ANATOMY AND PHYSIOLOGY

Cardiovascular System

HEART
For all its might, the cone-shaped heart is a relatively small, roughly
the same size as a closed fist—about 12 cm (5 in) long, 9 cm (3.5 in) wide at
its broadest point, and 6 cm (2.5 in) thick. Its mass averages 250 g (8 oz) in
adult females and 300 g (10 oz) in adult males. The heart rests on the
diaphragm, near the midline of the thoracic cavity. It lies in the mediastinum,
a mass of tissue that extends from the sternum to the vertebral column
between the lungs. About two-thirds of the mass of the heart lies to the left of
the body’s midline. Visualize the heart as a cone lying on its side. The pointed
end of the heart is the apex, which is directed anteriorly, inferiorly, and to the
left. The broad portion of the heart opposite the apex is the base, which is
directed posteriorly, superiorly, and to the right.

In addition to the apex and the base, the heart has several surfaces
and borders. The anterior surface is deep to the sternum and ribs. The
inferior surface is the part of the heart between the apex and the right border
and rests mostly on the diaphragm. The right border faces the right lung and
extends from the inferior surface to the base. The left border, also called the
pulmonary border, faces the left lung and extends from the base to the apex.

Layers and Coverings of the Heart

 The heart is located between the lungs in the thoracic cavity and is
surrounded and protected by the pericardium (peri- around). The pericardium
consists of an outer, tough fibrous pericardium and an inner, delicate serous
pericardium. The fibrous pericardium attaches to the diaphragm and also to
the great vessels of the heart. Like all serous membranes, the serous
pericardium is a double membrane composed of an outer parietal layer and
an inner visceral layer. Between these two layers is the pericardial cavity
filled with serous fluid. The wall of the heart has three layers: the outer
epicardium (epi- _ on, upon; cardia _ heart), the middle myocardium (myo
muscle), and the inner endocardium (endo- _ within, inward). The epicardium
is the visceral layer of the pericardium. The majority of the heart is
myocardium or cardiac muscle tissue. The endocardium is a thin layer of
endothelium deep to the myocardium that lines the chambers of the heart
and the valves.

Surface Structures of the Heart

 The human heart has four chambers and is divided into right and left
sides. Each side has an upper chamber called an atrium and a lower chamber
called a ventricle. The two atria form the base of the heart and the tip of the
left ventricle forms the apex. Auricles (auricle- little ear) are pouch-like
extensions of the atria with wrinkled edges. Shallow grooves called sulci
(sulcus, singular) externally mark the boundaries between the four heart
chambers. Although a considerable amount of external adipose tissue is
present on the heart surface for cushioning, most heart models do not show
this. Cardiac muscle tissue that composes the heart walls has its own blood
supply and circulation, the coronary (corona- crown) circulation. Coronary
blood vessels encompass the heart similar to a crown and are found in sulci.
On the anterior surface of the heart, the right and left coronary arteries
branch off the base of the ascending aorta just superior to the aortic
semilunar valve, and travel in the sulcus separating the atria and ventricles.
These small arteries are supplied with blood when the ventricles are resting.
When the ventricles contract, the cusps of the aortic valve open to cover the
openings to the coronary arteries.

A clinically important branch of the left coronary artery is the anterior

interventricular branch, also known as the left anterior descending (LAD)
branch that lies between the right and left ventricles and supplies both
ventricles with oxygen-rich blood. This coronary artery is commonly occluded
which can result in a myocardial infarct and, at times, death.

Great Vessels of the Heart

The great veins of the heart return blood to the atria and the great
arteries carry blood away from the ventricles. The superior vena cava, inferior
vena cava, and coronary sinus return oxygen-poor blood to the right atrium.
The superior vena cava returns blood from the head, neck, and arms; the
inferior vena cava returns blood from the body inferior to the heart. The
coronary sinus is a smaller vein that returns blood from the coronary
circulation. Blood leaves the right atrium to enter the right ventricle. From
here, oxygen-poor blood passes out the pulmonary trunk, the only vessel that
removes blood from the right ventricle. This large artery divides into the right
and left pulmonary arteries that carry blood to the lungs where it is
oxygenated. Oxygen-rich blood returns to the left atrium through two right
and two left pulmonary veins. The blood then passes into the left ventricle
that pumps blood into the large aorta. The aorta distributes blood to the
systemic circulation. The aorta begins as a short ascending aorta, curves to
the left to form the aortic arch, descends posteriorly and continues as the
descending aorta.

