Tutorial 1b

1. What happens in valve disease & treatment?

The three types of heart valve diseases are regurgitation, stenosis, and atresia. The
type of heart valve disease you have depends on which valve is affected and in what
way. Heart valve diseases can cause problems in any of the heart’s four valves: the
aortic, mitral, pulmonary, and tricuspid valves.

For example:
A bicuspid aortic valve is an aortic valve that forms with two flaps instead of three.
Mitral valve prolapse occurs when the mitral valve flaps bulge back (prolapse) or
flop into the left atrium. This may prevent the valve from forming a tight seal.
Pulmonary atresia and tricuspid atresia result when the pulmonary or tricuspid
valve openings do not form correctly when the heart is developing.

Atresia is a heart condition that may be present at birth (called a congenital heart
defect) or, rarely, acquired later in life. It occurs when a heart valve has no opening at
all. Instead, a solid piece of tissue forms between the chambers of the heart, which
blocks the flow of blood. There are two main types of heart valve atresia which are
pulmonary atresia that affects the pulmonary valve. In this condition, blood cannot
flow from the heart to the lungs through the pulmonary artery. Meanwhile, tricuspid
atresia affects the tricuspid valve in which blood cannot flow from the right atrium to
the right ventricle.

Regurgitation that is also known as backflow or insufficiency, happens when a valve

does not seal tightly. This allows blood to leak backward rather than flowing forward
through the heart or into an artery. Since some blood flows in the wrong direction,
your heart cannot work efficiently to get blood to your body. Regurgitation can
happen if valve flaps are not the right size or shape, or if the valve opening is
stretched. You may be born with heart valve regurgitation or develop it over time.

Stenosis describes a valve opening that is too small. The valve may be too narrow, or
the flaps may have formed incorrectly before birth. For example, the aortic valve may
form with two flaps instead of three. This is called a bicuspid aortic valve. This
condition and others that cause stenosis can make it difficult for blood to pass through
the valve, so the heart has to work harder to pump enough blood to the body.

TREATMENT

Medications
➔ Diuretics and vasodilators, to ease pressure on the heart and reduce the amount of
work the heart must do to pump blood
➔ Beta blockers to control the heart rate
➔ Blood thinners to treat or prevent blood clots
➔ Prostaglandin for newborns to keep certain pathways of the heart open and maintain
blood flow to the body

2. What went wrong in heart attack?

The blockage is caused by a buildup of plaque in the arteries (atherosclerosis). Plaque
is made up of deposits, cholesterol, and other substances. When a plaque breaks
(ruptures), a blood clot quickly forms. The blood clot is the actual cause of the heart
attack. If the blood and oxygen supply is cut off, muscle cells of the heart begin to
suffer damage and start to die. Irreversible damage begins within 30 minutes of
blockage. The result is heart muscle affected by the lack of oxygen no longer works as
it should.

3. What does it mean by angioplasty & coronary by-pass?

Angioplasty is a minimally invasive procedure used to open up blocked or narrowed
arteries. During the procedure, a thin catheter with a balloon is inserted into an artery
and threaded up to the area of blockage. The balloon is then inflated to widen the
artery and improve blood flow. A mesh tube called a stent can also be placed in the
artery during angioplasty to help keep it open permanently.

Coronary by-pass involves creating a new pathway around an area of blockage in an

artery. This new route allows blood to flow freely past any obstructions or restrictions
in its original path. Generally, this requires removing healthy tissue from another part
of your body and grafting it onto the artery.

4. What went wrong in heart failure?

Heart failure, also known as congestive heart failure, is a condition that develops
when your heart doesn’t pump enough blood for your body’s needs. This can happen
if your heart can’t fill up with enough blood. It can also happen when your heart is too
weak to pump properly. The heart may not provide tissues with adequate blood for
metabolic needs, and cardiac-related elevation of pulmonary or systemic venous
pressures may result in organ congestion. This condition can result from abnormalities
of systolic or diastolic function or, commonly, both. Although a primary abnormality
can be a change in cardiomyocyte function, there are also changes in collagen
turnover of the extracellular matrix. Cardiac structural defects (eg, congenital defects,
valvular disorders), rhythm abnormalities (including persistently high heart rate), and
high metabolic demands (eg, due to thyrotoxicosis) also can cause HF.

