Blood Disorders and Cardiovascular System

Blood Disorders
Cardiovascular System: Blood Vessels
Cardiovascular System: Blood Vessels
The David Sign
On a recent trip to Florence, Italy, I observed Michelan-
gelo’s David in the Accademia Galleria and was struck by
an interesting observation: the external jugular vein on
the right side of David’s neck is distended well above his
clavicle. Classic physical diagnosis teaching tells clini -
cians to observe the height of the jugular veins to esti -
mate central venous pressure (unless there is jugular ve-
nous outflow obstruction). Preferably, the internal
jugular vein is used for observation, but often the inter -
nal jugular vein is difficult to visualize, and thus the
smaller, less reliable, external jugular vein can be used,
because it is more superficial and easier to see. Impor-
tantly, neither jugular vein is normally persistently vis-
ible above the clavicle at rest in the upright position, as
it clearly is in the David (Figure). This finding on the
David is a sign of elevated intracardiac pressures and
possible cardiac dysfunction.
My initial response was one of fascination. The David

is an awe-inspiring work with incredible attention to de-
tail and accuracy in physical anatomy. With the knowledge
of a cardiologist, it appeared illogical to me for the David
to have jugular venous distention. I felt a chill go down my
back as I realized that this observation and its implications
were very possibly new and unrecognized. In addition, this
message (so to speak) from Michelangelo needed an ex-
planation. Immediately, my response was to document the
finding with multiple photographs for study and review.
I remember speaking with my girlfriend that day after we
visited the Accademia Galleria and discussing that I thought
I observed something very unique about the sculpture—
something that appears to have been hiding in plain sight
for more than 500 years.
When I returned home, I reviewed textbooks and
the medical literature and discussed this with a few medi -
cal and physiology colleagues. We had many very inter-
esting discussions trying to understand this paradox.
I also knew that I needed to know more about Michel-
angelo and his work.
Michelangelo, like some of his artistic contempo-
raries, had anatomical training,1,2 and in looking at the
David, one can clearly see that the external jugular vein
and the sternocleidomastoid muscle are anatomically
correct. Michelangelo’s sculpture depicts David just be-
fore his battle with Goliath. In reviewing other sculp-
tures of Michelangelo, I found that he demonstrates the
same finding of supraclavicular external jugular venous
distention again in his sculpture of Moses at the tomb
of Pope Julius the Second. Most would agree that the sit-
ting Moses is thought to be in an excited state. In con-
trast, the recently deceased Christ in Michelangelo’s
Pietà (1499) does not demonstrate jugular venous dis-
tention. Michelangelo did demonstrate the previously

recognized distention of the dependent veins in the
David, the Moses, and his Pietà. Dependent venous dis-
tention was recognized previously and clearly present
in earlier works, such as the Colossus of Constantine (circa
325), which he would have studied. (I did also notice in
photographs what could be the finding of jugular ve-
nous distention in the ancient sculpture Laocoön and His
Sons, but this sculpture was found in 1506, after the Da-
vid was completed; Michelangelo is said to have seen this
sculpture.) In my review of Michelangelo’s work, I could
find no mention of anyone writing about his depiction
of jugular venous distention.
To put this finding in context: at the time the David
was created, in 1504, William Harvey had yet to de-
scribe the true mechanics of the circulatory system. This
did not occur until 1628. In addition, while Harvey pos-
tulated that small vessels connected the arterial and ve-
nous vessels, capillaries were not identified until 1661
(by Marcello Malpighi).3
At this point in my investigation, I realized that Mi-
chelangelo must have noticed temporary jugular ve-
nous distention in healthy individuals who are excited.
In sculpture, one can only show a single image in time,
and he must have wanted to express this observation in
his work. I am amazed at his ability to recognize this find-
ing and express it in his artwork at a time when there was
such limited information in cardiovascular physiology. In-
terestingly, even today, this phenomenon is not dis-
cussed in typical cardiology textbooks.
Recognizing this message from Michelangelo also had
special meaning to me. I am a physician who has spent
more than 4 decades in the study and practice of medi -

cine. Now nearing the end of my career, I have turned to
Figure. An Image of Michelangelo’s David, Showing Jugular
Venous Distention
Photo credit: Daniel M. Gelfman, MD; image taken
September 28, 2018.
FROM
THE HEART
Daniel M. Gelfman,
MD
Division of Clinical
Affairs, Marian
University College of
Osteopathic Medicine,
Indianapolis, Indiana.
Corresponding
Author: Daniel M.
Gelfman, MD, Division
of Clinical Affairs,
Marian University
College of Osteopathic
Medicine, 3200 Cold
Spring Rd, Indianapolis,
IN 46222 ([email protected]
marian.edu).
Opinion
124 JAMA Cardiology February 2020 Volume 5, Number 2
(Reprinted) jamacardiology.com
© 2019 American Medical Association. All rights reserved.©

2019 American Medical Association. All rights reserved.
Downloaded From: https://jamanetwork.com/ by Roger Olson on
03/04/2020
Congenital Defects of the Heart
Math Unit Plan
Grade:
Week 1
Monday
Tuesday
Wednesday
Thursday
Friday
Lesson Title
State Math Standards
Learning Objectives

Instructional Strategy
Summary of Instruction
Differentiation
Materials, Resources, and Technology
Formative Assessment

