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GOOD MORNINGGOOD MORNING
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CARDIAC CYCLE&
HEART SOUNDS
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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
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INTRODUCTION
Cardiovascular system comprises ofHeart and Blood Vessels. Heart is thecentral pump and the blood vessels are
the series of distributing and collectingtubes. The function of cardio vascularsystem is to supply oxygen, nutrientsand other essential substances to the
tissues of the body and to removemetabolic end products from thetissues.
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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 muscleand filling of blood.
Thus, the cardiac cycle is defined as the
succession of coordinated activities,which take place during every heart
beat.
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The mechanical activities of the heart
during each cardiac cycle, cause theproduction of some sounds, which are
called Heart Sounds.
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Cardio Vascular System
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Size of Heart
Average Size of Heart
14 cm long
9 cm wide
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Location of Heart
posterior to sternum
medial to lungs
anterior to vertebral
columnbase lies beneath 2nd rib
apex at 5th intercostal
space
lies upon diaphragm
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Wall of the Heart
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Wall of the Heart
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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
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Heart Valves
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Pulmonary and Aortic ValveTricuspid Valve
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Skeleton of Heartfibrous rings to which the heart valves are attached
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Path of Blood Through theHeart
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Blood Supply to Heart
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Angiogram of CoronaryArteries
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Blood Vessels
arteriescarry blood away from ventricles of heart
arterioles
receive blood from arteries
carry blood to capillariescapillaries
sites of exchange of substances between blood and
body cells
venules
receive blood from capillaries
veins
carry blood toward ventricle of heart
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Arteries and Arterioles
Arterythick strong wall
endothelial lining
middle layer ofsmooth muscle and
elastic tissue
outer layer of
connective tissue
carries blood under
relatively high
pressure
Arteriolesthinner walls
endothelial lining
some smoothmuscle tissue
small amount of
connective tissue
helps control
blood flow into a
capillary
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Walls of Artery and Vein
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Arteriolesmallest arterioles only have a few smooth muscle fibers
capillaries lack muscle fibers
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Metarterioleconnects arteriole directly to venule
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Capillaries
smallest diameter blood vessels
extensions of inner lining of
arterioles
walls are endothelium only
semipermeable
sinusoids leaky capillaries
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Capillary Network
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Regulation of CapillaryBlood Flow
Precapillarysphincters
may close a
capillary
respond to needsof
the cells
low oxygen and
nutrients cause
sphincter to relax
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Exchange in theCapillarieswater and other substances leave capillaries because of net outward pressure
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
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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 valvescarries blood under relatively low pressure
serves as blood reservoir
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Venous Valves
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Characteristics of BloodVessels
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Arterial Blood Pressure
Blood Pressure force the blood exerts against the inner walls of the
blood vessels
Arterial Blood Pressurerises when ventricles contract
falls when ventricles relax
systolic pressure maximum pressure
diastolic pressure minimum
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Pulse
alternate expanding
and recoiling of the
arterial wall that
can be felt
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Factors That InfluenceArterial Blood Pressure
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Control of Blood PressureControlling cardiac output and peripheral resistance regulates blood pressure
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If blood pressure rises, baroreceptors initiatethe cardioinhibitory reflex, which lowers theblood pressure
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Baroreceptors in the Vena Cava signal
cardioaccelerator reflex and sends
sympathetic impulses to the heart.
Baroreceptors in Vena Cava stretchedsend signal to cardiac center sends
sympathetic impulses to the heart
Heart rate increases
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Dilating arterioles helps regulate blood
pressure
(peripheral resistance)
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Venous Blood Flow
not a direct result of heart
action
dependent on
skeletal muscle
contraction
breathing
venoconstriction
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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
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Cardiac ConductionSystem
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Electrocardiogram
An Electrocardiogram is a test that uses sound
waves to create a moving picture of the heart
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Benefits Accurate assessment tool that provides useful
information
Helps doctors determine the degree of themurmur, and assess overall health of heart
Drawbacks Time and Cost, ECGs require a substantial
amount of time and resources to perform
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recording of electrical changes that occur
in the myocardium
used to assess hearts ability to conduct
impulses
P wave atrial depolarization
QRS wave ventricular depolarizationT wave ventricular repolarization
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Composite of all action potentials of nodal
and myocardial cells detected, amplified and
recorded by electrodes on arms, legs andchest
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P wave SA node fires, atrial depolarization atrial systole
QRS complex atrial repolarization and diastole (signal obscured) AV node fires, ventricular depolarization ventricular systole
T wave ventricular repolarization
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Normal Electrocardiogram(ECG)
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Electrical Activity ofMyocardium1)atria begin to
depolarize
2) atria depolarize
3)ventricles begin todepolarize at apex;atria repolarize
4)ventricles depolarize
5) ventricles begin to
repolarize at apex6) ventricles repolarize
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Clinical Application
Ventricular fibrillation rapid, uncoordinateddepolarization of ventricles
Tachycardia rapid heartbeat
Atrial flutter rapid rate of atrial
depolarization
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HEART SOUNDS
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General Principles
Contraction of the myocardium generates pressure
changes which result in the orderly movement ofblood.