Internal Structures of the Heart

The heart has four valves that control the one-way flow of blood: two
atrioventricular (AV) valves and two semi lunar valves (semi- half; lunar-
moon). Blood passing between the right atrium and the right ventricle goes
through the right AV valve, the tricuspid valve (tri- three; cusp- flap). The left
AV valve, the bicuspid valve, is between the left atrium and the left ventricle.
This valve clinically is called the mitral valve (miter- tall, liturgical headdress)
because the open valve resembles a bishop’s headdress. String-like cords
called chordae tendineae (tendinous strands) attach and secure the cusps of
the AV valves to enlarged papillary muscles that project from the ventricular
walls. Chordae tendinae allow the AV valves to close during ventricular
contraction, but prevent their cusps from getting pushed up into the atria.
The two semilunar valves allow blood to flow from the ventricles to great
arteries and exit the heart. Blood in the right ventricle goes through the
pulmonary (semi lunar) valve to enter the pulmonary trunk, a large artery.
The aortic (semi lunar) valve is located between the left ventricle and the
aorta. These two semi lunar valves are identical, with each having three
pockets that fill with blood, preventing blood from flowing back into the
ventricles. The two ventricles have a thick wall between them called the
interventricular septum. Between the two atria is a thinner interatrial septum.

Coronary Circulation

There are two major coronary arteries: the right and the left. These two
arteries branch out of the aorta immediately after the aortic valve. The right
coronary artery splits into the marginal branch, which feeds blood into the
right ventricle, and the posterior interventricular branch, which supplies the
left ventricle. The left coronary artery is notably larger than the right
coronary artery because it feeds the left heart, which, as a result of it's more
powerful contractions, requires a more vigorous blood flow. The left coronary
artery splits into the anterior interventricular branch and a circumflex branch.
The anterior interventricular branch runs towards the apex of the heart,
providing blood for both of the ventricles and the ventricular septum. The
circumflex branch, on the other hand, follows the groove between the left
atrium and the left ventricle, providing blood supply to both of these
chambers until it reaches and joins with the right coronary artery in the
posterior of the heart.

The coronary arteries are especially subject to blockage and narrowing

which can cause a depletion of blood to certain parts of the heart, possibly
causing a heart attack.

Blood Flow through the Heart

 The function of the right side of the heart is to collect de-oxygenated
blood, in the right atrium, from the body and pump it, via the right ventricle,
into the lungs (pulmonary circulation) so that carbon dioxide can be dropped
off and oxygen picked up (gas exchange). This happens through the passive
process of diffusion. The left side (see left heart) collects oxygenated blood
from the lungs into the left atrium. From the left atrium the blood moves to
the left ventricle which pumps it out to the body. On both sides, the lower
ventricles are thicker and stronger than the upper atria. The muscle wall
surrounding the left ventricle is thicker than the wall surrounding the right
ventricle due to the higher force needed to pump the blood through the
systemic circulation.

Starting in the right atrium, the blood flows through the tricuspid valve
to the right ventricle. Here it is pumped out the pulmonary semilunar valve
and travels through the pulmonary artery to the lungs. From there, blood
flows back through the pulmonary vein to the left atrium. It then travels
through the mitral valve to the left ventricle, from where it is pumped
through the aortic semilunar valve to the aorta. The aorta forks and the blood
is divided between major arteries which supply the upper and lower body.
The blood travels in the arteries to the smaller arterioles, then finally to the
tiny capillaries which feed each cell. The (relatively) deoxygenated blood then
travels to the venules, which coalesce into veins, then to the inferior and
superior venae cavae and finally back to the right atrium where the process
began.