Summative Assessment
(a short description of the summative assessment)
Part 2: Rationale
© 2018 Grand Canyon University. All Rights Reserved.
Respiratory System
Henry’s Law
Dalton’s Law
Atmospheric Pressure = 760 mmHg
Atmospheric Pressure = PN2 + PO2 + PCO2 + PH2O
597(PN2) + 159(PO2) + .3(PCO2) + 3.7(PH2O) = 760 mmHg
760 x .786 = 597 760 x .209 = 159 760 x .0004 = .3 760 x .005
= 3.7

597(PN2) + 159(PO2) + .3(PCO2) + 3.7(PH2O) = 760 mmHg
760 x .786 = 597 760 x .209 = 159 760 x .0004 = .3 760 x .005
= 3.7
Sea level pressure =
760 mm Hg
Sea level PO2 =
159 mm Hg
Everest summit pressure =
253 mm Hg
Everest summit PO2 =
43.1 mm Hg
597(PN2) + 159(PO2) + .3(PCO2) + 3.7(PH2O) = 760 mmHg
760 x .786 = 597 760 x .209 = 159 760 x .0004 = .3 760 x .005
= 3.7
Arterial blood at sea
level - 97% saturated
Venous blood leaving
peripheral tissues at
sea level -
75% saturated

Arterial blood at
summit of Everest -
77% saturated
The Respiratory System
• Image from 1601 text, De Vocis
Auditusque Organis Historia
Anatomica, by Giulio Casserio
• Professor of head and neck
anatomy at University of
Padua
• William Harvey was one of
his students
• How many cardiorespiratory
structures can you identify?
CLASSICS IN THORACIC SURGERY
Leonardo da Vinci and the Sinuses of Valsalva
Francis Robicsek, MD
The Carolinas Heart Institute, the Heineman Medical Research
Laboratory, and the Carolinas Medical Center, Charlotte,
North Carolina

Recent studies indicate that eddy currents generated by
the sinuses of Valsalva play an important role in the
physiologic closure of the aortic valve. This process is
briefly discussed and evidence is presented that this fact
was well known and elaborated upon by the renaissance
artist Leonardo da Vinci. This fact is illustrated with his
words and drawings.
(Ann Thoruc Surg 1991;52:328-35)
God geornetricizes
Leonardo da Vinci
he semilunar valves, in contrast to atrioventricular T valves,
have no direct attachment to the myocar-
dium; therefore, their function is generally thought to be
entirely passive responding to fluctuation of the pressure
between the left ventricle and the aorta. Whenever the
pressure generated by ventricular systole exceeds that
reigning in the thoracic aorta, the aortic valve opens;
whenever the left ventricular pressure decreases to less
than the pressure in the aorta, the valve shuts. Recent
research, however, indicates that this process, which
occurs about 115,000 times a day, is far more complex. As
has been demonstrated by Clark [1] and others [ 2 4 ] ,
although the leaflets are the most dynamic parts of the
aortic valve, the motion of other associated structures
such as the vascular wall and the expansion of the entire
valve complex itself [ P 6 ] also play an important role.
Even more important in aortic valve function than these
factors are some particular features of the blood flow
induced by the presence of ellipsoidal sacculations of the
aortic wall, named after the great Italian anatomist, An-
tonio Valsalva .

If one may ask a cardiac surgeon what the aortic valve
consists of, the answer will likely be: “Three leaflets and
three commissures.” The same inquiry directed to a
physiologist would probably evoke a different response:
“Three leaflets, three commissures, and three sinuses.”
This emphasis on the functional significance of the si-
nuses of Valsalva is becoming more and more clear to
those who study circulatory dynamics, but is still not
appreciated by those who perform reconstructive opera-
tion at the aortic root.
The first scientific study in modern times on the role of
these sinuses in the closure of the aortic valve was made
by Henderson and Johnson [7], who demonstrated in
hydrodynamic model studies that the closure of the aortic
valve under pulsatile flow is not an abrupt event triggered
by sudden drop in ventricular pressure alone but rather a
Address reprint requests to Dr Robicsek, Heineman Medical
Research
Center, PO Box 35457, Charlotte, NC 28235.
gradual process in the course of which during decelera-
tion of flow the valve leaflets move gradually toward
closure. These observations have received additional sup-
port by van Steenhoven [&-lo], Peskin [ll, 121, Bellhouse
[1>15], and their associates. In elegant experiments Bell -
house constructed a rigid model of the aortic root with a
flexible valve and perfused it with a pulsatile flow of
water. The flow pattern was outlined by dye injection and
recorded by serial cinematography. The principal obser -
vations made in these studies were that after a rapid and
full opening of the leaflets, some of the blood ejected from
the left ventricle coils back at the sinus edge, then decel -
erates, reverses its direction along the sinus wall, and
forms vortices in the sinuses of Valsalva before it rejoins

the mainstream of forward flow. He further stipulated
that due to these eddy currents and deceleration, the
pressure exerted at the lateral aspects of the leaflets
exceeds that on their central surfaces and causes the
leaflets to approximate even before the systole is com-
pleted [14]. Because of this process only minimal reversed
flow is required for final valve closure, and regurgitation
does not occur (Figs 1, 2).
Nearly identical experiments were performed and sim-
ilar conclusions were drawn by Leonardo da Vinci in 1513
(Fig 3).
Leonardo was not only a superb painter and sculptor,
he also was a Renaissance man in the true sense of the
word: an exceptional architect, a talented mechanical and
hydraulic engineer, as well as the founder of functional
anatomy. His heritage includes about 200 richly annotated
anatomical sketches, all but a few now housed in the
private collection of Her Majesty the Queen of England
[161.
The lion’s share of Leonardo’s work on anatomy falls
into two distinct periods. His earlier drawings were made
about 1487 to 1493, mostly in Florence and in Milan. They
show his preoccupation with the structure of the skull and
the eye, which he called the ”window of the soul.” His
later work began around 1506 and continued until his
death in 1519 in France [17]. This period encompasses
studies on other organs and is permeated with the recog-
nition as to how mechanics relate to human physiology.
His views as an architect-engineer opened a heretofore
unseen functional perspective into the study of the hu-
man body, which he regarded as a God-created structure
”which feels and moves” but also as an “edifice governed
by the laws of mechanics” [18]. After comprehending

