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Cardiac phys
| Question | Answer |
|---|---|
| The heart is bounded anteriorly by the _____________ and the costal cartilages of the third, fourth, fifth ribs and inferiorly by the ___________. | sternum, diaphragm |
| What is located anteriorly and inferiorly toward the left 5th intercostal space? | the apex |
| This is known as the point of maximal impulse. S1 and S3 can also be auscultated here. | apex |
| What are the 3 layers of heart muscle? | epicardium, myocardium, endocardium |
| What is the sac around the heart called? | pericardium |
| What are the two layers of the pericardium? | parietal and visceral |
| What separates the atria and ventricles? | coronary sulcus aka AV sulcus |
| The RV and LV are separated by the _______________ __________, which descends from the coronary sulcus to the apex. | interventricular sulcus |
| What is the interventricular sulcus composed of? | anterior interventricular sulcus and posterior interventricular sulcus |
| The anterior IVS contains the ____, which course over the IV septum and continues posterior. | LAD |
| The atria and ventricular septa meet where in the heart? | the crux |
| The crux is important in determining what? | coronary artery dominance |
| One of 2 main veins that carry deoxygenated blood from the body to the right atria. | superior vena cava |
| one of 2 main veins that carry deoxygenated blood from the lower extremities to the right atria. | inferior vena cava |
| The largest single blood vessel in the body that carries oxygen rich blood from the left ventricle to the rest of the body. | Aorta |
| Transporter of de-oxygenated blood from the right ventricle to the lungs. | pulmonary artery |
| Transporter of oxygenated blood from the lungs to the left atrium. | pulmonary vein |
| Receives de-oxygenated blood from the body through the superior vena cava and inferior vena cava; has a muscle wall thickness of about 2um, | Right atrium |
| This valve separates the right atrium and right ventricle, and opens to allow de-oxygenated blood to enter the right ventricle. | tricuspid |
| Receives de-oxygenated blood from the right atrium. | right ventricle |
| Receives oxygenated blood from the lungs through the pulmonary veins. | left atrium |
| Blood passes through which valve from the left atrium to the left ventricle? | mitral valve |
| Receives oxygenated blood from the left atrium. | left ventricle |
| These muscles attach the lower portion of the inferior wall of the ventricles. They attach the cordae tendonae, which is attached to the mitral and tricuspid valves. | papillary muscles |
| What is the normal valve area of the tricuspid? | 7cm squared |
| Symptoms of tricuspid insufficiency occur with a valve area less than : | 1.5cm squared |
| What is normal area for the mitral valve? | 4-6cm squared |
| What area is considered mild mitral stenosis? | 1.5-2cm squared |
| What area is considered moderated mitral stenosis? | 1-1.5cm squared |
| What area is considered severe mitral stenosis? | <1cm squared |
| When do clinical symptoms start to occur in the mitral valve? | when the valve area is cut in half |
| The ____________ valves are situated within the outflow tracts of their corresponding ventricle. | semilunar |
| What valve separates the left ventricle from the pulmonary artery? | pulmonary valve |
| What valve separates the left ventricle from the aorta? | aortic valve |
| Above the aortic valve is a dilation known as the sinus of ___________, which allows the valve to open efficiently without occluding the ostia or openings that communicate with the coronary arteries. | valsalva |
| What is the normal valve area of the aorta? | 3-4 cm squared |
| Reduction in aortic valve area by how much is associated with increased symptoms. | 1/3 - 1/2 |
| What valve area produces severe AS? | <0.8 cm squared |
| What supplies blood to all tissues except the lungs? | systemic aka peripheral aka greater circulation |
| What circulation carries deoxygenated blood away from the heart, then returns oxygenated blood back to the heart? | pulmonary circulation |
| What transports blood under high pressure to body tissues, consists of strong vascular walls, and blood flows rapidly through them? | arteries |
| What are the last small branches of the arterial system that contain control valves in which blood is released into capillaries? | arterioles |
| What has a strong muscular wall capable of completely closing or dilating that has a greater effect on altering blood flow to the capillaries? | arterioles |
| What functions in the exchange of fluid, nutrients, hormones, and other substances between blood and interstitial fluid? | capillaries |
| Capillary walls are very thin and permeable. T/F | T |
| What are the collectors of blood from the capillaries and delivers it to the veins? | venules |
| What functions as a conduit of blood away from the tissues and back to the heart? | veins |
