CARDIOVASCULAR SYSTEM

Case 1

Maria, a 16-year old girl, sought consult for episodes of palpitations. She denies any chest pain or chest
tightness. There is no history of fainting, dyspnea or other associated symptoms. There are no known
cardiac conditions in her family. She has had no prior major illnesses. Physical examination showed
distinct S1 and S2, with normal rate and regular rhythm. She insisted on having a full cardiac work-up,
including tests to evaluate the possibility of a heart attack. ECG was normal, and the cardiac enzymes
came back negative.

ANATOMY
1. Trace the adult circulatory system in contrast to the fetal circulation
2. Enumerate the valves of the heart.
3. Differentiate the right atrium from the left atrium. Differentiate the right ventricle from the left
ventricle.

HISTOLOGY
1. Parts of the electrical conduction system of the heart and its properties
2. What is the sinoatrial node and its significance?
3. What are the histological properties of the Purkinje fibers?

PHYSIOLOGY
1. State the steps in excitation-contraction coupling in cardiac muscle. What is the special role of
Ca++ in the control of contraction and relaxation of cardiac muscle?
2. Beginning in the SA node, diagram the normal sequence of cardiac activation (depolarization)
and the role played by specialized cells. What are the sympathetic and parasympathetic nervous
system influence on heart rate and cardiac excitation in general? Explain the palpitations
presented in this case.
3. Draw, in correct temporal relationship, the pressure, volume, heart sound, and ECG changes in
the cardiac cycle. Identify the intervals of isovolumic contraction, rapid ejection, reduced
ejection, isovolumic relaxation, rapid ventricle filling, reduced ventricular filling and atrial
contraction.
4. Explain why the ECG tracing is different in each 12 leads.
5. Describe the timing and causes of the four heart sounds.

BIOCHEMISTRY
1. Give a brief description of the following cardiac biomarkers with their corresponding functions
a. Myoglobin
b. Troponins I, T and C
c. Creatine kinase-MB (CK-MB)
d. Lactate dehydrogenase (LDH)
2. Illustrate a diagram showing the biomarkers with their corresponding diagnostic timeline in a
medical case, such as of acute myocardial infarction (AMI). Explain briefly
3. Which of the markers stated above is considered to be the most diagnostic and of high
prognostic value in myocardial necrosis? Give a brief explanation
4. What is the importance of enzyme markers? State at least two (2) other enzymes that can be
used as markers of cellular damage in the body
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Case 2

A group of 15-year old athletes were scheduled to participate in a regional tournament with
representatives from other schools. During their routine check-up at their school clinic, the nurse noted
that they all had bradycardia, heart rates ranging from 55-58 beats per minute. Concerned, the nurse
had the group sent to a nearby hospital for further evaluation. The students were all physically active,
did not have any prior major illnesses, and were currently symptom free. Physical examination was
essentially normal apart from the slightly slow heart rate.

ANATOMY
1. Enumerate the great vessels of the heart

2. Enumerate the R-L shunts in the fetal circulation and it remnant in adults

3. Illustrate the relations and landmarks of the mediastinum with respect to the heart and the thorax.

HISTOLOGY
1. What makes up the circulatory system and what are its components?
2. What are the layers of the heart?
3. What makes up the cardiac skeleton?

PHYSIOLOGY
1. Describe how arterial systolic, diastolic, mean and pulse pressure are affected by changes in:
a. Stroke volume
b. Heart rate
c. Arterial compliance
d. Total peripheral resistance
2. What are the various phases of ventricular systole and ventricular diastole? Contrast the
relationship between pressure and flow into and out of the left and right ventricles during each
phase of the cardiac cycle
3. What is preload, afterload, and contractility?
4. Draw a ventricular pressure-volume loop and on it label the phases and events of the cardiac
cycle
5. What is the principle behind Frank Starling mechanism?
6. Explain why the athletes are bradycardic in this case

BIOCHEMISTRY
1. What are the biochemical changes seen in athletes performing prolonged heavy exercise sets in
terms of the following:
a. Serum magnesium
b. Serum potassium
c. Serum sodium
d. Blood urea and creatinine
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Case 3

Luke, 18 years old, Filipino, had recently been invited by relatives in the United States to visit during
Christmas. Upon arrival, he began to shiver, unused to the cold and snow. He noted that his fingers and
toes had become pale and nub. He also had the sudden urge to urinate despite limited fluid intake over
the flight. His relatives, who met him at the airport, immediately scolded him for not wearing gloves and
helped him warm up. Buried under the blankets and holding a warm drink, he noted that his skin had
started to look a little flushed.

ANATOMY
1. Trace the blood supply of the heart and its venous drainage

2. Illustrate the fibrous skeleton of the heart

3. Surface anatomy of the chest wall in relation to the heart.

HISTOLOGY
1. What are the tissues of the vascular wall?
2. What are the differences between arteries, veins and capillaries?
3. What are some of the arterial sensory structures within the circulatory system that help in the
regulation of blood flow/pressure?
4. What makes up a microvascular system? Which alternative pathway plays a role in
thermogenesis?

PHYSIOLOGY
1. What is the relationship between pressure, flow and resistance in the vasculature?
2. What are the factors that shift laminar flow to turbulent flow? Describe the relationship
between velocity, viscosity, and audible events, such as murmurs and bruits
3. What is the sequence of events in the baroreflex that occur after an acute increase or decrease
in arterial blood pressure?
4. Contrast the sympathetic and parasympathetic nervous system control of heart rate,
contractility, total peripheral resistance, and venous capacitance.
5. Explain the effect of changes in temperature in the peripheral vascular system

BIOCHEMISTRY
1. Endotherms, such as humans face the vital challenge of maintaining an elevated and constant
core temp (36-380C) independently of climactic fluctuations. As ambient temperature declines, a
physiologic increase of heat production occurs through activation of non-shivering (NST) and
shivering (ST) thermogenic process. Define the following:
a. Thermogenesis
b. Non-shivering thermogenic process (NST) – what is the main contributor?
c. Shivering thermogenic process (ST) – what is the main contributor?
d. Burst shivering rate
2. Heat is a by product of all exothermic biochemical reactions, which includes combustion of
metabolic substrates e.g. CHO, lipids, and proteins. Which substrate accounts for most of the
total heat produced? Which least contributes?