function, Leonardo proceeded with attempts to enhance
the same; he designed life belts and webbed gloves to
enable man to swim better, and fabricated wings and
parachutes to make him float in the air.
0 1991 by The Society of Thoracic Surgeons 0003-
4975/91/$3.50
Angioplasty Blood Vessel Disorders
Coronary Artery Bypass Grafting
(CABG)
CABG Movie
Congenital Defects of the Heart
Rene Laennec, 1781 - 1826
Inventor of the Stethoscope 80
In 1816, I was consulted by a young woman laboring under
general
symptoms of diseased heart, and in whose case percussion and
the application of the hand were of little avail on account of the
great degree of fatness. The other method just mentioned [direct
auscultation] being rendered inadmissible by the age and sex of
the
patient, I happened to recollect a simple and well-known fact in
acoustics, . . . the great distinctness with which we hear the
scratch
of a pin at one end of a piece of wood on applying our ear to the
other. Immediately, on this suggestion, I rolled a quire of paper

into
a kind of cylinder and applied one end of it to the region of the
heart
and the other to my ear, and was not a little surprised and
pleased
to find that I could thereby perceive the action of the heart in a
manner much more clear and distinct than I had ever been able
to
do by the immediate application of my ear.
Rene Laennec, August 1819
In the preface to, De l'Auscultation Médiate
81
82 83
First stethoscope in the United Kingdom
Brought from Paris in 1822 by Thomas Hodgkin Hodgkin’s
Disease
Displayed at Gordon Museum of Pathology, King’s College
London
Normal Resting Values
6000 ml/min or 6.0 l/min =
75/beats/min X 80 ml/beat
Moderate Exercise Values
13.44 l/min =
120/beats/min X 112 ml/beat
Heavy exercise

CO can be 18-30 l/min
Elite athletes
CO can increase ≈ 700% to
40 l/min!!!!
98
92
Blood
Objectives
• List the components of the cardiovascular
• Describe the important components and major functions of
blood.
• List the characteristics and functions of red blood cells.
• Describe the structure of hemoglobin and indicate its
functions.
• Discuss red blood cell production and maturation.
• Explain blood typing and the basis for ABO and Rh
incompatibilities.
• Categorize the various white blood cells on the basis of
structure and function.
• Describe the structure, function, and production of platelets.
• Describe the reaction sequences responsible for blood clotting.
The cardiovascular system
• A mechanism for rapid transport of nutrients, waste products,
gases, and cells
Blood
• Fluid connective tissue
• Functions include

• Transporting dissolved gases, nutrients, hormones, and
metabolic wastes
• Regulating pH and ion composition of interstitial fluids
• Restricting fluid loss at injury sites
• Defending the body against toxins and pathogens
• Regulating body temperature by absorbing and redistributing
heat
• Physical Characteristics of Blood
• Thicker & heavier than H2O
• Temp. = 100.4°F (38°C)
• Volume = 5-6 liters for males, 4-5 liters for females
• Blood = 8% of total body weight
The composition of blood
• Plasma (45%) and formed elements (55%) comprise whole
blood
• Red blood cells (RBC)
• White blood cells (WBC)
• Platelets
• Can fractionate whole blood for analytical or clinical purposes
Hemopoiesis
• Process of blood cell formation
• Hemocytoblasts are circulating stem cells that divide to form
all types of blood cells
93
Plasma
• 92 percent of plasma is water

• Higher concentration of dissolved oxygen and proteins than
interstitial fluid
Plasma proteins
• More than 90 percent are synthesized in the liver
• Albumins
• 60 percent of plasma proteins
• Responsible for viscosity and osmotic pressure of blood
Additional Plasma Proteins
• Globulins
• ~35 percent of plasma proteins
• Include immunoglobins which attack foreign proteins and
pathogens
• Include transport globulins which bind ions, hormones, and
other compounds
• Fibrinogen
• Converted to fibrin during clotting
• Removal of fibrinogen leaves serum
Abundance of RBCs
• Erythrocytes account for 99.9 percent of the formed elements
• Hematocrit measures the percentage of whole blood occupied
by formed elements
• Commonly referred to as the volume of packed red cells
Structure of RBCs
• Biconcave disc, providing a large surface to volume ration
• Shape allows RBCs to stack, bend, and flex
• RBCs lack organelles
• Typically degenerate in about 120 days

Hemoglobin
• Molecules of hemoglobin account for 95 percent of the
proteins in RBCs
• Hemoglobin is a globular protein, formed from two pairs of
polypeptide subunits
• Each subunit contains a molecule of heme which reversibly
binds an O2 molecule
• Damaged or dead RBCs are recycled by phagocytes
RBC life span and circulation
• Replaced at a rate of ≈ 3,000,000 new blood cells entering the
circulation per second
• Components of hemoglobin individually recycled
• Heme stripped of iron and converted to biliverdin, then
bilirubin
• Iron is recycled
94
RBC production
• Erythropoeisis = the formation of new red blood cells
• Occurs in red bone marrow
• Process speeds up with in the presence of EPO
(erythropoietin)
• RBCs pass through reticulocyte and erythroblast stages
Blood types
• Determined by the presence or absence of surface antigens
(agglutinogens)
• Antigens A, B, and Rh (D)