5. Describe how does the heart obtain its nutrients and oxygen?
The heart gets its oxygen and nutrients through special blood vessels called coronary
arteries. These vessels branch into tiny capillaries that weave through heart muscle.
Oxygen molecules, carried by hemoglobin in red blood cells, detach and diffuse into
heart muscle cells (cardiomyocytes). Nutrients like fatty acids and glucose enter these
cells through specific protein transporters. Inside the cells, mitochondria use oxygen
and nutrients to produce energy (ATP) through cellular respiration. This energy
 powers the heart's continuous pumping action. Without proper blood flow through
coronary arteries, heart cells can quickly become starved of oxygen and die.

6.

A-B = b) Isovolumic contraction

B-C = a) Ejection of blood into aorta
C-D = c) Isovolumic relaxation
D-A = d) Passive filling and atrial contraction

7. What is viscosity?
Viscosity is blood's thickness and resistance to flow. In the cardiovascular system,
blood viscosity determines how easily blood moves through vessels and how hard the
 heart must work to pump it. Normal blood viscosity is 3-4 times that of water. It's
mainly affected by the number of red blood cells, protein levels, and temperature.
High blood viscosity can cause problems like increased strain on the heart, reduced
blood flow to tissues, and higher risk of clots. Conditions like dehydration,
polycythemia, and diabetes can increase blood viscosity.

8. State TWO (2) determinants of blood pressure.

● Blood volume
● Peripheral resistance

9. Describe electrical conduction system in the heart.

As electricity moves through your heart, it causes each part to contract. This process
is called the electrical cascade. While all heart muscle can conduct electricity, some
areas, known as the electrical conduction system, allow the cascade to travel at
different speeds.

The cascade travels through the electrical conduction system in this order where it
starts at sinoatrial node. The sinoatrial (SA) node is a group of cells that acts as the
heart's natural pacemaker. It is located in the right atrium. Here, the upper chambers
of the heart start to squeeze. Next, it moves to the atrioventricular node (AV) node
which is found between the upper chambers. It is smaller than the SA node, and
electricity moves more slowly here. This slowdown gives the ventricles time to fill
with blood.

The cascade continue to travel to Bundle of His which is a group of cells extending
from the AV node down the center of the heart. It conducts electricity faster than the
surrounding tissue, directing the electrical cascade further into the heart. It will then
moves to Bundle branches where The Bundle of His splits into two branches near the
division of the heart's top and bottom chambers. These branches carry the electrical
signal to the outer areas of the heart, especially the ventricles.

Lastly, as the bundle branches spread out, they form a web of conducting fibers called
Purkinje fibers. Together, the Bundle of His, bundle branches, and Purkinje fibers are
known as the His-Purkinje system. It resembles an upside-down umbrella, where the
Bundle of His is the handle, the branches are the stem, and the Purkinje fibers are the
canopy.

Electricity travels down and spreads out at the bottom of the heart, then moves
upward along the outer areas. This is how the heart pumps blood upward and out of
the heart.
10. The rising phase of action potential in contractile myocardium and autorhythmic
myocardium is due to sodium ion and calcium ion entry, respectively.

11. Describe how our body restored its normal blood pressure when there is an
increase in blood pressure?

When blood pressure increases, the body activates several mechanisms to restore it to
normal levels.

Firstly, the baroreceptor reflex, which consists of stretch-sensitive sensors located in

the carotid sinus and aortic arch, detects the rise in pressure. These sensors send
signals to the brainstem, which responds by reducing sympathetic nervous activity.
This results in a lower heart rate and decreased force of contraction, while increasing
parasympathetic activity, leading to vasodilation and further lowering of the heart
rate.

Next, the kidneys react to the increased blood flow by reducing the release of renin,
which subsequently lowers the production of angiotensin II. This process results in
vasodilation and decreased fluid retention. Additionally, the kidneys excrete excess
sodium and water, which helps lower blood volume and blood pressure.

There is also a vascular response, where blood vessels relax and dilate in response to
the increased pressure. This dilation reduces resistance and assists in lowering blood
pressure.

Lastly, hormonal regulation plays a role, with the heart releasing atrial natriuretic
peptide (ANP). This hormone promotes vasodilation and encourages the kidneys to
excrete sodium and water, further aiding in the reduction of blood pressure. Together,
these processes work efficiently to quickly restore elevated blood pressure to normal
levels.