Blood flows from an area ofhigh pressure to an
area oflow 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.
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Heart SoundsLubb
first heart sound occurs during ventricular systole A-V valves closing
Dupp second heart sound occurs during ventricular diastole pulmonary and aortic semilunar valves
closing
Murmur abnormal heart sound
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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
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A heart which is beating normal makes two
sounds, "lubb" when the valves between the
atria and ventricles close, and "dupp" whenthe valves between the ventricles and the
major arteries close.
Normal Blood Flow
Cardiac chambersCardiac valves
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A heart murmur is an abnormal, extra
sound during the heartbeat cycle made by
blood moving through the heart and itsvalves
Abnormal Blood Flow,
(pulmonary valve stenosis )
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Cardiovascular diagram of anormal heart sound
Lubb-dupp associated with the human heartbeat
C di l Di f E l
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Cardiovascular Diagram of a Earlysystolic murmur
Notice the extra noise in-between the lubb-dupp. This can be attributed to a heart
murmur
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CARDIAC CYCLE
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The cardiac cycle is regulated by the cardiac
center in the medulla oblongata which
regulates sympathetic and parasympa-thetic
input.
M j E t f C di C l
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Major Events of Cardiac Cycle
Atrial systole
Isovolumetric contraction
Ventricular ejection
Isovolumetric relaxation
Ventricular filling
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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
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Ventricular Systole/Atrial diastole
A-V valves close
atria relaxed
blood flows into atria
ventricular pressure increases and opens semilunarvalves
blood flows into pulmonary trunk and aorta
R t f C di C l
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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
Di t l d S t l
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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.
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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 ofthe SA node.
Atrial contraction can aid filling of the ventricles in stenosis of theAV valves.
The force of atrial contraction can also push blood back into thevein. This can be observed by the pulse in jugular vein of anormal person lying w/ the head and chest elevated about 30degrees. If there is an observable jugular pulse higher on the
neck of a person sitting upright, it is indication that the pressurein 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 forcesthem closed so that blood cannot flow back into the atria.
Vibrations following closure of the AV valves creates the 1stheart sound, the lub of lub-dup.
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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 drivingforce 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 bloodstarts 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
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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 atriumcontracts 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
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ATRIAL SYSTOLEPressures & Volumes
The "a" wave occurs when theatrium contracts, increasing atrialpressure (yellow).
Blood arriving at the heart cannotenter the atrium so it flows backup the jugular vein, causing thefirst discernible wave in the
jugular venous pulse. Atrial pressure drops when the
atria stop contracting.
During atrial systole the atriumcontracts and tops off the volumein the ventricle with only a smallamount of blood.
Atrial contraction is completebefore the ventricle begins tocontract.
ATRIAL SYSTOLE
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ATRIAL SYSTOLEECG
An impulse arising from the SA node results in depolarization andcontraction of the atria (the right atrium contracts slightly before theleft 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
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ATRIAL SYSTOLEHeart 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.
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ISOVOLUMETRIC
CONTRACTION
The Beginningof systole
ISOVOLUMETRIC CONTRACTION
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ISOVOLUMETRIC CONTRACTIONHeart
The atrioventricular (AV) valves
close at the beginning of this
phase.
Electrically, ventricular systole is
defined as the interval betweenthe 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 andthe opening of the semilunar
valves (aortic and pulmonary
valves).
ISOVOLUMETRIC CONTRACTION
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ISOVOLUMETRIC CONTRACTIONPressures & Volumes
The AV valves close when the
pressure in the ventricles (red)
exceeds the pressure in the atria
(yellow).
As the ventricles contractisovolumetrically -- their volume
does not change (white) -- the
pressure inside increases,
approaching the pressure in the
aorta and pulmonary arteries(green).
ISOVOLUMETRIC CONTRACTION
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ISOVOLUMETRIC CONTRACTIONECG
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 marksthe 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
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ISOVOLUMETRIC CONTRACTIONHeart Sounds
The first heart sound (S1, "lub") is due to the closing AV valves and
associated blood turbulence.
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RAPID EJECTION
RAPID EJECTION
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RAPID EJECTIONHeart
The semilunar (aortic and
pulmonary) valves open at the
beginning of this phase.
RAPID EJECTION
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RAPID EJECTIONPressures & Volumes
While the ventricles continue
contracting, the pressure in theventricles (red) exceeds the pressure inthe aorta and pulmonary arteries(green); the semilunar valves open,blood exits the ventricles, and thevolume in the ventricles decreasesrapidly (white).
