Contents I.CardiacActionPotentials.........................2 II.CardiacConduction..................................2 III.CardiacEmbryology..................................2 IV.CongenitalHeartDefects.........................3 V.Electrocardiography.................................3

VI.CardiacMechanicalParameters...............4 VII.CalciumandCardiacMechanics...............4VIII.TheCardiacCycle.....................................4 IX.SystemicVascularResistances.................5 X.FactorsAffectingCoronaryCirculation....5

Aleaderisbestwhenpeoplebarelyknowthatheexists,notsogoodwhenpeopleobeyandacclaimhim,worstwhentheydespisehim.Failtohonorpeople,Theyfailtohonoryou.Butofagood

leader,whotalkslittle,whenhisworkisdone,hisaimsfulfilled,theywillallsay,"Wedidthisourselves."

LaoTze,TaoTeChingCh.17

OhmsLawUsedforsystemicchangesP=QR COR (SVHR)R ((EDVESV)HR)R

Poiseuilles(pwahsoys)LawUsedforlo angescalch

Q=P r4

CO=P r4

Compliance

C=

CarrdiopulmoonaryExammIITablesPage2

TableIPha

FastRe(Na+dep

SlowRe(Ca2+dep

TableII

TableIIIEmbryonicSAngioblasticSplanchnicmMesothelial

Aorticarche

Vitellineaa.Vitellinevv.ProximalumDistalumbilUmbilicalvvAnteriorcarCommoncaTruncusarteSinusvenosBubluscordSeptumprimSeptumsecuSubendocarswellings

Ductusveno

Ductusarter

Foramenov

ase Ap

esponsependent)

AtreVePuInis

esponsependent)

SA

Iion=Pionx

Image

Structure Embccords Formmesoderm Invecells Mig

esCarrSupp

Supp Retumbilicalaa. Carrlicalaa. Carrv. Carrrdinalvv. Carrrdinalvv. Unioeriosus Carrus Empis Poumum Splitundum Comrdial

Form

osus Con

riosus Con

vale Shun

pplicableCells

trialcells(shortestefractoryperiod)

entricularcells

urkinjeFibers

nhibitedbychemia

AandAVnodes

x(Emembrane

bryonicFunctionmendocardialheaeststubesformingratesontomyocar

rybloodtoembryopliespharyngeala

plyyolksacurnbloodfromyorydeoxygenatedbrydeoxygenatedbryoxygenatedbloorybloodfromanteonofanteriorandrybloodfromprimptiescardinalvv.,cchconnectingprimtsprimordialatriampletesdivisionof

minorificesoftru

nectsumbilicalv.

netspulmonarya

ntsbloodrightto

t

log ou

in

Cells

Atrialcontractile

AVnode

Purkinjesystem

Ventricularcont

arttubesmid3rdwprimordialmyocardium

ofromprimordialarches

lksacbloodfromhearttbloodfromhearttodtosinusvenosueriorembryotosinposteriorcardina

mordialventricletocarriesbloodintomordialventricleaatday28atria

ncusarteriosusan

tohepaticv.,bypa

.toaorta,bypassi

lefttobypasslun

CardiacAImage

utside

nside);Positivecu

Cardia

ecells

tractilecells

Cardia

week,functions4th

ardium

heart

oplacentaoplacentausfromplacentanusvenosuslvv.orestoffetusprimordialatriumandaorticarches

ndAVcanal

assingportalv.

nglungs

gs

ActionPotenPhase

0

1

2

3

4

0

2

3

4

urrent=cation

acConductioConductionve

0.30.5m/s

0.02m/s

4m/s

0.30.5s

acEmbryoloAdultStructureEndocardiumMyocardiumEpicardium1:maxillarya.,3:commonand4L:distalaortic5:disappears6:pulmonaryaCeliaca.sup&Hepaticv.,hepInternaliliacaaMedialumbilicRoundlig.oflivLbrachiocephaSuperiorvenacAscendingaortL coronarysinAorticvestibuleValveofforamForamensecun

Heartvalves

Ligamentumve

Ligamentumar

Fossaovalis

ntialsConcurrentActionRapidupstroke FOpeningofm(actClosureofh(inactBrief,rapidrepolaPlateau Ca2+ in,byE/NE,sympabyACh,parasyRepolarization KOpeningofh(inacDiastole restoraCa2+ in throughLtbyE/NE,sympabyACh,parasy

Diminishedplatea

RepolarizationK

Diastolerestora

nsmoveout,n

onelocity T

L

.