12. How to ensure unidirectional blood flow?

The heart valves, including the pulmonary valve, right atrioventricular (AV) valve,
left AV valve, and aortic valve, prevent the backflow of blood and ensure that blood
flows in one direction. These valves must open and close completely to allow
sufficient blood to pass through and to prevent any backward leaks.

13. How to minimise friction in the heart?

The pericardium is a double-layered membrane that surrounds and protects the heart,
minimizing friction during its movements. It consists of two main layers: the fibrous
pericardium, a tough outer layer that anchors the heart, and the serous pericardium, a
 delicate inner layer divided into the parietal layer, which lines the fibrous layer, and
the visceral layer (epicardium), which covers the heart muscle.

Between the parietal and visceral layers is the pericardial cavity, containing
pericardial fluid that lubricates the heart, allowing it to beat smoothly and efficiently
without irritation from surrounding tissues.

14. How does the heart contract (cellular & molecular)?

The heart contracts through a mechanism known as excitation-contraction coupling,

which connects electrical signals to mechanical action. This process begins when
pacemaker cells in the sinoatrial (SA) node generate an action potential (electrical
signal). This electrical impulse propagates throughout the heart muscle (myocardium),
initiating the opening of voltage-gated sodium (Na⁺) channels, which leads to
depolarization. Depolarization subsequently opens L-type calcium channels,
facilitating the entry of calcium ions (Ca²⁺) into the cytoplasm from the extracellular
environment. The influx of Ca²⁺ stimulates the release of additional calcium from the
sarcoplasmic reticulum (SR) through ryanodine receptors. The rise in intracellular
calcium binds to troponin, inducing a conformational shift that displaces tropomyosin
from the actin-binding sites. This enables myosin to bind with actin, resulting in
muscle contraction via the sliding filament mechanism. Once the action potential
ceases, calcium is transported back into the SR and expelled from the cell by calcium
ATPases, resulting in muscle relaxation. This ongoing cycle enables the heart to
contract steadily and efficiently pump blood.

15. Describe homeostasis of blood pressure.

Homeostasis of blood pressure refers to the body mechanism for maintaining

stable blood pressure levels within a narrow, optimal range to ensure adequate blood
flow to vital organs. The changes in blood pressure either increase or decrease will be
detected by baroreceptor. When the blood pressure increases, the baroreceptor will be
stimulated so that more afferent impulses will be sent towards the cardiovascular
centre. This will stimulate the cardio-inhibitory center to increase the parasympathetic
nervous system activity and inhibit cardiac-accelerator center to decrease the
sympathetic nervous system activity. The decrease in sympathetic impulses sent to the
heart will cause the reduction in heart rate and contractility. Simultaneously, the blood
 vessels also experience vasodilation due to the decrease rate of vasomotor impulses.
These will result in decreased cardiac output and rate of return blood pressure so that
the blood pressure will be back in normal range. If blood pressure drops,
baroreceptors signal the brain to raise the pressure, by increasing heart rate and
constricting blood vessels.

Other mechanism that involved in blood pressure homeostasis is

Renin-Angiotensin-Aldosterone System (RAAS). When blood pressure drop, the
kidney release renin, which triggers the formation of Angiotensin II. Angiotensin II
cause blood vessels to constrict and stimulates the release of aldosterone, leading to
sodium and water retention by the kidneys. This increase blood volume and help raise
blood pressure.

16. Describe ion movements and state of ions channels in the action potentials of
autorhythmic and cardiac cells during depolarization, repolarization and rapid
repolarization.

ION MOVEMENTS & STATE OF ION CHANNELS (AUTORHYTMIC CELLS)

In autorhythmic cells, the cycle will start with pacemaker potential state first
as the funny channels open and cause slow depolarization as both of the Na+ channels
open and K+ channels close. This causes the decreased efflux of K+ as the membrane
becomes less permeable to K+. Meanwhile, Na+ still constantly influx into the
membrane resulting in K+ to build up and Na+ flows inward constantly. As
depolarization proceeds, Ca2+ channels open before reaching the threshold state and
this allows Ca2+ influx until threshold level is achieved (-40mV). Large influx of
Ca2+ occurs at the threshold level but as the peak membrane potential is achieved
(around +20mV), the calcium channel closes afterwards, and the voltage-gated K
channel opens which causes repolarization by the efflux of K+. At -60 mV, K+
channels close and the membrane returns to its resting state back.

