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ANATOMY, PHYSIOLOGY, & PATHOPHYSIOLOGY

CARDIACCARDIAC SYSTEM

FOR CODERS

• Understand medical terms

• Synthesize clinical findings

• Comprehensive view of patient care

• See problems and procedures in your mind’s eye

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ANATOMY• Chambers• Chambers

• Valves

• Conduction System

• Cardiac Circulation

HEART CHAMBERS

"Diagram of the human heart (cropped)" by Own work. Licensed under CC BY‐SA 3.0 via Commons ‐

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HEART CHAMBERS

• Left Ventricle▫ Pumps blood to body (high resistance)Pumps blood to body (high resistance)

▫ More muscular

▫ Pressure 120mmHg systolic, 0‐10mmHg diastolic

• Right Ventricle▫ Pumps blood to lungs (low resistance)

▫ Less muscular

▫ Pressure <25mmHg systolic, <5mmHg diastolic

HEART CHAMBERS

"Heart ant wall infarction" by Patrick J. Lynch, medical illustrator ‐ Patrick J. Lynch, medical illustrator. Licensed under CC BY 2.5 via Commons ‐

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HEART CHAMBERS• Right Atrium▫ Receives blood from body (SVC&IVC)

Fill i ht t i l▫ Fills right ventricle▫ Site of sinoatrial node▫ Central line/Pacemaker placement

• Left Atrium▫ Receives blood from lungs

▫ Fills left ventricle (“atrial kick”)▫ Fills left ventricle ( atrial kick )

▫ Potential site for clot formation

HEART CHAMBERS

• Atrial Action▫ Prefill Ventricles▫ Prefill Ventricles▫ Frank‐Starling Law▫ “Atrial Kick”

• Ventricular▫ Relaxation = diastole▫ Relaxation = diastole▫ Contraction = systole

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HEART VALVES

"2011 Heart Valves" by OpenStax College ‐ Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.. Licensed under CC BY 3.0 via Commons 

HEART VALVES

• Stenosis (narrowing)▫ Ventricles can’t fill (mitral tricuspid)▫ Ventricles can t fill (mitral, tricuspid)

▫ Ventricles can’t empty (aortic, pulmonic)

▫ = poor cardiac output• Regurgitation/Insufficiency (leaking)▫ Wasted ventricular effort (aortic, pulmonic)

▫ Duplicated ventricular effort (mitral tricuspid)Duplicated ventricular effort (mitral, tricuspid)

▫ = poor cardiac output

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AORTIC INSUFFICIENCY

• Aortic backflow wastes effortwastes effort

• Overfills left ventricle

• Impairs inflow from left atrium

"Blausen 0039 AorticRegurgitation" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. ‐ Own work. Licensed under CC BY 3.0 via Commons 

MITRAL STENOSIS

• Left ventricular cannot fully fillcannot fully fill

• Causes:▫ Rheumatic fever

▫ Calcification▫ Endocarditis

"Blausen 0648 MitralValveStenosis" by Blausen Medical Communications, Inc. ‐ Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons 

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MITRAL STENOSIS

AORTIC STENOSIS

• Left ventricular cannot fully emptycannot fully empty

• Causes:

o Hypertension

o Cholesterol

o Diabetes

"Blausen 0040 AorticStenosis" by BruceBlaus ‐ Own work. Licensed under CC BY 3.0 via 

o Endocarditis

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AORTIC STENOSIS

VALVULAR DISEASE TREATMENT

• Stenosis▫ Balloon valvuloplasty▫ Valve replacement

• Insufficiency▫ Valve replacement

▫ Valve repair

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BALLOON VALVULOPLASTY

"Blausen 0889 MitralValvuloplasty" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

VALVE REPLACEMENT

"Mechanical heart valves" by Z22 - Own work. Licensed under CC BY-SA 4.0 via Commons

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CONGENITAL DEFECTS ‐ ASD

VENTRICULAR SEPTAL DEFECT

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SEPTAL DEFECT REPAIR

SEPTAL DEFECT PLUG

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BLUE BABY SYNDROME

BLUE BABY SYNDROME• Blalock‐Taussig Shunt

"Blalock shuntWiki" by Pezard - Own work. Licensed under CC BY-SA 3.0 via Commons

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BLUE BABY SYNDROME

• Vivien Thomas

Assistant to Dr Alfred• Assistant to Dr. Alfred Blalock

• Primarily developed Blalock‐Taussigtechniques

• Job title and pay: janitor• Job title and pay: janitor

• Honorary doctor 1976

HEART FAILURE

• = Cardiac output which is insufficient for the needs of the bodyneeds of the body.