Blood Vessels
Blood circulates inside the blood vessels, which form a closed transport
system, the so-called vascular system. Like a system of roads, the vascular
system has its freeways, secondary roads, and alleys. As the heart beats,
blood is propelled into the large arteries leaving the heart. It then moves
successively smaller and smaller arteries and then into the arterioles, which
feed the capillary beds in the tissues. Capillary beds are drained by venules,
which in turn empty into the great veins (venae cavae) entering the heart.
Thus arteries, which carry blood away from the heart, and veins, which drain
the tissues and return the blood to the heart, are simply conducting vessels.
Only the tiny hair-like capillaries, which extend and branch through the tissue
and connect the smallest arteries (arterioles) to the smallest veins (venules),
directly serve the needs of the body cells. The capillaries are the side streets
or alleys that intimately intertwine among the body cells. It is only through
their walls that exchanges between the tissue cells and the blood can occur.

Layers of Blood Vessel Walls

 The walls of blood vessels have three coats, or tunics.

The tunica intima which lines the lumen or interior of the blood vessels,
is a thin layer of endothelium (squamous epithelial cells) resting on a
basement membrane. Its cells fit closely together and form a slick surface
that decreases friction as blood flows through the vessel lumen.

The tunica media is the bulky middle coat. It is mostly smooth muscle
and elastic tissue. The smooth muscle, which is controlled by the sympathetic
nervous system, is active in changing the diameter of the vessels. As the
vessel constrict or dilate, blood pressure increases or decreases, respectively.

The tunica externa is the outermost tunic; it is composed largely of

fibrous connective tissue. Its function is basically to support and protect the
vessels.

The Microcirculation
 The microcirculation is that portion of the circulatory system for
exchange of water, gases, nutrients, and waste material. As such, it is the
most important part of the cardiovascular system because it is where the
exchange with tissues takes place. Although the microcirculation is
considered as a closed system, its walls are much more permeable than any
other part of the circulation.

Factors Affecting Flow of Blood

The flow of a fluid through a vessel is determined by the pressure
difference between the two ends of the vessel and also the resistance to flow.
• Pressure Difference. For any fluid to flow along a vessel there must
be a pressure difference otherwise the fluid will not move. In the
cardiovascular system, the “pressure head” or force is generated by
the pumping of the heart and there is a continuous drop in pressure
from the left ventricle to the tissue and also from the tissue back to the
right atrium.
• Resistance to Flow. Resistance is a measure of the ease with which a
fluid flows through a tube: the easier it is the less resistance to flow,
and vice versa. In the circulatory system, the resistance is usually
described as vascular resistance, or also known as peripheral
resistance. Resistance is essentially a measure of the friction between
the molecules of the fluid, and between the tube wall and the fluid. The
 resistance depends on the viscosity of the fluid and the radius and
length of the tube.
• Radius of the Tube. The smaller the radius of a vessel, the greater is
the resistance to the movement of particles. Small alterations in the
size of the radius of the blood vessels, particularly of the more
peripheral vessels, can greatly influence the flow of blood.
Atheromatous changes in the walls of large and medium-sized arteries
cause narrowing of the lumen of the vessels and result in an increased
vascular resistance.
• Length of the Tube. The longer the tube, the greater the resistance
to the flow of liquid through it. A longer vessel will require a greater
pressure to force a given volume of liquid through it than will a shorter
vessel.
• Viscosity of the Fluid. Viscosity is a measure of the intermolecular or
internal friction within a fluid or in other words, of the tendency of the
fluid to resist flows. The greater the viscosity of the fluid, the greater is
the force required to move that liquid.

Blood

Blood is a specialized bodily fluid (technically a tissue) that is

composed of a liquid called blood plasma and blood cells suspended within
the plasma. The blood cells present in blood are red blood cells (also called
RBCs or erythrocytes), white blood cells (including both leukocytes and
lymphocytes) and platelets (also called thrombocytes). Plasma is
predominantly water containing dissolved proteins, salts and many other
substances; and makes up about 55% of blood by volume. Mammals have
red blood, which is bright red when oxygenated, due to hemoglobin. Some
animals, such as the horseshoe crab use hemocyanin to carry oxygen,
instead of hemoglobin.

By far the most abundant cells in blood are red blood cells. These
contain hemoglobin, an iron-containing protein, which facilitates
transportation of oxygen by reversibly binding to this respiratory gas and
greatly increasing its solubility in blood. In contrast, carbon dioxide is almost
entirely transported extracellularly dissolved in plasma as bicarbonate ion.
White blood cells help to resist infections and parasites, and platelets are
important in the clotting of blood.