| Walls of the venous system are very thin and distensible, which makes it easier for the vessels to carry a large amount of blood. T/F | T |
| Blood pressure is controlled _______________ of local blood flow or cardiac output. | independent |
| Arterioles will constrict based on nerve reflexes in response to decreases in the mean arterial pressure below what? | 100 mmHg |
| What intrinsic reflexes are found on the walls of the carotid sinus and respond to changes in the wall stress? | baroreceptors |
| What reflexes are located in low pressure areas? | cardiopulmonary reflexes |
| Which reflex responds to increases in atrial pressure and volume, including tachycardia? | bainbridge reflex |
| What are located in the aortic arch and carotid sinus that respond to hypoxia, hypocapnia, and acidosis? | chemoreceptors |
| Chemoreceptors will stimulate breathing, but also _________ areas of the brain and arterial system when pressure is too low to stimulate the baroreceptors? | vasoconstricts |
| What response is stimulated by brain stem hypoxia. It occurs with severe hypotension and causes a powerful vasoconstriction to maintain cerebral perfusion? | CNS ischemic response |
| The CNS ischemic response is also known as what? | cushings reflex |
| What are a couple examples of extrinsic reflexes? | cold, pain |
| What are the 3 layers of the aorta made up of? | intima, media, and adventicia |
| What occurs when there is a tear in the intima leading to separation of the tunica media and formation of a false lumen? | aortic dissection |
| _____________ fibers within the aorta allow it to stretch under pressure. | connective |
| Connective fibers are especially dense in the wall of the _______________ aorta, which experiences the greatest force with each heart beat. | ascending |
| When the diameter is 1.5 times the size of the aorta, this is what? | an aneurysm |
| What is the beginning of the aorta? | the root |
| The aortic root gives rise to 2 _______ arteries and ends at the beginning of the ascending aorta (sinotubular junction). | coronary |
| The 2 coronary arteries are responsible for carrying oxygen rich blood to the heart muscle. T/F | T |
| What part of the aorta leaves the left ventricle and has little support from surrounding tissues and is the most vulnerable part of the aorta? | ascending aorta |
| What arteries that come from the arch of the aorta supply blood to the head and upper body? | inominate, left common carotid, and left subclavian |
| Where does the descending aorta end? | the diaphragm |
| What arteries that feed the spinal cord are contained in the descending aorta? | intercostal arteries |
| The beginning portion of the descending aorta is most vulnerable to injury. T/F | T |
| What portion of the aorta begins at the diaphragm and ends at the visceral vessels? | thoracic abdominal aorta |
| What part of the aorta begins below the renal arteries, which supply blood to the kidneys? | abdominal aorta |
| The aorta ends where it divides into the two ________ arteries. | iliac |
| Oxygen rich arteries that supply the myocardium are? | coronary arteries |
| Deoxygenated vessels involved in coronary circulation are? | coronary veins |
| What arteries run on the surface of the heart? | epicardial coronary arteries |
| What arteries run deep within the heart muscle? | subendocardial coronaries (blockage to these arteries is critical) |
| What artery originates from the aorta, distal to the aortic valve and appears on the surface of the heart between the pulmonary trunk and the auricle of the right atrium? | RCA |
| What are the branches of the RCA? | marginal, posterior interventricular, and AV nodal branch |
| Where does the RCA distribute to? | R atrium and R ventricle and variable portions of the L atrium and ventricle |
| Where does the left coronary artery arise from? | the base or ascending aorta |
| What are the major branches of the LCA? | anterior interventricular branch and circumflex |
| Where does the LCA distribute to? | both ventricles, IV septum, and left atrium |
| What opens directly into the heart chambers and returns blood back to the right atrium? | coronary sinus |
| Failure of the coronary circulation causes what? | ischemic heart disease |
| What are the branches of the left main? | LAD, LCX, and possibly the diagonal margin |
| Where does the LAD provide collateral circulation to? | the anterior wall of the RV |
| What arises from the left main and is directed posteriorly as it travels around the left side of the heart within the left AV sulcus? | left circumflex |
| _____________ is determined by the coronary artery that crosses the crux and provides blood flow to the posterior descending artery. | Dominance |
| What is the dominant artery in 60% of the population? | RCA |
| What percent of the population has left coronary dominance? | 25% |