• Systolic – decreased ejection fraction▫ Failure of pumping action

• Diastolic – normal ejection fraction▫ Failure of filling action

• Congestive• Congestive▫ Venous return (preload) exceeds cardiac output

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HEART FAILURE

• Causes – any acute or chronic condition which insults, stresses, or damages myocardium:, , g y▫ Hypertension▫ Valvular disease▫ Ischemic disease

▫ Myocardial infarction

▫ Cardiomyopathy

▫ Myocarditis

HEART FAILURE• Normal end‐diastolic volume   140ml• Normal ejection fraction            >50%• Normal stroke volume >70ml• Systolic heart failure▫ EDV 140ml▫ EF 25%▫ SV 35ml

• Diastolic heart failure▫ EDV 70ml▫ EF 50%EF 50%▫ SV 35ml

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HEART FAILURE

• Symptoms▫ Dyspnea▫ Tiredness▫ Swelling

• Treatment▫ Diuretics (furosemide)

▫ Decrease vascular resistance (ACEI’s)▫ Cardiac stimulants (digoxin)

CONGESTIVE HEART FAILURE

"Elevated JVP" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons "Combinpedal" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons 

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CONGESTIVE HEART FAILURE

"Pulmonaryedema09" by James Heilman, MD ‐ Own work. Licensed under CC BY‐SA 3.0 via Commons 

CONDUCTION MECHANISM• Specialized, conductive heart cells

• Not nerves

• Sinoatrial node – primary pacemaker

• Atrioventricular node – relay station, 2nd pacemaker

• Right bundle branch

• Left bundle branch▫ Left anterior branch/fascicle▫ Left posterior branch/fascicle

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CONDUCTION MECHANISM

"ConductionsystemoftheheartwithouttheHeart-en" by Madhero88 (original files); Angelito7

CONDUCTION MECHANISM

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CONDUCTION MECHANISM• Electrocardiogram (EKG)

CONDUCTION MECHANISM

• 12‐lead EKG

• Axis of

conduction

"EKG leads" by Npatchett - Own work. Licensed under CC BY-SA 4.0 via Commons -

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CONDUCTION MECHANISM

CONDUCTION PROBLEMS

• Atrial Fibrillation

• Atrioventricular Blocks• Atrioventricular Blocks▫ 1st, 2nd, 3rd degree

• Bundle Branch Blocks

• Left, right, bifascicular, left hemi

• Re‐entrant pathways

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ATRIAL FIBRILLATION

"Atrial Fibrillation" by BruceBlaus - Own work. Licensed under CC BY-SA 4.0 via Commons –

ATRIAL FIBRILLATION

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ATRIAL THROMBUS

ATRIAL THROMBUS

• Source of embolic CVAembolic CVA

• Treated with anticoagulants

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HEART CONDUCTION BLOCKS• AV Blocks▫ 1st degree – delay▫ 2nd degree – missed conductions

▫ 3rd degree – total lack of conduction• Bundle Blocks▫ 1, 2, or 3 fascicles (bundles) blocked▫ Conduction becomes incidental

▫ Contraction is less organized

HEART BLOCKS

• 1st Degree

• 2nd Degree

• 3rd Degree

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Wolf‐Parkinson‐White Syndrome

CORONARY CIRCULATION

Blausen 0260 CoronaryVessels Anterior" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

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CORONARY CIRCULATION

Blausen 0260 CoronaryVessels Anterior" by Blausen Medical Communications, Inc. - Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons

CORONARY CIRCULATIONLatin “corona” = crown

"Blausen 0256 CoronaryArteries 02" by BruceBlaus - Own work. Licensed under CC BY 3.0 via Commons -

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CORONARY CIRCULATION

• Left (main) ▫ Left anterior descending▫ Left anterior descending▫ Circumflex

▫ Left marginal

• Right ▫ Posterior descending▫ Right marginalRight marginal

• Fill during diastole

"Blausen 0256 CoronaryArteries 02" by BruceBlaus - Own work. Licensed under CC BY 3.0 via Commons

CORONARY ARTERY DISEASE

• Arteriosclerosis = hardening of artery walls ‐> hypertension, etc.yp ,

• Atherosclerosis = plaque buildup and narrowing ‐> stenosis, obstruction

• Often used interchangeably, or “CAD”

• ICD‐10 index prefers “arteriosclerosis”