CARDIAC CELLS
For cardiac cells, there are five phases which are, 0,1,2,3, and 4. Initially, the
membrane potential is at the resting stage (phase 4) . Then, depolarization occurs by
the influx of Na+ that is caused by the fast channels Na+ opening (phase 0). Moving
into phase 1, Na channels close and the permeability to Na+ starts to drop. However,
transient K+ channels open and K+ efflux occurs. Phase 2 starts by the opening of
Ca2+ channels and fast K+ channels close. Calcium influx occurs and as the cell
peaks at around +20mV, calcium channels close and K+ Channels open.
Repolarization occurs by the efflux of K+ (phase 3). And at -60 mV, K+ channels
close and back to the resting stage.
17. Describe how heart rate can be reduced and increased.

Heart rate (HR) is regulated by a complex autonomic nervous system (ANS),

hormones, and other physiological mechanisms. Changes in heart rate can be
influenced by various internal and external factors, and the body has several ways to
increase or decrease the heart rate depending on the demands of the body, such as
during exercise, stress, rest, or sleep.

Heart rate can be increased by sympathetic nervous system. When the body
needs to respond to physical or stress, SNS release noradrenaline which binds to
beta-1-adrenergic receptors in the heart. This leads to increased heart rate , where
sinoatrial node fire more frequently. During acute stress or exercise, the adrenal
glands release adrenaline into the bloodstream. it acts on the heart in the same way as
noradrenaline, stimulating beta-1 adrenergic receptors and further increase heart rate

The parasympathetic nervous system, through the vagus nerves, slows the
heart rate. The vagus nerve releases acetylcholine at the SA node which slows the
firing rate of the SA node which reducing heart rate. It also decrease conduction
velocity through AV node which further slows the hearts electrical impulses.

There are also some factors that can influence heart rate such as age, fitness
level, emotional state, temperature, blood volume & blood pressure.

18. Explain how conduction system is physically represented as an ECG.

The characteristic waveform in an electrocardiogram (ECG or EKG)

represents the heart's conduction system, which is responsible for coordinating its
rhythmic contractions. The P wave, first wave on the ECG, represents atrial
depolarization (contraction). When the atria contract, it generates a small electrical
signal that is recorded as the P wave. At the PR interval, the time taken for the
electrical signal to travel from the atria to the ventricles through the atrioventricular
(AV) node. This delay allows the ventricles to fill with blood before contracting. Next,
at the QRS Complex, where it is indicated as the large spike following the PR
interval, it represents ventricular depolarization (contraction). As the electrical signal
 travels through the bundle branches and Purkinje fibres, it triggers the contraction of
the ventricles. The flat, horizontal line following the QRS complex, the ST segment,
represents the time between ventricular depolarization and repolarization. This
segment is usually isoelectric (at the baseline) and reflects the period when the
ventricles are contracted and preparing to relax. Lastly, as the ventricles relax, the
electrical signal changes, resulting in the T wave. This represents ventricular
repolarization (relaxation). The electrical activity that takes place during the cardiac
cycle can be seen on the ECG. Analysing the ECG waveform can help diagnose a
variety of cardiac conditions by identifying changes or abnormalities in the
conduction system.

19. How ECG can be used to detect problems in the conduction system.

Electrocardiogram represents the summed electrical activity of all cells

recorded from the surface of the body. ECG is divided into waves (P, Q, R, S, T)
which are P wave shows atrial depolarization, P-R segment shows conduction through
AV node and AV bundle, QRS complex shows ventricular depolarization and T wave
shows ventricular depolarization. ECG can be used to detect problems in the
conduction system because based on the abnormal reading of the ECG we can know
there is a problem with the heart. For example, if the ECG shows a P-R interval
longer than 0.2 seconds, then we can say it as first-degree AV block and it can be due
to anatomical or functional impairment in the conduction system. So, basically ECG
can help to identify an unusually fast heart (tachycardia) or unusually slow heart rate
(bradycardia). Besides, ECG also can detect irregular heartbeats or what we called as
arrhythmia that may occur when any part of the heart’s electrical system doesn’t work
properly.
 20.

A- Aortic Valve Open

B- Aortic Valve Closes

C - Mitral Valve Closes

D - Mitral Valve Open

E - End Diastolic Volume

F- End Systolic Volume