| What are the 3 main venous systems in the heart? | coronary sinus, anterior cardiac veins, and thesbian veins |
| What are the 3 types of cardiac muscle? | atrial, ventricular, and excitatory and conduction muscle fibers |
| The cardiac muscle is striated similar to _____________ muscle. | skeletal |
| Cardiac muscle contains myofibrils that contain _________ and __________. | actin and myosin |
| What are the cell membranes that separate individual cardiac muscle cells from one another? | intercalated discs |
| Cardiac muscle is a mass of many heart muscle cells. T/F | T |
| Action potentials can be conducted between the atrial synctium and the ventricles by a special conduction system called the____ ________________. | AV bundles |
| What is cardiac RMP? | -85 --- -95 |
| Phase 0 is: | depolarization |
| Phase 1 is: | initial repolarization |
| Phase 2 is : | the plateau phase |
| The CA influx delays repolarization and prolongs the ______________ ______________ period. | absolute refractory |
| Phase 3 is: | terminal repolarization and returns the resting membrane potential near 0 |
| Phase 4 is: | diastole |
| The ____________ conduction system is a group of specialized cardiac cells that pass an electrical signal throughout the heart. | intrinsic |
| What is the intrinsic conduction system composed of? | SA node, AV node, bundle of His, right and left bundle branches, and the Purkinje fibers |
| What is the velocity of conduction of the excitatory action potential along the atrial and ventricular muscle fibers? | 0.3 - 0.5ms |
| What is the primary pacemaker of the heart? | SA node |
| What is the time interval during which a normal cardiac impulse cannot be reexcited? | Absolute refractory period |
| What is the period during which the muscle is more difficult to excite, but can be excited? | Relative refractory period |
| The refractory period and the rhythmic rate of contraction in the _____ is faster than the _____________. | atria, ventricles |
| Where does cardiac innervation originate? | the ANS and T4-T5 |
| What is autonomic outflow divided into? | SNS and PSNS |
| Rate is: | dromotropic |
| strength of myocardial contraction is : | inotropic |
| What is the SA node also known as? | keith flack node |
| What 2 cell types are contained in the SA node? | P-cells and intermediate/transitional cells |
| What inhalational anesthetics decrease SA node automaticity? | halothane, iso, and ethrane |
| Internodal tracts are found where? | in the atrium |
| What are the 3 major internodal tracts? | anterior, posterior, middle |
| What tract sends fibers to the LA and through the septum to the AV node? | anterior or bachman's bundle |
| What tract continues along the terminal crest to enter the atrial septum and then the AV node? | posterior |
| What tract curves behind the superior vena cava before descending to the AV node? | middle or wenckebach's tract |
| What causes a delay in the cardiac action potential? | AV node |
| Why is there a greater resistance to the action potential at the AV node? | cell size is small |
| What extends to the lower end of the AV node and enters the posterior part of the ventricle and purkinji system? | bundle of His |
| What is the preferred channel for the conduction of the action potential? | AV bundle |
| What does the purckinji system consist of? | bundle branches |
| What is the period from one ventricular contraction to the next? | cardiac cycle |
| What is the first phase of diastole? | isovolumetric relaxation |
| During isovolumetric relaxation, which valves are closed? | mitral and aortic valves |
| What is the 2nd phase of diastole? | true filling phase |
| What happens in the first period of filling? | mitral valve opens |
| What is the second period of filling? | diastasis |
| What is the 3rd period of filling also known as? | atrial kick (rapid filling) |
| What is the first phase of systole? | isovolumetric contraction |
| During the first phase of systole, there is an increase in ________, but no increase in ___________. | pressure, volume |
| What is the second phase of systole? | true systole |
| During true systole, what valve opens and what valve closes? | aortic valve opens; mitral valve closes |
| During the first 1/3rd of true systole what happens? | rapid ejection |
| What represents ventricular depolarization? | QRS complex |
| What is the first negative deflection on the EKG? | Q wave |
| What on the EKG is representative of the time from the end of ventricular depolarization to the beginning of repolarization? | ST segment |
| In the ST segment, what is considered abnormal elevation in the standard lead and precordial leads? | 1mm-standard 2mm- percordial |
| What is representative of ventricular repolarization? | T wave |
| The T wave is normally upright in what leads? | I, II, V3-V6 |
| The T wave is usually inverted in what lead? | AVr |
| The T wave should not exceed what height in the standard or precordial leads? | 5mm or 10mm |
