscle cell layers since they need to pump the blood. Arteries are the vessels that lead immediately from the heart and other that lead from those. Arterioles are basically very small versions of arteries, with much fewer muscle cells. They feed to the capillaries.

b. Veins and venules. These blood vessels carry blood back to the heart from the rest of the body. For the most part, they carry oxygen poor, "blue" blood, but there is one exception. The pulmonary veins carry oxygen rich, "red" blood back to the heart from the lungs. These vessels have very small muscle layers and have valves. Venules are very small versions of veins. They directly take blood from the capillaries. Unlike arteries, they are low pressure and rely on contractions to carry blood back to the heart

c. Capillaries. Capillaries are the smallest types of blood vessels. It is in the capillaries that oxygen exchange and other exchanges of nutrients and wastes take place. It is so because capillaries only have a cell thick wall made of epithelial cells, and materials can easily pass through. Arterioles feed into capillaries and venules take used blood from it.

Blood
There are three main components of blood:

Red Blood Cells (Erythrocytes)- these blood cells are formed in the red bone marrow and are formed in the process of hematopoiesis (or more specifically, erythropoiesis). These cells lack a nucleus and are used to carry oxygen to the cells throughout the body. Each erythrocyte has a lifespan of about 120 days, and at the end of their lifespan, they are filtered out of the blood in the spleen. Erythrocytes also cannot reproduce. These cells contain hemoglobin- a protein that is used to allow the erythrocyte to carry oxygen.

Platelets (Thrombocytes)- These blood cells are also formed in the red bone marrow and are formed in the process of hematopoiesis. These cells also do not contain a nucleus. These cells are produced from fragmentation of a larger precursor cell- the megakaryocyte. These cells help allow the blood to clot. Therefore this cell is necessary for the process of hemostasis- the process by which bleeding stops.

White Blood Cells (Leukocytes)- These blood cells are also formed in the red bone marrow and are formed in the process of hematopoiesis. Leukocytes help aid in the immune system. There are many different kinds of leukocytes, including: lymphocytes, basophils, neutrophils, eosinophils, monocyte, macrophage.


 * Types of White Blood Cells
 * Granulocytes - Granulocytes are white blood cells that have differently stained granules when viewed under a microscope. Granulocytes are Basophils, Neutrophils, and Eosinophils.
 * Basophils - Basophils are a type of White Blood Cell, and more specifically a granulocyte. It is actually the least common white blood cell in the body. They are thought to be associated with allergies, as they can secrete a substance known as histamine.
 * Agranuloctyes - Agranulocytes are white blood cells that lack visible granules in the cytoplasm and have spherical or ovoid nuclei. Agranulocytes are Lymphocytes and Monocytes.
 * Lymphoctyes - Lymphyoctyes makeup about 25% of all white blood cells in the blood (2nd most numerous) and are often found in lymphatic tissue. They contain a large, purple staining nucleus that takes up most of the volume of the cell.
 * Monocytes - These white blood cells are less common, making up only around 3-8% of the total amount of white blood cells in the blood. They are the one of the largest cells in the body and contain a U-shaped nucleus.

Hematopoiesis
Hematopoiesis is the process by which all blood cells (erythrocytes, thrombocytes, and leukocytes) are made. All the blood cells start out as a stem cell. Then the stem cell specializes to eventually become one of the types of blood cells.

Disorders Mentioned in Rules
Congestive Heart Failure:
 * General Overview: AKA heart failure, CHF is the leading cause of hospitalization in people over 65, in which the heart is unable to pump properly. Left CHF is more common than right. In systolic left CHF, the left ventricle cannot contract normally, and reduces force that blood is being pushed out. In diastolic left CHF, the left ventricle stiffens and cannot relax, which prevents heart from filling with blood in between beats. Right CHF usually occurs when left CHF spreads from being untreated, and causes fluid to get into the lungs. Four classes of CHF: 1 (experiencing no symptoms during physical activity), 2 (physical activity causes fatigue, palpitations, shortness of breath), 3 (mild exercise causes symptoms very quickly), 4 (no physical activity can be done without facing symptoms).
 * Causes: Hypertension can cause heart muscle to become thicker and overworked, eventually causing the muscle to not work as well. Coronary Artery Disease limits blood flow to the heart muscle, causing it to not work as well as it should. Valves that don’t work correctly force ventricles to work harder to pump blood.
 * Diagnosis: Blood tests, EKG, Chest X-ray, Echocardiogram, Exercise (stress) test, cardiac catheterization, MRI.
 * Symptoms: Early: fatigue, swelling of legs, ankles, and feet, weight gain, increased urination need. Mid: irregular heartbeat, cough from lungs, wheezing, shortness of breath (indicates pulmonary edema). Late: chest pain, rapid breathing, blue skin, fainting.
 * Treatment: No cure, treatment of symptoms through heart healthy diet, and exercising. Medications include ACE inhibitors, Beta blockers, diuretics, angioplasty, valve repair surgery.