• Antibodies are in plasma (agglutinins) that do not react with
antigens
• Cross-reactions only occur when antigens meet antibodies in
incompatible transfusions
• Incompatible blood transfusions cause donated RBC's to be
attacked causing
agglutination (clump)
• These cells lodge, swell & rupture: hemolysis
• ***Hint: Donors RBC must be compatible with recipient’s
plasma antibodies***
Blood Type Compatible Donor Types Incompatible Types
A A, O B, AB
B B, O A, AB
AB A, B, AB, O ---
O O A, B, AB
Rh System
First worked out on the rhesus monkey - Also based on antigens
on RBC surface
Those with Rh antigens are Rh+ - Those without Rh antigens
are Rh-
Normally plasma does not contain anti-Rh antibodies
Antibodies develop only upon greater exposure to Rh antigens
Donation reactions would occur only upon multiple
incompatible transfusions
The most common problem is during pregnancy

Rh+ fetus & Rh- mother can cause problems in later pregnancies
Mom will be exposed to Rh+ blood during delivery and will
then make anti-Rh antibodies
A second pregnancy will cause mom's anti-Rh antibodies to
cross placenta
If fetus is Rh- there is no problem - If fetus is Rh+ hemolysis
will occur in fetal blood
This is erythroblastosis fetalis (hemolytic disease of the
newborn [HDN])
Kids born with this receive gradual transfusions before or after
birth (with Rh-)
Injections to mom after first pregnancy can prevent problems w/
second
95
Leukocytes
• Have nuclei and other organelles
• Defend the body against pathogens
• Remove toxins, wastes, and abnormal or damaged cells
• Are capable of amoeboid movement (margination) and positive
chemotaxis
• Some are capable of phagocytosis
Types of WBC
• Granular leukocytes
• Neutrophils – 50 to 70 percent total WBC population

• Eosinophils – phagocytes attracted to foreign cells that have
reacted with antibodies
• Basophils – migrate to damaged tissue and release histamine
and heparin
Types of WBC
• Agranular leukocytes
• Monocytes – become macrophage
• Lymphocytes – includes T cells, B cells, and NK cells
Differential count
• Indicates a number of disorders by determining which WBC is
responding to disease
WBC Production
• Granulocytes and monocytes are produced by bone marrow
stem cells
• Divide to create progenitor cells
• Stem cells may originate in bone marrow and migrate to
peripheral tissues
• Lymphocytes originate in bone but develop in lymphoid tissue
(thymus, spleen . .)
Platelets
• Flattened discs
• Circulate for 9-12 days before being removed by phagocytes
Platelet functions
• Transporting chemicals important to clotting
• Forming temporary patch in walls of damaged blood vessels
• Contracting after a clot has formed
Platelet production (thrombocytopoiesis)

• Megakaryocytes release platelets into circulating blood
96
Hemostasis
• Prevents the loss of blood through vessel walls
• Three phases:
• Vascular phase
• Platelet phase
• Coagulation phase
Hemostasis
• Vascular phase
• Local blood vessel constriction (vascular spasm)
• Platelet phase
• Platelets are activated, aggregate at the site, adhere to the
damaged surfaces
• Coagulation phase
• Factors released by platelets and endothelial cells interact
with clotting factors to
form a clot
• Basically: Fibrinogen in the presence of thrombin converts to
Fibrin
• Fibrin is the basic framework of a blood clot
115

The Respiratory System
Objectives
• Describe the primary functions of the respiratory system.
• Identify the organs of the respiratory system and describe their
functions.
• Define and compare the processes of external and internal
respiration.
• Summarize the physical principles governing the movement of
air into the lungs and
the diffusion of gases into the blood.
• Explain the important structural features of the respiratory
membrane.
• Describe how O2 and CO2 are picked up, transported, and
released in the blood.
Functions of the respiratory system
• Gas exchange between air and circulating blood
• Moving air across the exchange surface of the lungs
• Protection of respiratory surfaces
• Production of sound
• Provision for olfactory sensations
Organization of the respiratory system
• Upper respiratory system
• Nose, nasal cavity, paranasal sinuses, pharynx
• Lower respiratory system
• Larynx, trachea, bronchi, bronchioles, alveoli
The Respiratory tract
• Passageways carrying air to and from the alveoli
• Upper respiratory passages filter and humidify incoming air

• Lower passageways include delicate passages and alveolar
exchange surfaces
Respiratory mucosa
• Respiratory epithelium and underlying connective tissue
supported by lamina propria
• Lines conducting portion of respiratory tract
• Protected from contamination by respiratory defense system
The nose and nasal cavity consists of
• External nares
• Nasal cavity
• Vestibule
• Superior, middle, and inferior meatuses
• Hard and soft palates
• Internal nares
• Nasal mucosa
116
The Pharynx
• Shared by the digestive and respiratory systems
• Divided into three sections:
• Nasopharynx – superior portion
• Oropharynx – continuous with the oral cavity
• Laryngopharynx – between the hyoid bone and the esophagus
The Larynx
• Air passes through the glottis on the way to the lungs
• Cartilages of the larynx
• Three large cartilages
• Thyroid, cricoid, and epiglottis

