it include circulation, cardiac cycle and changes occure in different phase. blood pressure and its regulation. cardiac output and factor affectiing it. Normal Echocardiography and its study.

1. DR.BIJAY KUMAR SAH
MBBS(BANGLADESH)
NMC REG NO. 17158

2. PULMONARY CIRCULATION:-
This is the circulation of blood from the right ventricle of the heart
to the lungs and back to the left atrium. In lungs, carbondioxide
is excreted and oxygen is absorbed.
SYSTEMIC CIRCULATION:-
The blood pumped out from the left ventricle is carried by the
branches of the aorta around the body and returns to the right
atrium of the heart by the superior and inferior venacava.
JUNCTIONAL TISSUE OF HEART:-
1) S.A node(sino-artial node)
2) Internodal pathways
3) A.V node(atrio-ventricular node)
4) Bundle of his or A-V bundle
5) Right & left bundle branch
6) Purkinje fibres
a) anterior(bachmann’s)
bundle
b) middle(wenchelbach’s)
bundle
c) posterior(thorel’s)
bundle

3. CONDUCTIVE TISSUES OF HEART:-
CONDUCTIVE
TISSUE
VELOCITY OF
CONDUCTION
(M/S)
RATE OF IMPULSE
GENERATION
(IMPLUSE/MIN)
S.A NODE 0.05 70-80
AV NODE 0.05 40-60
BUNDLE OF HIS 1 30-36
PURKINJE FIBRE
SYSTEM
4 15-20
ATRIAL PATHWAY 1 60
ATRIAL MUSCLE 0.3 -
VENTRICULAR
MUSCLE
1 20-40

4. PACEMAKER TISSUE:-
1) Sinoatrial node
2) Atrio-ventricular node
3) Purkinje fibre
S.A NODE IS CALLED THE PACE MAKER OF THE HEART,BECAUSE:-
1) It generates normal cardiac impulse at first.
2) It maintains the normal cardiac rhythm.
3) The rate & rhythm originated by SA node is higher than that of any
other part of the heart.
RESERVE PACEMAKER:- When SA node fails to generate impulse then
the AV node become the pacemaker & produces impulse at its own
rate of 40-60 impulse/min. so it is called reserve pacemaker. Then
the heart contract at rate 40-60 impulse/min.
ECTOPIC PACEMAKER:- A pacemaker elsewhere than SA node is called
ectopic pacemaker. Obviously an ectopic pacemaker causes an
abnormal sequence of contraction of different part of the heart.
This often occurs in the AV node or purkinji fibres. Under rare
condition a point in the atrial or ventricular muscle develops
excessive excitability & becomes the pacemaker.

5. CONDUCTION OF IMPULSE THROUGH THE HEART:-
1) Depolarization of the SA node,the rate of which is
influenced by the autonomic nervous system.
2) Spread of electrical activity over the atrial surface,
reaching the AV node.
3) Slow conduction through the AV node area to the bundle
of His.
4) Conduction of the impluse down the bundle its right & left
branches out to the minute branches surrounding
ventricular myocardial cells.
5) Activation of the ventricular muscle.
6) Repolarization of the purkinji system and of atrial and
ventricular muscle.

7. CARDIAC CYCLE
The cyclic repetition of various changes in heart from beat to
beat is called cardiac cycle.

8. PHASES OF CARDIAC CYCLE:-

11. VOLUME AND PRESSURE CHANGES IN CARDIAC CYCLE:-

12. APEX BEAT
Apex beat is the lowest and outer most point of definite
cardiac pulsation.
LOCATION:- in the left 5th intercostal space, 9 cm from the
midsternal line or just medial to the left mid clavicular line.
IMPORTANCE:-
1) Measurement of the heart rate.
2) Position of the heart-whether dextrocardia or not.
3) Different heart disease.
4) Displacement of mediastinum due to pneumothorax.
Pleural effusion, left ventricular hyperthrophy etc.

13. CARDIAC OUTPUT
The amount of blood that is ejected by each ventricle per
minute is called cardiac output. It is the product of stroke
volume and heart rate.
cardiac output= SV * HR=70ml *72=5040ml/min.
=Average 5 L/min(range5-6 L/min)
MALE= 5.6 L/min
FEMALE= 4.9 L/min
STROKE VOLUME:- The amount of blood pumped out by each
ventricle in each beat is called stroke volume. It is about 70
ml.