| What is the small upright deflection after the T wave that is usually non-detectable? | V wave |
| What wave is thought to represent repolarization of the papillary muscles and purkinji fibers? | Q wave |
| What is normal coronary blood flow? | 4-7% of cardiac output or 225-250cc/min |
| What is the ability of the heart to maintain coronary blood flow through a range of MAP of 50-120mmHg? | autoregulation |
| When arterial blood exceeds or falls below these levels, the autoregulation becomes ____________ dependent. | pressure |
| During hypotension, when the coronary vesicles are maximally dialted, coronary blood flow is determined by what? | MAP - RAP (or CVP 2-8mmhg) |
| How is CPP determined? | DBP - LVEDP |
| What phenomenon is of concern with the administration of vasodilating agents in anesthesia? | coronary steal phenomenon |
| In the coronary steal phenomenon the area with normal _____________ is the only area that has the ability to dilate and increase coronary flow. | autoregulation |
| What anesthetic agent has myocardial protective properties during periods of ischemia? | isoflurane |
| How does isoflurane protect the heart? | decreases oxygen free radicals, preserves myocardial ATP stores, and inhibits increased intracellular CA |
| The volume of blood pumped by the heart each minute is? | cardiac output |
| How is CO calculated? | CO= HR x SV |
| What is normal CO? | 5-6L/min |
| What are the determinants of SV? | preload, afterload, contractility, and ventricular compliance |
| What is CO corrected by? | CI |
| How is CI calculated? | CI= CO/BSA |
| What is normal CI? | 2.5- 3.5 L/min |
| End diastolic volume is also known as: | preload |
| The relationship between EDV and CO is shown by what principle? | Frank Starling Principle |
| In healthy hearts, the EDV for the right side is approximately equal to the left. T/F | T |
| How is EDV measured? | PCWP and RAP |
| What are the determinants of preload? | blood volume, ventricular compliance, myocardial contractility, and venous tone |
| Increase in intrathoracic pressure during inspiration will decrease ________ ___________. | blood volume |
| Increased activity causes an increase in tone, which increases ___________. | volume |
| _________ _________ is determined by the volume of blood in the heart at the beginning of systole (EDV), and the amount of blood remaining in the ventricle at closure of the aortic valve at the end of systole (ESV) | stroke volume |
| The equation for SV is: | SV= EDV-ESV |
| Normal SV = | 55-100ml |
| The degree of stretch of the left ventricle fibers, influenced by the amount of blood in the ventricle, determines the amount of work the ventricles can do. | EF |
| What is normal EF? | 60-70% |
| How is EF calculated? | EF = EDV- ESV/ EDV |
| Severe impairment occurs with an EF less than what? | 40% |
| Wall stress or tension faced during ventricular contraction is: | afterload |
| What is afterload dependent on? | shape, radius, size, wall thickness, aortic impedence, arterial wall stiffness, blood viscosity |
| SVR is usually used to measure afterload, however this only measures what? | peripheral arterial tension |
| What states that the larger the radius, the greater the wall tension required to develop CO? | Law of Laplace |
| What is determined by the automaticity of the sinus node? | HR |
| What is the SA node rate? | 60-80 |
| What is the AV node rate? | 40-50 |
| Increased HR = Increased ? even if SV is constant | CO |
| Increased HR shortens the filling time between beats, decreasing diastolic filling at rates of > ? | 160 |
| What is the inotropic state of the heart independent of preload, afterload, and HR? | contractility |
| Systole- contractility is determined by the length of the sarcomere, which is dependent on what electrolyte? | calcium |
| Diastole- myocardial relaxation occurs as a result of reuptake or binding of Ca ions by what? | the sarcoplasmic reticulum |
| What effect says that increasing afterload, increases contractility? | Anrep effect |
| What is the forced frequency or staircase phenomenon? | Treppe phenomenon |
| As ventricles fill with blood, the pressure and volume that results are determined by what? | compliance |
| When is compliance decreased? | dilated cardiomyopathy, tamponade, htn |
| Heart pump and adjustment of the pump to extreme changes occurs by way of what 2 mechanisms? | intrinsic regulation and ANS |
| What mechanism describes that the greater the heart muscle is stretched during filling, the greater the force of the contraction and a greater quantity of blood is ejected? | Frank starling |
| graphic analysis of ventricular pumping is illustrated via what? | pressure- volume loops |
| The area within the loop which is the product of the SV and afterload is what? | stroke work |
| The max amount of pressure that can be developed at any given volume is what point on the loop? | ESPVR |