• Paired cartilages
• Arytenoids, corniculate, and cuneiform
• Folds of the larynx
• Inelastic vestibular folds
• Delicate vocal folds
Sound production
• Air passing through the glottis vibrates the vocal folds
producing sound waves
• Pitch depends on conditions of vocal folds
• Diameter
• Length
• Tension
The laryngeal musculature
• Muscles of the neck and pharynx position and stabilize the
larynx
• When swallowing, these muscles
• Elevate the larynx
• Bend the epiglottis over the glottis
The Trachea
• Extends from the sixth cervical vertebra to the fifth thoracic
vertebra
• A tough, flexible tube running from the larynx to the bronchi
• Held open by C-shaped tracheal cartilages in submucosa
• Mucosa is similar to the nasopharynx
The primary bronchi
• Trachea branches in the mediastinum into right and left
bronchi

• Bronchi enter the lungs at the hilus
117
The Lungs
Lobes and surfaces of the lungs
• Lobes of the lung are separated by fissures
• Right lung has three lobes
• Left lung has two lobes
• Concavity on medial surface = cardiac notch
The bronchial tree
• System of tubes formed from the primary bronchi and their
branches
• Primary bronchi branch into secondary or lobar bronchi
• Secondary bronchus goes to each lobe of the lungs
• Secondary bronchi branch into tertiary bronchi
• Tertiary bronchi supply air to a single bronchopulmonary
segment
The bronchioles
• Ultimately branch into terminal bronchioles
• Delivers air to a single pulmonary lobule
• Terminal bronchiole becomes respiratory bronchioles
Alveolar ducts and alveoli
• Respiratory bronchioles end in ducts and sacs
Respiratory membrane

• Simple squamous epithelium
• Endothelial cell lining an adjacent capillary
• Fused basal laminae
Cells of the respiratory membrane include
• Septal cells
• Produce surfactant which keep alveoli open
• Alveolar macrophage
• Patrol epithelium and engulf foreign particles
The pleural cavities and pleural membranes
• Each lung covered by one pleura
• Pleura—serious membranes lining the pleural cavity
• Parietal—attaches to the walls of the pleural cavity
• Visceral—adheres to the surface of the lungs
• Pleural fluid—fills and lubricates the space between the pleura
118
Respiratory physiology
• External respiration
• Exchange of gases between interstitial fluid and the external
environment
• The steps of external respiration include
• Pulmonary ventilation – moving air between external
environment and lungs
• Gas diffusion – moving gases across respiratory membrane
and into blood

• Transport of O2 and CO2 – in blood from lungs into the
systems
• Internal respiration
• Exchange of gases between interstitial fluid and cells
Pulmonary ventilation
• Movement of air depends upon
• Boyle’s law
• Pressure and volume inverse relationship
• Volume depends on movement of diaphragm and ribs
• Pressure and airflow to the lungs
• Compliance – an indication of the expandability of the lungs
Respiratory volumes - Spirometry
• Tidal Volume (VT)
• Amount of air inhaled or exhaled with each breath
• Inspiratory Reserve Volume (IRV)
• Inhaled air above VT
• Expiratory Reserve Volume (ERV)
• Exhaled air below VT
• Vital Capacity (VC)
• VT + IRV and ERV
• Residual Volume (RV)
• Air left in lungs after maximum exhalation
• Total Lung Capacity (TLC)
• VC + RV

Gas Diffusion
• Dalton’s law and partial pressure
• Individual gases in a mixture exert pressure proportional to
their abundance
Atmospheric pressure (760 mm Hg) = PO2 + PCO2 + PN2 +
PH2O
Atmospheric PO2 = 21% .21 x 760 mm Hg = 160 mm Hg
Atmospheric PCO2 = .04% .0004 x 760 mm Hg = .3 mm Hg
Atmospheric PN2 = 78.5% .785 x 760 mm Hg = 597 mm Hg
119
Transportation of O2 and CO2
Oxygen transport
• 3% dissolved in plasma
• 97% carried in hemoglobin (heme portion) as oxyhemoglobin
(HbO2)
• The amount of oxygen hemoglobin can carried is dependent
upon
• PO2
• pH – higher values result in less saturation
• temperature – higher temps cause Hb to release O2
Carbon dioxide transport
• 7 % dissolved in plasma
• 23 percent bound to hemoglobin

• carbaminohemoglobin
• 70 % carried as carbonic acid, which dissociates into a
hydrogen ion and bicarbonate
ion
• Carbon dioxide plus water reversibly reacts to form a
hydrogen ion and
bicarbonate ion
• CO2 + H2O ⇔H+ + HCO3-
• Most of the H+ is taken up by Hb, which therefore serves as a
buffer
• The + HCO3- move out of RBC and into plasma in exchange
for a Cl-, this is
the chloride shift
The efficiency of the respiratory system decreases with age as:
• Elastic tissue deteriorates causing lower lung compliance and
vital capacity
• Chest movements are restricted by arthritic changes
• Some degree of emphysema normally occurs
97
The Heart
Objectives
• Describe the organization of the cardiovascular system.
• Describe the location and general features of the heart,
including the pericardium.