14. FACTORS INFLUENCING CARDIAC OUTPUT:-
A) PHYSIOLOGICAL:
1) Age:- age cardiac output.
2) Sex:- 10% less in female than male.
3) Surface area:- more surface area cardiac output.
4) Posture:- Cardiac Output(CO) in sitting & lying position
than in standing posture.
5) Exercise:- exercise CO.
6) Emotion:- CO.
7) Temperature:- temperature HR CO.
8) Pregnancy:- CO.
9) Epinephrin, Histamin:- CO.

15. B) PATHOLOGICAL:-
INCREASE CO DECREASE CO
1) HYPERTHYROIDISM 1)HYPOTHYROIDISM
2) ANAEMIA 2)HAEMORRHAGE
3) FEVER 3) CONGESTIVE
CARDIAC FAILURE
4) FIBRILATION &
FLUTTER
4)SHOCK
5) BERIBERI
6) ARTERIO-VENOUS
FISTULA
7) PAGET’S DISEASE

16. BLOOD PRESSURE
The lateral pressure exerted by the blood on the vessel wall
by its contained blood while flowing through it is called
blood pressure. BP= CO*TPR( total peripheral resistance).
NORMAL:- 120/80 mm of Hg.
TYPES OF BLOOD PRESSURE:-
1) Systolic pressure:- 110-140, average 120.
2) Diastolic pressure:- 60-90, average 80.
3) Pulse pressure:- it is difference between systolic and
diastolic pressure. Normal= 30-40, average 40.
4) Mean pressure:- it is the diastolic pressure + 1/3rd of pulse
pressure. Normal= 78-98, average 96.

17. FACTOR INFLUENCING BLOOD PRESSURE:-
1) Peripheral resistance: TPR BP.
2) Cardiac output: CO BP.
3) Age: rises with the age.
4) Sex: 10% less in female.
5) Body weight: increase wt increase BP.
6) Posture: in the recumbent position the diastolic pressure is
lower than in the sitting or in the standing position.
7) Exercise: it increase blood pressure.
8) Emotional & excitement: increase BP.
9) Sleep: systolic pressure falls by about 15-20 mm of Hg.
10) Exposure to cold: cause rise of BP.
11) Meals: increase slight after meal.

18. REGULATION OF BLOOD PRESSURE:-
1) BARORECEPTOR FEEDBACK MECHANISM:

23. NORMAL HEART RATE:-
60-100 beats/min (in female more than male).
Average: 72 beats/min.
PULSE:- Pulse is the rhythmic expansion & elongation of the
arterial wall passively produced by the pressure changes
during ventricular systole & diastole.
RANGE:- Normal 60-100 beat/min (average=72/min).
Foetus 140-160 beats/min
New bron 130-140 beats/min
Children 80-120 beats/min
adult 60-100 beats/min
Old age 75-80 beats/min

24. CHARACTERISTICS OF PULSE:-
1) Rate: it is the number of pulse per minute. Normally it
coincides with heart rate.
2) Rhythm: it indicates that the pulses are regular or not.
3) Volume: it indicates the rise of pulse wave above the
diastolic level.
4) Character: whether normal or abnormal.
5) Condition of the vessel wall: soft & easily compressible
pulse indicates low cardiac output. Hard and non-
compressible pulse indicates atherosclerosis.
CLASSIFICATION:-
1) Arterial pulse
2) Venous pulse
3) Capillary pulse

25. PROCEDURE OF FEELING PULSE:-
Pulse are felt by placing 3 fingers side by side on the radial artery.
Fingers are – index, middle & ring.
INDEX:- adjust the pressure.
MIDDLE:- remains stationary and feels the apperance and
disapperance of pulse wave.
RING:- applies a constant maximum pressure to stop retrograde
ulnar collateral pulsation.
FUNCTION OF CIRCULATION:-
1) To transport nutrients to the body tissues.
2) To transport waste products away.
3) To conduct hormones from one part of the body to the
another part.
4) In general, to maintain an appropriate environment in all the
tissue fluids of the body for optimal survival and function of
the cells.

26. ECG (ELECTROCARDIOGRAM)
ECG is a graphic recording from the surface of the body of the
electrical changes of the heart in each cardiac cycle.