.

.

ogye

2:stapediala.dinternalcarotidacarch,4R:Rsubcla

a.andductusarterinfmesentericaa

paticportalv.a.,superiorvesicalallig.veralicv.cava(Rant&Rcota,pulmonarytrunnus,R smoothRe,conusarteriosuenovale/fossaovandum

enosum

rteriosum

nsFastNa+ intivation)gatesattivation)gatesat+arizationK+outK+outatheticactivitympatheticactivityK+ out,relativerefrctivation)gates,cltionofmembranetypevoltagegatedatheticactivitympatheticactivity

auduetoslowedC

K+out,relativerefr

tionofmembrane

egativecurren

Timefrominitiald

Left:.01.05s,Righ

07.16s

16.22s

16.22s

Image

aa.aviana.

riosus.

laa.

mmon)nkatriumsalis

65mVallowsfor+potentialsetsref

y,Ca2+channelblocractoryperiodosureofm(activaepotentialviaNa+

dchannels

y,Ca2+channelblo

Ca2+influxwithno

ractoryperiod

epotentialviaNa+

nt=cationsmo

depolarization

ht:.03.09s

s

rapidinfluxfractoryperiod

ckers,adenosine

ation)gates+/K+ pump

ockers,adenosine

rmalK+efflux

+/K+pump

ovein

CarrdiopulmoonaryExammIITables ge3 Paa

TableIVDefectDextrocardiAtrialseptal

Ventriculars

PersistenttrTranspositioTetralogyofPatentDuctCoarctation

TableV

Axis

AxNoRigLeExDe

Arrythm

ias

Ar

Sin

Sin

1st

2n

3rd

(C

PrCo

PrCo

PrCo

PaTa

At

At

Ve

12Lead

Interpretation

Lo

Inf

Se

An

La

V

aldefects

septaldefects

runcusarteriosusonofgreataa.fFallotusArteriosusofaorta

xisormalAxisghtAxisDeviationeftAxisDeviationxtreme(Northweseviationrrythmia

nusTachycardia

nusBradycardia

tdegreeAVblock

ddegreeAVblock

ddegreeAVblockompleteheartblo

rematureAtrialontraction(PAC)

rematureAVnodaontraction

rematureVentricuontraction(PVC)

aroxysmalVentricachycardia

trialFlutter

trialFibrillation

entricularFibrillat

ocationinHeart

feriorwall

eptalwall

nteriorwall

ateralwall

Occurrence(li6/104,3xfema1012/104(25CHDs),male>1/1045/10423xfemale10%withoutC

Diagram

Range30

n 10030

st)Axis90

k

k

kock)

al

ular

cular

tion

Leads

II,III,

V1,V2

V3,V4

V5,V6

ivebirths) DP

ale M%ofall>female

SBTAPM

CHD,2xmale 9

Le

IIIIIIaVaVaV

e Ca100 No180 RV90 HT

180 Ba

Str

s

aVF

2

4

6

CongenitDescriptionPrimitivehearttubMostlyduetoshorSmallVSDs(3050%BodyreceivespartTruncalridgesandAorticopulmonaryPulmonarystenosiMostcommonlyse90%occurdirectly

Electroad Sites(

RALA

RALL

I LALLVL (RA/LL)VR (LA/LL)

VF (RA/LA)ausesormalheartconduVH,RBBBTN,LBBB,LAH

ad,badnews

ip

Imag

talHeartDe

beloopstotheleftrtordefectivesep%)closespontaneiallyoxygenatedbaorticopulmonaryseptumdidnotss,VSD,dextroposeenaftermaternaoppositeDA,pred

ocardiograp+) Axis

A 0

L 60

L 120

LA 30

RA 30

)LL 90

uction

Descriptio

RapiddepNormalP

SlowdepoNormalP

SlowcondNormalP

PartialnoNormalP

CompleteAtrialrate

DepolarizaPwavepr

DepolarizaNoPwave

DepolarizaNoPwave

EssentiallySustained

Rapiddepirregularly

VeryrapidNoPwave

ChaoticdeNovisible

ge

efects

tinsteadofright,cptumprimumorseously,mostlymembloodyseptumfailtodepiralwithrestofhition(Rshift)ofaolrubellainfection,ductal:reopenDA