| The filling curve of the ventricle and the passive properties of the myocardium is what point on the loop? | EDPVR |
| The EDPVR curve is reciprocal of ventricular compliance. T/F | T |
| When would you see an increased afterload loop? | htn, aortic stenosis |
| Ventricles become dilated w/o thickening of the wall, which results in an increase in ESV and EDV. Pressure remains constant and the curve is shifted to the right. | dilated cardiomyopathy |
| An increase in thickness and mass of the myocardium, which results in decreased chamber compliance. LV pressures are elevated. ESV is increased and EDV is decreased. | Left ventricular hypertrophy |
| What impairs LV filling so that there is a decrease in preload. This also leads to a decrease in SV by the Frank-starling mechanism and a fall in CO and aortic pressure. | Mitral stenosis |
| This is a condition in which the aortic valve fails to close completely at the end of systolic ejection, causing leakage of blood back through the valve during LV diastole. | Aortic insufficiency |
| When the LV begins to contract and pressure is increased, blood will flow back into the left ventricle. This is called what? | aortic regurg |
| What is it called when blood flows back into the left atria during ventricular systole? | mitral regurg |
| In mitral regurg, there is no true period of isovolumetric relaxation. T/F | T |
| The heat pump can be increased by almost 100% by the ____, and decreased to zero by the _____. | SNS, PSNS |
| In an individual, the SNS can increase HR to ? | 180-200 |
| Strong ______ stimulation to the heart can stop the heart for a few seconds, but the heart usually escapes and will beat at a rate of 20-40. This stimulation can also decrease heart strength by 30%. | vagal |
| What is the most important determinant of CO, as long as afterload and contractility are not affected? | Preload |
| What is forced expiration against a closed glottis? | valsalva maneuver |
| What are located at the bifurcation of internal and external carotids and aortic arch? | baroreceptors |
| What goes through Herrings nerve and either the glossopharyngeal or vagus nerve? | afferent pathways |
| When there is inhibition of the vasomotor center of the medulla what happens? | decrease SNS, increase PSNS, and decrease HR, contractility, and vasodilation |
| What reflex is caused by traction on the extraocular muscles, conjunctiva, or orbital structures? | oculocardiac reflex |
| Disturbing the oculocardiac reflex produces what responses? | hypotension, decreased HR, and arrhythmias |
| The oculocardiac reflex can be seen with what? | retrobulbar blocks, trauma, and post enucleation |
| Stimulation of the oculocardiac reflex can be blunted by what? | removing the noxious stimuli, or by administering an anticholinergic |
| What reflex is seen in patients undergoing abdominal surgery when there is traction on the mesentery or gall bladder? | celiac reflex |
| Stimulation of the celiac reflex results in : | bradycardia, hypotension, and apnea |
| The atria and aorta contain receptors that respond to pressure changes. These receptors will increase or decrease HR in response to high or low BP. T/F | T |
| What reflex responds in a shock state, failing heart, or overtransfused heart that will increase HR and BP. | Bainbridge reflex |
| Increased ICP causing cerebral ischemia. The response to this reflex is htn, bradycardia, and resp variability. | Cushings |
| What reflex responds to a decrease in O2 sat and an increase in CO2. The response is increase in resp drive and increase in BP. | chemoreceptor reflex |
| Brain % CO? | 15 |
| Heart % CO? | 3.3 |
| kidneys % CO? | 23 |
| liver % CO? | 29 |
| Lungs % CO? | 3.5 |
| Muscle % CO? | 19 |
| Rest % CO | 9.7 |
| What are the 2 specialized excitatory and conductive systems that control cardiac contractions? | SA node and internodal pathways |
| Where is the SA node located? | superior lateral wall of the right atria |
| The SA node has the ability of self____________, which is why it ordinarily controls the rate of the entire heart. | excitation |
| What is the action potential of the SA node? | -55 to -60 |
| The sinus node exhibits only activation of the slow _______ channels. Action potential is much slower than the ventricle. | Ca |
| Conduction through the atria occurs at what speed? | 0.3m/sec |
| Atria conduction will occur through several tracts and bundles, which spread to the L atria and eventually to the ___ node. | AV |
| The ___ node delays the impulse to allow time for the atriam to empty into the ventricle. | AV |
| The _______ fibers lead the AV node through the AV bundles. | purkinji |
| The AV bundles are a one way system, which prevents re-entry of cardiac impulses back to the atriam. T/F | T |
| Total time for the transmission of cardiac impulses is about how long? | 0.06 seconds |
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