• Discuss the differences between nodal cells and conducting
cells, and describe the
components and functions of the conducting system of the heart.
• Identify the electrical events associated with a normal
electrocardiogram.
• Explain the events of the cardiac cycle including atrial and
ventricular systole and
diastole, and relate the heart sounds to specific events in the
cycle.
• Define cardiac output, heart rate, and stroke volume and
describe the factors that
influence these variables.
• Explain how adjustments in stroke volume and cardiac output
are coordinated at
different levels of activity.
The cardiovascular system is divided into two circuits
• Pulmonary circuit
• blood to and from the lungs
• System circuit
• blood to and from the rest of the body
• Vessels carry the blood through the circuits
• Arteries carry blood away from the heart
• Veins carry blood to the heart
• Capillaries permit exchange
Anatomy of the Heart
The pericardia

• Visceral pericardium or epicardium
• Parietal pericardium
• Pericardial fluid between the above two
• Superficial fibrous pericardium is anchored to mediastinum
Superficial anatomy of the heart
• The heart consists of four chambers
• Two atria and two ventricles
• Major blood vessels of the heart include
• Inferior and superior vena cavae
• Aorta and pulmonary trunk
The heart wall
• Components of the heart wall include
98
• Epicardium – visceral pericardium
• Myocardium – cardiac muscle
• Endocardium – simple squamous epithelium
Internal anatomy and organization
• Atria
• Thin-walled chambers that receive blood from the veins (VC
& PV)
• Pump blood into ventricles
• Ventricles
• Thick-walled chambers separated from the atria by AV valves
• Pump blood into arteries (PA & Aorta)

• Chordae tendineae
• Tendinous fibers attached to the AV valves and papillary
muscles
Blood flow through the heart
• Right atrium
• Tricuspid valve
• Right ventricle
• Pulmonary valve – pulmonary trunk – pulmonary arteries
• Pulmonary circuit – pulmonary veins
• Left atrium
• Bicuspid valve(mitral valve)
• Left ventricle
• Aortic valve
• Aorta and systemic circuit – vena cava – right atrium
Heart chambers and valves
• Structural Differences in heart chambers
• The left side of the heart is more muscular than the ri ght side
• Functions of valves
• AV valves prevent backflow of blood from the ventricles to
the atria
• Semilunar valves prevent backflow into the ventricles from the
pulmonary trunk
and aorta
Blood supply to the heart
• Coronary arteries include the right and left coronary arteries,

marginal arteries,
anterior interventricular artery (anterior descending), and the
circumflex artery
• Coronary veins include the great cardiac vein, anterior and
posterior cardiac veins,
the middle cardiac vein, and the small cardiac vein, and the
coronary sinus
99
Cardiac physiology
• Two classes of cardiac muscle cells
• Specialized muscle cells of the conducting system (control
heartbeat)
• Contractile cells (produces powerful contractions that propels
blood)
The conducting system
• The conducting system includes
• Sinoatrial (SA) node
• Atrioventricular (AV) node
• Conducting cells
• Atrial conducting cells are found in internodal pathways
• Ventricular conducting cells consist of the AV bundle, bundle
branches, and
Purkinje fibers
Impulse conduction through the heart

• SA node begins the action potential
• Stimulus spreads to the AV node
• Impulse is delayed at AV node
• Impulse then travels through ventricular conducting cells (AV
bundle, bundle
branches, and Purkinje fibers)
• Then distributed by Purkinje fibers
The electrocardiogram (ECG)
• A recording of the electrical events occurring during the
cardiac cycle
• The P wave accompanies the depolarization of the ventricles
• The QRS complex appears as the ventricles depolarize (masks
atrial repolarization)
• The T wave indicates ventricular repolarization
Contractile cells
• Resting membrane potential of approximately –90mV
• Action potential
• Rapid depolarization
• A plateau phase unique to cardiac muscle
• Repolarization
• Refractory period follows the action potential
Calcium ion and cardiac contraction
• Cardiac action potentials cause an increase in Ca2+ around
myofibrils
• Ca2+ enters the cell membranes during the plateau phase
• Additional Ca2+ is released from reserves in the sarcoplasmic
reticulum

100
The cardiac cycle
• The period between the start of one heartbeat and the
beginning of the next
• During a cardiac cycle
• Each heart chamber goes through systole and diastole
• Correct pressure relationships are dependent on careful timing
of contractions
Pressure and volume changes: atrial systole
• Rising atrial pressure pushes blood into the ventricle
• Atrial systole
• The end-diastolic volume (EDV) of blood is in the ventricles
Pressure and volume changes: ventricular systole
• Isovolumetric contraction of the ventricles: ventricles are
contracting but there is no
blood exiting chamber
• Ventricular pressure increases forcing blood through the
semilunar valves
Pressure and volume changes: ventricular diastole
• The period of isovolumetric relaxation when all heart valves
are closed
• Atrial pressure forces the AV valves open
Heart sounds
• Auscultation – listening to heart sound via stethoscope
• Four heart sounds
• S1 – “lubb” caused by the closing of the AV valves

• S2 – “dupp” caused by the closing of the semilunar valves
• S3 – a faint sound associated with blood flowing into the
ventricles
• S4 – another faint sound associated with atrial contraction
Cardiodynamics - stroke volume and cardiac output
• Cardiac output – the amount of blood pumped by each
ventricle in one minute
• Cardiac output equals heart rate times stroke volume
CO
cardiac output
(ml/min)
=
Hr
heart rate
(beats/min)
X
SV
stroke volume
(ml/beat)
Normal Resting Values
6000 ml/min or 6 l/min = 75/beats/min X 80 ml/beat
Moderate Exercise Values
13.44 l/min = 120/beats/min X 112 ml/beeat
Heavy exercise can increase CO to 18-30 l/min