phy

Voltage

Con

Hyp

Loss

Fluid

Exce

Isch

Intervals\

Segm

ents

on

polarizationsofthewavesforeachQ

olarizationsofthewavesforeachQ

ductionofSAimpuwavesforeachQ

nconductionofSAwaves,somewith

nonconductionoeiscompletelyind

ationofasingleirresentinectopicb

ationofAVnodeiepresentduetos

ationofanirritablepresent,irregula

yseveralPVCsinaVTisanonperfu

polarization(2003yorafraction(e.g

ddepolarization(>espresent,irregul

epolarizationsthrowaveforms

Normal

causessitusinversecundum;e.g.patmbranouspartofs

evelop;alwayspreheart,LVpumpsinorta,Rventricular,normalinpremaAusingPGE2,postd

dition

pertrophy

sofmyocardium

daroundthehear

essiveairinlungs

hemia

Image

eSAnode,e.gexeRS,rate>100/min

SAnode,e.g.sleeRS,rate20

AimpulsesthroughoutaQRSfollowi

ofSAimpulsesthroependentofvent

ritablefocusinthebeat,normalcondu

ndependentofSAsimultaneousdepo

lefocusinthevenarandlengthened

arow:wideQRSdsing,lifethreaten

360bpm)ofasing.2:1,3:1);visible

>360bpm)ofmanlarRRinterval

oughoutmanyven

Rwaveprogressio

susentforamenovalseptum;massivel

esentwithVSDntopulmonaryarthypertrophy cyatureinfants,possiductaldevelopco

e,resultsinpulmeftrightshunt

ery,RVintoaortaanosisnotseenatiblelackofTGFllateralcirculation

VoltageEffec

QRS

QRS

rt QRS

QRS

isoelectric

Int

PRQRSQT

HTN

tbirth

n

ct

cline(seenasS

Normaltime

Notedefle

ercisen

ep

AVnode00ms,anyrate

ghtheAVnodengit

oughtheAVnodericularrate

eatriaindependeuctionthroughthe

Anodeolarizationofatria

ntricles(>120ms)QRSco

uration,noPwaveingarrhythmia

leatrialfocus;AVsawtoothPwav

yatrialfoci;AVno

ntricularfoci,non

onthroughprecor

STinI)

120200ms

CarrdiopulmoonaryExammIITablesPage4

TableVI

Parameter

Cardiacoutp

Heartrate(HPreload

Afterload

EndDiastoli(EDV)EndSystolic(ESV)

Strokevolum

Contractility

EjectionveloAorticpressVasoconstriFluidretenti

TableVI

TableVIPhase

RapidFilling

Diastasis

Atrialsystol

Isovolumiccontraction

Ejection

Isovolumicrelaxation

I

Dir

put(CO)SV,venMC

HR) SymCOVasrete

icvolumeCO,

cvolumeHR,

me(SV)EDVrete

ySymCa2

ocity Conure/MAP Vasction 1ion

IIImag

IIIEKG

g EndTtoisoe

Isoelectricto

e StartofPtoQ

QRtoS

StomidT

MidTtoend

ectHR,venousreturnoconstriction,insCFP,lowvenouscompathetics

soconstriction,fluention,MAP,cham

,Venousreturn,P

,MAP

V,Contractility,fluentionmpathetics,catech2+,digitalisntractility,Preloadsoconstrictionagonists

ge

Valv

lectricMitrMitr

ostartofP Noc

QR Noc

MitrMitrAortMitr

dTAortMitr

CCaused

Invn,VO2,spiration,ompliance

Vace

Pa

idmberradius

M

Preload HR

uidMA

holamines,Pa

d Ao1

CAgen

Catec(epin

Cardi(Digit

vesralopensralopen,aorticclo

change

change

ralcloses(1stsounral&aorticclosedticopensralclosed,aorticoticcloses(2ndsounral&aorticclosed

CardiacMecbyverse

asoconstriction,Rntralvenouspress

arasympathetics

itralregurgitation

R

AP,vasoconstricti

arasympathetics,is

orticpressure,Afte

1antagonists,2

Calciumandt

cholaminesephrine,NE)

acglycosidestalis)