• ICD‐10 tabular prefers “atherosclerosis”p

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ATHEROSCLEROSIS

"Blausen 0257 CoronaryArtery Plaque" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

ATHEROSCLEROSIS

• Plaque made of▫ Fat/Cholesterol▫ Fat/Cholesterol▫ Inflammatory tissue

▫ WBCs

▫ Calcium• Plaque caused by:▫ Fat smoking alcohol sedentary lifestyleFat, smoking, alcohol, sedentary lifestyle

"Atherosclerosis disease progression" by Npatchett ‐ Created by uploading user in Gimp based on a public domain image created by the US federal government. Licensed under CC BY‐SA 3.0 

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ATHEROSCLEROSIS

• % occlusion equalsequals 

% of plaque 

cross‐section

• “80% occlusion proximal LAD”proximal LAD

"RCA atherosclerosis" by Nephron - Own work. Licensed under CC BY-SA 3.0 via Commons

ATHEROMA• Carotid endarterectomy, at bifurcation

"Carotid Plaque" by Ed Uthman. Licensed under CC BY 2.0 via Commons

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ATHEROSCLEROSIS

• Disease Progession:

• Fatty streakFatty streak

• Atherosclerosis

• Angina (+/‐ spasm)

• Unstable angina

• Myocardial infarction

• Microangiopathy (capillary disease)

ANGINA

• Angina Pectoris

• Latin “angere” = “to strangle”Latin  angere     to strangle

• Narrowing of coronary artery▫ Atherosclerosis▫ Spasm▫ Stenosis

• Oxygen starvation (ischemia) of myocardiumyg ( ) y

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ANGINA

• Vagus innervation

Referral common• Referral common

• Degree of pain not necessarily degree of ischemia

"Angina pectoris" by Ian Furst - Own work derivative of File:Aorta scheme.jpg and File:Gray1220.png. Licensed under CC BY-SA 3.0 via Commons

ANGINA• (stable) “Angina”▫ Increased cardiac oxygen demand

▫ On exertion stress stimulants etc▫ On exertion, stress, stimulants, etc.

▫ Relieved by rest, vasodilators• “Unstable angina”▫ Borderline oxygen supply▫ At rest, severe, prolonged, unabated by rest▫ May evolve into MIMay evolve into MI

▫ May require PTCA, CABG

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ANGINA vs. ACUTE CORONARY SYNDROME

• Anginaf l▫ Patient feels it

▫ No damage

• Acute coronary syndrome▫ Spectrum of USA, NSTEMI, STEMI

▫ Dysfunction of or damage to myocardium

MYOCARDIAL INFARCTION• Ischemia = oxygen starvation

• Infarction = tissue death

• Atherosclerosis

• Clot▫ Inflammation

▫ Embolization

▫ Hypercoagulability▫ Happenstance

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MYOCARDIAL INFARCTION

"Blausen 0463 HeartAttack" by Blausen Medical Communications, Inc. ‐Donated via OTRS, see ticket for details. Licensed under CC BY 3.0 via Commons 

"Heart ant wall infarction" by Patrick J. Lynch, medical illustrator ‐ Patrick J. Lynch, medical illustrator. Licensed under CC BY 2.5 via Commons 

MYOCARDIAL INFARCTION

• “STEMI” = ST Elevation MI▫ Severe complete or permanent blockageSevere, complete, or permanent blockage

▫ Full‐thickness of myocardium dies

• “NSTEMI” = Non‐ST Elevation MI▫ AKA “nontransmural”, “subendocardial”

▫ Mild, partial, or temporary blockage

▫ Partial thickness of myocardium diesy

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MYOCARDIAL INFARCTION• Normal

• STEMI

NSTEMI• NSTEMI▫ Normal EKG or certain abnormalities

▫ Elevated Troponin T▫ Elevated CK/MB fraction

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CORONARY INTERVENTIONS

• Dissolve clot▫ Thrombolytics▫ Thrombolytics

• Open stenosis 

‐ PTCA

• Bypass stenosis▫ CABG

"Blausen 0259 CoronaryArteryDisease 02" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

PTCA

• Usually with stent

Bare metal• Bare metal

• Drug eluting▫ Anticoagulant drug

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CABG

"Blausen 0151 CABG 02" by BruceBlaus. When using this image in external sources it can be cited as:Blausen.com staff. "Blausen gallery 2014". Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. - Own work. Licensed under CC BY 3.0 via Commons

CONCLUSION

"Apikal4D" by Kjetil Lenes - Own work. Licensed under CC BY-SA 3.0 via Commons