Atrial Fibrillation:
 * General Overview: AKA arrhythmia, is an irregular heartbeat that is caused by the electrical system of the heart not functioning properly. It increases risk of stroke and heart disease. It can cause blood to pool up in the atria because the atria and ventricles are not contracting in the pattern they’re supposed to.
 * Causes: Age, genetics, heart disease, hypertension, COPD, emphysema, pulmonary embolism, sick sinus syndrome.
 * Diagnosis: Cardiologists may listen to heartbeat to get pulse and rhythm, may listen to lungs, and check for signs of heart valve or heart muscle problems. An EKG will be taken and a Holter monitor might be placed for a day or two.
 * Symptoms: Fatigue, irregular heartbeat, fluttering or “thumping” in chest, dizziness, shortness of breath, anxiety, chest pain (indicative of heart attack), chest pressure, sweating, fatigue, weakness, excessive sweating.
 * Treatment: Blood thinners, rate controllers, rhythm controllers, anticoagulants, beta blockers, calcium channel blockers, digoxin, sodium channel blockers, potassium channel blockers, electrical cardioversion (like AED), ablation, pacemaker, open heart maze procedure.

Myocardial Infarction (Heart Attack):
 * General Overview: AKA heart attack, a myocardial infarction is the death of heart muscle due to the muscle not getting enough oxygen. Heart attacks usually occur over the span of several hours. Heart attacks are usually preceded by anginas, which are brief periods of chest pain.
 * Causes: Coronary artery disease is the main cause of a heart attack, for it blocks the blood flow to the muscle of the heart, causing it to die. Risks include hypertension, high cholesterol levels, obesity, smoking, genetic history, and sedentary lifestyle.
 * Diagnosis: Diagnosis is done through an EKG, which can also help determine which areas of cardiac muscle were affected by the heart attack.
 * Symptoms: Discomfort in chest, arms, or breastbone area, choking feeling, sweating, nausea, rapid/irregular heartbeat, shortness of breath, dizziness.
 * Treatment: Aspirin, to prevent blood clotting, other antiplatelets, angioplasties or insertion of stents may be done to prevent another one from occurring.

Atherosclerosis:
 * General Overview: Clogging of arteries due to the buildup of fats (cholesterol), and narrows the blood vessels. It is the most common cause of cardiovascular disease.
 * Causes: Begins with cholesterol or hypertension damaging endothelium of arteries. LDL cholesterol gathers to form plaque, narrowing and hardening arteries. People have a higher risk if they have hypertension, high LDL cholesterol levels, and smoking.
 * Diagnosis: Angiogram is done to determine sites of blockage.
 * Symptoms: None when starting off, start to occur after plaque ruptures or blockage is so severe as to block blood flow. When they do occur, commonly there will be pain in legs or chest when exerting.
 * Treatment: Stents, angioplasty, coronary bypass surgery, blood thinners, cholesterol medication (statins), heart-healthy diet, more exercise, weight loss.

Bradycardia:
 * General Overview: Low heart rate, characterized under 60 bpm at rest. Occasionally, having bradycardia will not mean anything, as it might be natural. Bradycardia is diagnosed only when symptoms are present.
 * Causes: May be caused as a result of the heart’s electrical system not functioning properly. Factors that increase risk include smoking, drug abuse, hypertension, thyroid disease, and some medications like beta blockers.
 * Diagnosis: EKG will be done and heart monitor may be put on for 24 hours.
 * Symptoms: Dizziness, shortness of breath, fainting, confusion, fatigue, weak pulse.
 * Treatment: Treatment is based on cause, so if hypothyroidism is the cause, then they’ll treat for hypothyroidism. Pacemaker may also be inserted to set normal rhythm of heart.

Tachycardia:
 * General Overview: Type of arrhythmia in which heart beats faster than normal while at rest, characterized with over 100 bpm. Three types: supraventricular, ventricular, and sinus tachycardia. In supraventricular, electrical signals in atria misfire, causing heart rate to speed up, which prevents blood from filling the chambers and leads to decreased flow of blood to body. Ventricular is similar, except misfiring occurs in ventricles, which still leads to decreased flow of blood to body. In sinus tachycardia, SA node sends out signals faster than normal, but flow of blood is normal.
 * Causes: Sinus tachycardia can be caused by strenuous exercise, anxiety, fever, fear, stress, certain medications, street drugs, anemia, hyperthyroidism, or heart failure. Supraventricular affects those that smoke, drink, or have a lot of caffeine. Ventricular occurs with lack of oxygen, sarcoidosis, electrolyte imbalance, cardiomyopathy, or some medications.
 * Diagnosis: Tests like EKG, exercise stress tests, or magnetic source imaging may be done.
 * Symptoms: Dizziness, lightheadedness, shortness of breath, fainting, heart palpitations, chest pain, rapid pulse. Sometimes, people are asymptomatic.
 * Treatment: Less caffeine and alcohol consumption, quit smoking, fibrillator (reset electrical system).