TheCAction

osedAtrialpresFastestratRateoffillventriclesAtrialpresVentricula

nd) Fastestrisventricular

openVentriculaAtrialpres

nd)Fastestfal

chanicalPar

atrialpressure,sure

on

schemia,toxins

erload

agonists

rameters

Direct

EDV,Preload,pupressure

ESVVelocity,EDV

Preload,SV,EDP

CO,pulsepressu

Velocity,SV,dP/

ESV,AfterloadMAP,Preload,ASV,Preload,Afte

dCardiacMeAction

Phosphorylat

Phosphorylat

Phosphorylat

InhibitsNa+/K

CardiacCycl

ssureventricularrvolumerises(toseinpressure untirpressure=aorticrvolumefallstoEssuredrops,thenr

linpressure

echanics

tesCa2+channels

tesphospholamba

testroponinI

K+pump

e

rpressure

riaand

rpressureppedoff)lcpressureESVrises

EffectsInvers

ulse

SV

Velocit

P

SV

ure

/dt ESV

Velocit

fterload SV,COerload

Effect

Ca2+inf

ansarcoplarelaxati

binding

intraceintrace

e

Thepresshowingparametcycle.

ty

ty,SVO

lux,contractility

asmicreticulamCon

gofCa2+totroponi

ellularNa+,Na+ellularCa2+,cont

Image

Illustration

surevolumecurvthelocationsofcersduringthecar

y

a2+reuptake,

inC,contractilit

Ca2+antiporteracttractility

eertaindiac

ty

tivity,

CardiopulmonaryExamIITables Page5

TableIX SystemicVascularResistances

Series(Vessels),ConstantFlow;SVR=R1+R2 Parallel(Systems),ConstantPressure;

=

1+

2

Vessel Flow(CO) Pressure Resistance(

) System Flow Pressure(MAP) Resistance(

)

Aorta 5L/min 100mmHg Renal 1L/min 100mmHg H

L/=100mmHg/L/min

LgArtery 5L/min 95mmHg H

L/=1mmHg/L/min Splanchnic 0.8L/min 100mmHg

H

. L/=125mmHg/L/min

SmArtery 5L/min 85mmHg H

L/=2mmHg/L/min Muscle 0.5L/min 100mmHg

H

. L/=200mmHg/L/min

Arteriole 5L/min 35mmHg H

L/=10mmHg/L.min Coronary 0.5L/min 100mmHg

H

. L/=200mmHg/L/min

Capillary 5L/min 15mmHg H

L/=4mmHg/L/min Cerebral 1L/min 100mmHg

H

L/=100mmHg/L/min

Venule 5L/min 10mmHg H

L/=1mmHg/L/min Cutaneous 0.4L/min 100mmHg

H

. L/=250mmHg/L/min

Vein 5L/min 5mmHg H

L/=1mmHg/L/min Other 0.8L/min 100mmHg

H

. L/=125mmHg/L/min

VenaCava 5L/min 2mmHg H

L/=0.6mmHg/L/min

TableX FactorsAffectingCoronaryCirculationFactor EffectonCoronaryCirculation

CardiacCycleLVflowishighindiastoleandlowinsystoleRVflowisopposite;highinsystole,lowindiastole

MyocardialTissuePressure Resistsflowduringsystole,highestinendocardium renderingitvulnerabletoischemiaTachycardia flowbyshorteningdiastole,flowduetometabolic vasodilationHypoxia Increasescoronarybloodflow5x

PressureflowAutoregulationMaintainsconstantflowdespitepressurechanges,myogenic responseRespondstopressure(stretch)bycontractingRespondstopressurebydilation,e.g.coronarystenosis

MetabolicAutoregulation Adjustmentofbloodflowduetometabolicrate,e.g.vasodilation via adenosine,K+ATPchannels,ATP/ADP,O2,CO2,K+,lactate

NitricOxide(NO) Causesvasodilationinresponsetoshearstress orparasympatheticstimulation, causeslargeepicardialcoronarydilationEndothelin Causesvasoconstriction,commoninatherosclerosis,MI,CHF

SympatheticActivityflowbyincreasingHRandcontractility andflowbyincreasingmetabolicactivity1receptorsconstrictmediumandlargearteriestomaintaintransmuralpressure2receptorsvasodilatecoronaryarterioles

OxygenConsumption LeftventricularMVO2=810mL/min/100g,extractionis75%,meaningincreasesindemandmustbemetbyincreasedLVbloodflowEnergyConsumption 60%tension,20%nonEC,15%SRCa2+ pumping,5%electricalactivity

SubstrateUtilizationFattyacids60%,carbohydrate/glucose 3540%Heartshiftstowardsglucoseorlactatemetabolismduringischemia/hypoxia