Blood is circulated around the body through blood vessels by the

pumping action of the heart. Arterial blood carries oxygen from inhaled air to
the tissues of the body, and venous blood carries carbon dioxide, a waste
product of metabolism produced by cells, from the tissues to the lungs to be
exhaled.
Medical terms related to blood often begin with hemo- or hemato- (BE:
haemo- and haemato-) from the Greek word "αἷμα" for "blood." Anatomically
and histologically, blood is considered a specialized form of connective tissue,
given its origin in the bones and the presence of potential molecular fibers in
the form of fibrinogen.
Constituents of human blood

Blood accounts for 7% of the human body weight, with an average

density of approximately 1060 kg/m³, very close to pure water's density of
1000 kg/m3. The average adult has a blood volume of roughly 5 litres,
composed of plasma and several kinds of cells (occasionally called
corpuscles); these formed elements of the blood are erythrocytes (red blood
cells), leukocytes (white blood cells) and thrombocytes (platelets). By volume
the red blood cells constitute about 45% of whole blood, the plasma
constitutes about 55%, and white cells constitute a minute volume.

Whole blood (plasma and cells) exhibits non-Newtonian fluid dynamics;

its flow properties are adapted to flow effectively through tiny capillary blood
vessels with less resistance than plasma by itself. In addition, if all human
haemoglobin was free in the plasma rather than being contained in RBCs, the
circulatory fluid would be too viscous for the cardiovascular system to
function effectvely.
Cells

4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In

mammals, mature red blood cells lack a nucleus and organelles. They contain
the blood's hemoglobin and distribute oxygen. The red blood cells (together
with endothelial vessel cells and other cells) are also marked by glycoproteins
that define the different blood types. The proportion of blood occupied by red
blood cells is referred to as the hematocrit, and is normally about 45%. The
combined surface area of all the red cells in the human body would be
roughly 2,000 times as great as the body's exterior surface.

4,000-11,000 leukocytes: White blood cells are part of the immune

system; they destroy and remove old or aberrant cells and cellular debris, as
well as attack infectious agents (pathogens) and foreign substances. The
cancer of leukocytes is called leukemia.

200,000-500,000 thrombocytes: Platelets are responsible for blood

clotting (coagulation). They change fibrinogen into fibrin. This fibrin creates a
mesh onto which red blood cells collect and clot, which then stops more
blood from leaving the body and also helps to prevent bacteria from entering
the body.
Plasma
About 55% of whole blood is blood plasma, a fluid that is the blood's
liquid medium, which by itself is straw-yellow in color. The blood plasma
volume totals of 2.7-3.0 litres in an average human. It is essentially an
aqueous solution containing 92% water, 8% blood plasma proteins, and trace
amounts of other materials. Plasma circulates dissolved nutrients, such as,
glucose, amino acids and fatty acids (dissolved in the blood or bound to
plasma proteins), and removes waste products, such as, carbon dioxide, urea
and lactirc acid.
Other important components include:
• Serum albumin
• Blood clotting factors (to facilitate coagulation)
• Immunoglobulins (antibodies)
• Various other proteins
• Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have
been removed. Most of the proteins remaining are albumin and
immunoglobulins.

The normal pH of human arterial blood is approximately 7.40 (normal

range is 7.35-7.45), a weak alkaline solution. Blood that has a pH below 7.35
is too acidic, while blood pH above 7.45 is too alkaline. Blood pH, arterial
oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2) and HCO3 are
carefully regulated by complex systems of homeostasis, which influence the
respiratory system and the urinary system in the control the acid-base
balance and respiration. Plasma also circulates hormones transmitting their
messages to various tissues.