As more blood enters the arteries,pressure there builds until the flow ofblood reaches a peak.
The "c" wave of atrial pressure is notnormally discernible in the jugularvenous pulse. Right ventricularcontraction pushes the tricuspid valveinto the atrium and increases atrialpressure, creating a small wave into thejugular vein. It is normally simultaneouswith the carotid pulse.
RAPID EJECTION
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RAPID EJECTIONECG
No Deflections
RAPID EJECTION
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RAPID EJECTIONHeart Sounds
None
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REDUCED EJECTION
The end ofsystole
REDUCED EJECTION
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REDUCED EJECTIONHeart
At the end of this phase the
semilunar (aortic and pulmonary)
valves close.
REDUCED EJECTION
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REDUCED EJECTIONPressures & Volumes
After the peak in ventricular and
arterial pressures (red and
green), blood flow out of the
ventricles decreases and
ventricular volume decreasesmore slowly (white).
When the pressure in the
ventricles falls below the
pressure in the arteries, blood in
the arteries begins to flow backtoward the ventricles and causes
the semilunar valves to close.
This marks the end of ventricular
systole mechanically.
REDUCED EJECTION
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REDUCED EJECTIONECG
The T wave is due to ventricular repolarization. The end of the T
wave marks the end of ventricular systole electrically.
REDUCED EJECTION
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REDUCED EJECTIONHeart Sounds
None
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ISOVOLUMETRIC
RELAXATION
The
beginning of Diastole
ISOVOLUMETRIC RELAXATION
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ISOVOLUMETRIC RELAXATIONHeart
At the beginning of this phase the
AV valves are closed.
ISOVOLUMETRIC RELAXATION
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ISOVOLUMETRIC RELAXATIONPressures & Volumes
Throughout this and the previoustwo phases, the atrium in diastolehas been filling with blood on topof the closed AV valve, causingatrial pressure to rise gradually
(yellow). The "v" wave is due to the back
flow of blood after it hits theclosed AV valve. It is the seconddiscernible wave of the jugularvenous pulse.
The pressure in the ventricles(red) continues to drop.
Ventricular volume (white) is at aminimum and is ready to be filledagain with blood.
ISOVOLUMETRIC RELAXATION
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ISOVOLUMETRIC RELAXATIONECG
No Deflections
ISOVOLUMETRIC RELAXATION
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ISOVOLUMETRIC RELAXATIONHeart 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.
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RAPID VENTRICULAR
FILLING
RAPID VENTRICULAR FILLING
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Heart
Once the AV valves open, blood
that has accumulated in the atria
flows rapidly into the ventricles.
RAPID VENTRICULAR FILLING
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Pressures & Volumes
Ventricular volume (white)
increases rapidly as blood flows
from the atria into the ventricles.
RAPID VENTRICULAR FILLING
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ECG
No Deflections
RAPID VENTRICULAR FILLING
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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.
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REDUCED VENTRICULAR
FILLING
(Diastasis)
REDUCED VENTRICULAR FILLING
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Heart
Rest of blood that has
accumulated in the atria flows
slowly into the ventricles.
REDUCED VENTRICULAR FILLING
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Pressures & Volumes
Ventricular volume (white)
increases more slowly now. The
ventricles continue to fill with
blood until they are nearly full.
REDUCED VENTRICULAR FILLING
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ECG
No Deflections
REDUCED VENTRICULAR FILLING
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Heart Sounds
None
Hypertension
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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
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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
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ea e
Quit smoking; adjust diet; exercise
Drug therapies- strategies differ
Reduce heart rate calcium channel blockers
reduce calcium flow into heart muscle and thereforeheart rate, relax smooth muscle lining coronaryarteries
beta blockers (reduce stimulation bysympathetic nervous system)
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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 incombination
Age related changes
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g g
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
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Coronary artery disease results when coronaryarteries cannot deliver blood adequately
Usual cause: plaques in arterial walls
Angina pectoris (pain) results when body is notreceiving adequate oxygen
Myocardial infarction (heart attack) results whenblood supply to heart is completely blocked; muscledies
Conclusion
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To clinicians heart sounds provide importantinformation about the normal function of theheart and assist in diagnosing cardiacabnormalities. Any abnormal heart sounds
and certain murmurs are important indicatorsof specific cardiac abnormalities.
Hence, the integrated function of heart and
blood vessel constitute an important , basicpart of routine clinical examination andpractice.
References
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Understanding Human anatomy & Physiology : Sylvia Maden 2nd
Edition
Textbook of Medical Physiology : Guyton & Hall 9 th 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] 38 th
edition Cunninghams manual of practical anatomy (vol. 2 Abdomen &
Thorax)
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