Elite athletes can increase CO ≈ 700% to 40 l/min!!!!
101
SV ⇑ from ⇑ in End-Diastolic Volume (120ml resting)
venous pressure ⇑ ventricular volume
This stretches the LV myocardium = ⇑ force of contraction
Starling's Law
*Why does RHR ⇓ for athletes?
The proportion of blood ejected from the LV compared to total
volume is
termed ejection fraction (65%)
Summary: regulation of heart rate and stroke volume
• Sympathetic stimulation increases heart rate
• Parasympathetic stimulation decreases heart rate
• Circulating hormones, specifically E, NE, and T3, accelerate
heart rate
• Increased venous return increases heart rate
• EDV is determined by available filling time and rate of venous
return
• ESV is determined by preload, degree of contractility, and
afterload
Heart Disease mostly from poor coronary circulation
Ischemia decreased O2 supply
Angina Pectoris chest pain from ischemia w/o death to
myocardium.
Caused by: stress (Ψ or phys.), atherosclerosis, ↑BP, nicotine...

Myocardial Infarction (MI) Heart attack - #1 cause of death in
USA
Necrosis of myocardium.
Congenital Heart Disease #1 cause of full term newborn fatality
Atrial Septal Defect (ASD)
Foramen ovale remains open after birth
Ventricular Septal Defect (VSD)
Hole in interventricular septum
Patent Ductus Arteriosus (PDA)
Patent fetal Ductus Arteriosus
Tetrolagy of Fallot
VSD, aorta arising from RV or VSD, pulmonic RV hypertrophy
Largest contributor to "blue baby"
Transposition of the Great Vessels
Aorta arises from the RV
Pulmonary artery arises from the LV
Other Heart Diseases
Rheumatic heart disease, congestive heart disease, arrhythmic
heart disease

102
Blood Vessels and Circulation
Objectives
• Distinguish among the types of blood vessels.
• Describe fluid and dissolved material transport of the
cardiovascular system.
• Describe the factors that influence blood pressure and blood
pressure regulation.
• Discuss the movement of fluids between capillaries and
interstitial spaces.
• Describe how blood flow and pressure in tissues is regulated.
• Identify the principle blood vessels of each circuit and the
areas they serve.
• Describe fetal circulation and the changes at birth and during
aging.
Structure of vessel walls
• Walls of arteries and veins contain three distinct layers
• Tunic intima
• Tunica media
• Tunica externa (adventitia)
Differences between arteries and veins
• Compared to veins, arteries
• Have thicker walls
• Have more smooth muscle and elastic fibers
• Are more resilient
Arteries
• Undergo changes in diameter

• Vasoconstriction – decreases the size of the lumen
• Vasodilation – increases the size of the lumen
• Classified as either elastic (conducting) or muscular
(distribution)
• Small arteries (internal diameter of 30 um or less) are called
arterioles
Capillaries
• An endothelial tube inside a basal lamina
• These vessels
• Form networks
• Surround muscle fibers
• Radiate through connective tissue
• Weave throughout active tissues
• Capillaries have two basic structures
• Continuous
• Fenestrated
• Flattened fenestrated capillaries = sinusoids
103
Capillary beds
• An interconnected network of vessels consisting of
• Collateral arteries feeding an arteriole
• Metarterioles
• Arteriovenous anastomoses
• Capillaries
• Venules

Veins
• Collect blood from all tissues and organs and return it to the
heart
• Are classified according to size
• Venules
• Medium-sized veins
• Large veins
Venous valves
• Venules and medium-sized veins contain valves
• Prevent backflow of blood
Distribution of blood
• Total blood volume is unevenly distributed
• Venoconstriction maintains blood volume
• Veins are capacitance vessels
• Capacitance = relationship between blood volume and pressure
Circulatory pressure
• Circulatory pressure is divided into three components
• Blood pressure (BP)
• Capillary hydrostatic pressure (CHP)
• Venous pressure
Resistance (R)
• Resistance of the cardiovascular system opposes the
movement of blood
• For blood to flow, the pressure gradient must overcome total
peripheral resistance

• Peripheral resistance (PR) is the resistance of the arterial
system
Overview of cardiovascular pressures
• Factors involved in cardiovascular pressures include
• Vessel diameter
• Cross-sectional area of vessels
• Blood pressure
• Blood viscosity
104
Arterial blood pressure
• Arterial blood pressure
• Maintains blood flow through capillary beds
• Rises during ventricular systole and falls during ventricular
diastole
• Pulse is a rhythmic pressure oscillation that accompanies each
heartbeat
• Pulse pressure = difference between systolic and diastolic
pressures
• Example of Pulse Pressure for BP of 120/90: PP = 120 – 90;
PP = 30
• Mean arterial pressure (MAP) = diastolic pressure + (pulse
pressure ÷ 3)
Example of MAP for BP of 120/90
MAP = 90 + (30 ÷ 3)
MAP = 90 ÷ 10
MAP = 100 mm Hg

Capillary exchange
• Flow of water and solutes from capillaries to interstitial space
Processes that move fluids across capillary walls
• Diffusion
• Filtration
• Hydrostatic pressure (CHP)
• Reabsorption
Venous pressure and venous return
• Assisted by two processes
• Muscular compression
• The respiratory pump
Cardiovascular regulation
• Autoregulation
• Neural mechanisms
• Endocrine mechanisms
Autoregulation of blood flow within tissues
• Local vasodilators accelerate blood flow in response to:
• Decreased tissue O2 levels or increased CO2 levels
• Generation of lactic acid
• Release of nitric acid
• Rising K+ or H+ concentrations in interstitial fluid
• Local inflammation
• Elevated temperature
105
Neural mechanisms
• Adjust CO and PR to maintain vital organ blood flow

• Medullary centers of regulatory activity include
• Cardiac centers
• Vasomotor centers control
• Vasoconstriction via adrenergic release of NE
• Vasodilation via direct or indirect release of NO
Reflex control of cardiovascular function
• Baroreceptors reflexes monitor stretch
• Atrial baroreceptors monitor blood pressure
• Chemoreceptor reflexes monitor CO2, O2, or pH levels
Hormones and cardiovascular regulation
• Antidiuretic hormone – released in response to decreased
blood volume
• Angiotensin II – released in response to a fall in blood
pressure
• Erythropoietin – released if BP falls or O2 levels are
abnormally low
• Natriuretic peptides – released in response to excessive right
atrial stretch
Exercise and the cardiovascular system
• Light exercise results in
• Extensive vasodilation
• Increased venous return
• A rise in cardiac output
• Heavy exercise results in
• Increased blood flow to skeletal muscles
• Restriction of blood flow to nonessential organs
Cardiovascular response to hemorrhaging: short term

• Carotid and aortic reflexes increase CO and peripheral
vasoconstriction
• Sympathetic nervous system elevates blood pressure
• E and NE increase cardiac output and ADH enhances
vasoconstriction
Cardiovascular response to hemorrhaging: long term
• Decline in capillary blood pressure recalls fluids from
interstitial spaces
• Aldosterone and ADH promote fluid retention
• Increased thirst promotes water absorption across the digestive
tract
• Erythropoietin ultimately increases blood volume and
improves O2 delivery
106
Identify the Below Landmarks on the Heart
Chambers
Right atrium
Right ventricle
Left atrium
Left ventricle
Valves
Right AV (tricuspid) valve
Left AV (bicuspid or mitral) valve
Chordae tendineae
Papillary muscles
Pulmonary semilunar valve
Aortic semilunar valve
Fibrous skeleton

Vessels
Superior vena cava
Inferior vena cava
Pulmonary trunk
Pulmonary arteries
Pulmonary veins
Right coronary artery
Left coronary artery
Anterior interventricular (anterior
descending) coronary artery
Great cardiac vein
Coronary sinus, and it’s opening to
right atrium
Other Structures
Foramen ovale
Fossa ovalis
Ductus arteriosus
Ligamentum arteriosum
Parietal pericardium
Visceral pericardium (epicardium)
Myocardium
Endocardium
Interatrial septum
Interventricular septum
Sinoatrial (SA) node
Internodal pathways
Atrioventricular (AV) node
AV bundle
Bundle branches
Purkinje fibers
Identify the Below Systemic Arteries

Ascending aorta
Thoracic aorta
Brachiocephalic trunk
Subclavian
Axillary
Brachial
Deep brachial
Radial
Ulnar
Common Carotid
Internal Carotid
External Carotid
Facial
Superficial Temporal
Occipital
Vertebral
Basilar
Cerebral arterial circle (circle of Willis)
Anterior communicating
Anterior cerebral
Posterior communicating
Posterior cerebral
Celiac trunk
Common hepatic
Superior mesenteric
Renal
Inferior mesenteric
Common iliac
Internal iliac
External iliac
Femoral
Popliteal
Anterior tibial

Posterior tibial
107
Identify the Below Systemic Veins
Superior vena cava
Brachiocephalic trunk
Subclavian
Axillary
Cephalic
Brachial
Basilic
Radial
Ulnar
Median cubital
Internal jugular
External jugular
Temporal
Facial
Vertebral
Inferior vena cava
Hepatic
Renal
Gonadal
Common iliac
Internal iliac
External iliac
Femoral
Poplilteal
Posterior tibial
Great saphenous
Hepatic portal circulation

Superior mesenteric
Inferior mesenteric
Splenic
Hepatic portal vein
108
Special circulation
• The brain
• Four arteries which anastomose insuring constant blood flow
• Cerebral arterial circle (Circle of Willis)
• The heart
• Coronary arteries arising from the ascending aorta
• The lungs
• Pulmonary circuit, regulated by local responses to O2 levels
• Opposite other tissues (declines in O2 cause vasodilation)
• Hepatic portal system
• Contains substance absorbed by the stomach and intestines
• Delivers these compounds to the liver for
• Storage
• Metabolic conversion
• Detoxification and Excretion
• Fetal Circulation
• Fetal blood flow to the placenta is supplied via paired
umbilical arteries
• A single umbilical vein drains from the placenta to the ductus
venosus

• Collects blood from umbilical vein and liver
• Empties into the inferior vena cava
• No need for pulmonary function in the fetus
• Two shunts bypass the pulmonary circuit
• Foramen ovale
• Ductus arteriosus
• Cardiovascular changes at birth
• Lungs and pulmonary vessels expand
• Ductus arteriosus constricts and becomes ligamentum
arteriosum
• A valvular flap closes the foramen ovale forming fossa ovalis
• Ductus venosus closes and forms ligamentum arteriosum
Age-related changes in blood may include
• Decreased hematocrit
• Constriction or blockage of peripheral veins by a thrombus
• Pooling of blood in the veins of the legs
Vessels are less elastic, prone to Ca2+ deposits and thrombi
formation

Blood Disorders and Cardiovascular System

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