Color
Hemoglobin
 Hemoglobin is the principal determinant of the color of blood in
vertebrates. Each molecule has four heme groups, and their interaction with
various molecules alters the exact color. In vertebrates and other
hemoglobin-using creatures, arterial blood and capillary blood are bright red
as oxygen impacts a strong red color to the heme group. Deoxygenated
blood is a darker shade of red with a bluish hue; this is present in veins, and
can be seen during blood donation and when venous blood samples are
taken. Blood in carbon monoxide poisoning is bright red, because carbon
monoxide causes the formation of carboxyhemoglobin. In cyanide poisoning,
the body cannot utilize oxygen, so the venous blood remains oxygenated,
increasing the redness. While hemoglobin containing blood is never blue,
there are several conditions and diseases where the color of the heme groups
make the skin appear blue. If the heme is oxidized, methemoglobin, which is
more brownish and cannot transport oxygen, is formed. In the rare condition
sulfhemoglobinemia, arterial hemoglobin is partially oxygenated, and
appears dark-red with a bluish hue (cyanosis), but not quite as blueish as
venous blood.

Veins in the skin appear blue for a variety of reasons only weakly
dependent on the color of the blood. Light scattering in the skin, and the
visual processing of color play roles as well.

Pancreatic Islets
The pancreas, located close to the stomach in the abdominal cavity is
a mixed gland. Probably the best-hidden endocrine glands in the body are the
pancreatic islets, formerly called the islets of Langerhans. These little masses
of hormone-producing tissue are scattered among the enzyme-producing
acinar tissue of the pancreas. Two important hormones produced by the islet
cells are insulin and glucagons.

High levels of glucose in the blood stimulate the release of insulin from
the beta cells of the islets. Insulin acts on just about all body cells and
increases their ability to transport glucose across their plasma membranes.
Once inside the cells, glucose is oxidized for energy or converted to glycogen
or fat for storage. These activities are also speeded up by insulin. Since
insulin sweeps the glucose out of the blood, its effect is said to be
hypoglycemic. As blood glucose levels fall, the stimulus for insulin release
ends (negative feedback control). Insulin is the only hormone that decreases
blood glucose levels. Insulin is absolutely necessary for the use of glucose by
the body cells. Without it, essentially no glucose can get into the cells to be
used.

Glucagons act as an antagonist of insulin; that is, it helps to regulate

blood glucose levels but is a way opposite to that of insulin. Its release by the
alpha cells of the islets is stimulated by low blood levels of glucose. Its action
is basically hyperglycemic. Its primary target organ is the liver, which
stimulates to break down stored glycogen to glucose and to release glucose
into the blood.

A. Insulin
The main function of the insulin is to participate in maintaining
homeostasis of blood glucose level and to promote other metabolic activities
that are anabolic. When absorbed nutrients, especially glucose, are in excess
of immediate needs insulin promotes storage.
It reduces high blood nutrients by:
• Acting on cell membranes and stimulating uptake and utilization of
glucose by muscles and connective tissue cells;
• Increasing conversion of glucose to glycogen, especially in the liver
and skeletal muscles;
• Accelerating uptake of amino acids by cells, and the synthesis of
proteins;
• Promoting synthesis of fatty acids and storage of fat in adipose tissue,
and;
• Preventing the breakdown of protein and fat and gluconeogenesis.

B. Glucagon
 The effect of glucagon is increasing blood glucose levels by
stimulating:
Conversion of glycogen to glucose (in the liver and skeletal muscle);
Gluconeogenesis, the manufacture of glucose by the body from
noncarbohydrate materials.

C. Somatostatin
The effect of somatostatin (also produced by hypothalamus) is to
inhibit the secretion of both insulin and glucagons. It delays intestinal
absorption of glucose.

Metabolism
Metabolism is a broad term referring to all chemical reactions that are
necessary to maintain life. In involves catabolism, in which substances are
broken down to simpler substances, and anabolism, in which larger molecules
or structures are built from smaller ones. During catabolism, energy is
released and captured to make ATP, the energy-rich molecule used to
energize all cellular activities, including catabolic reactions.

Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the
body use carbohydrates as their preferred fuel to produce cellular energy
(ATP). Glucose, also known as blood sugar, is the major breakdown product of
carbohydrate digestion. Glucose is also the major fuel used for making ATP in
most body cells. Basically, the carbon atoms released leave the cells as
carbon dioxide, and the hydrogen atoms removed (which contain energy-rich
electrons) are eventually combined with oxygen to form water. These
oxygen-using events are referred to collectively as cellular respiration.

The overall reaction is summed up simply as:

C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy).