 The heart is a hollow, muscular organ situated in the

space between lungs (mediastinum) & rests on the

diaphragm , its about 12 cm in length & about 9 cm in
width
Cardiac Muscle
 Contract as a single unit
 Simultaneous contraction due to depolarizing at the
same time
 Automaticity
 The heart is about the size of a clenched fist and
comprises.
 The heart composed of four layers:
 Endocardium,
 Myocardium,
 Epicardium,
 and the pericardium..
 endocardium is the inner layer and is consists of
endothelial tissue that lines the inner surface of
the heart and the cardiac valves.
 The myocardium is the middle layer and is
composed of muscle fibers that enable the heart to
pump.
 Epicardium is the outer layer, is tightly adherent
to the heart and the base of the great vessels.
 A thin, fibrous, double-layered sac known as the
pericardium surrounds the heart.
 The outer layer is known as the parietal
pericardium
 and the inner layer is called the visceral
pericardium
 Between these two layers is a small amount of
pericardial fluid (30 to 50 mL) that serves as a
lubricant between the two layers & lubricant the
surface of the heart , & decrease the friction during
systole .
 The heart consists of four chambers:

 right and left atrium

 right and left ventricles.
Heart valves
 The cardiac valves are composed of fibrous tissue
and allow blood to flow in one direction.
 The valves open and close as a result of blood flow
and pressure differences.
 The tricuspid and mitral valves are known as the
atrioventricular (AV) valves because they are
located between the atria and the ventricles.

 The pulmonic and aortic valves are known as the

semilunar valves because each has three leaflets
shaped like half-moons.
Circulation of the blood
 The blood passes through the tricuspid valve into
the right ventricle, which then pumps the blood
through the pulmonic valve into the pulmonary
circulation.
 After gas exchange in the lungs, oxygenated blood
returns to the left atrium, passes through the
mitral valve, enters the left ventricle, passes
through the aortic valve, and finally enters the
aorta
Coronary Arteries

 The left and right coronary arteries and their branches

supply arterial blood to the heart. These arteries originate
from the aorta just above the aortic valve leaflets.

 The heart has large metabolic requirements, extracting

approximately 70% to 80% of the oxygen delivered (other
organs consume, on average, 25%).
The left coronary artery has three branches.

1. the artery from the point of origin to the first

major branch is called the left main coronary
artery. two bifurcations arise off the left main
coronary artery
2. left anterior descending artery (LAD), which
courses down the anterior wall of the heart

3. circumflex artery, which circles around to the

lateral left wall of the heart.
 The right side of the heart is supplied by the right
coronary artery, which progresses around to the
bottom or inferior wall of the heart.

 The posterior wall of the heart receives its blood

supply by an additional branch from the right
coronary artery called the posterior descending
artery.
 The coronary arteries are perfused during diastole.
An increase in heart rate shortens diastole and can
decrease myocardial perfusion.
 Patients, particularly those with coronary artery
disease (CAD), can develop myocardial ischemia
(inadequate oxygen supply) when the heart rate
accelerates.
Cardiac Output

 Cardiac output is the amount of blood pumped

out of the ventricle .

 The cardiac output in a resting adult is about (5) L

per minute but varies greatly depending on the
metabolic needs of the body. Cardiac output is
computed by multiplying the stroke volume by the
heart rate.
 Stroke volume (SV) :The amount of blood ejected
by the left ventricle with each heartbeat .
 the heart rate is 60 to 80 beats per minute (bpm)
 The average resting stroke volume is about 70 mL, and
Cardiac output can be affected by changes in either
stroke volume or heart rate.
Cardiac Output/Index
 Cardiac output
 CO = HR (beats/minute) X SV (liters/beat)
 Normal adult: 4-8 liters/minute

 Cardiac index
 CI = CO(liter/minute)/Body surface area (m2)
 Normal adult: 2.8-4.2 liter/minute/m2
 Normalizes liter flow to body size
 Stroke Volume

 Preload

 Afterload

 Contractility
Stroke Volume

 Preload
 The amount of stretch placed on the cardiac muscle just prior to
systole (the amount of the ventricle at end diastole)
 Diastole : filling stage of cardiac cycle.

 Afterload
 The force or pressure at which the blood is ejected from the
left ventricle
 Equated with systemic vascular resistance (SVR)
 Contractility is a term used to denote the force
generated by the contracting myocardium under any given
condition

 The resistance of the systemic BP to left ventricular

.
ejection is called systemic vascular resistance.

 The resistance of the pulmonary BP to right ventricular

ejection is called pulmonary vascular resistance
 The percentage of the end-diastolic volume that is
ejected with each stroke is called the ejection
fraction (EF)
(EF) = 50-70%
 HEALTH HISTORY AND CLINICAL MANIFESTATIONS
For the patient experiencing an acute MI, the nurse
obtains the health history using a few specific questions
about the onset and severity of chest discomfort,
associated symptoms, current medications, and
allergies.
At the same time, the nurse observes the patient’s general
appearance and evaluates hemodynamic status (heart rate
and rhythm, BP).
Cardiac Signs and Symptoms

• Chest pain or discomfort (angina pectoris, MI, valvular

heart disease) Shortness of breath or dyspnea (MI, left
ventricular failure, HF)

• Edema and weight gain (right ventricular failure, HF)

• Palpitations (dysrhythmias resulting from myocardial
ischemia, stress, electrolyte imbalance)
• Fatigue (earliest symptom associated with several
cardiovascular disorders)
• Dizziness and syncope or loss of consciousness (postural
hypotension, dysrhythmias, vasovagal effect,
cerebrovascular disorders)
 Physical Exam
 Inspection  Percussion
 General appearance  Auscultation
 Jugular venous distension
 Good stethoscope
(JVD)
 Skin  Positioning
 Extremities  Normal tones – S1/S2
 Palpation  Extra tones – S3/S4
 Pulses  Murmurs
 Point of maximal impulse
 Rubs
(PMI)
HEART SOUNDS

HEART SOUNDS
The normal heart sounds, S1 and S2, are produced primarily by
the closing of the heart valves. The time between S1 and S2 corresponds to
systole This is normally shorter than the
time between S2 and S1 (diastole). As the heart rate increases diastole
shortens.
S1—First Heart Sound. Closure of the mitral and tricuspid valves
creates the first heart sound (S1),

S2—Second Heart Sound. Closing of

the aortic and pulmonic valves
produces the second heart sound (S2).
 Murmurs are created by the turbulent flow of blood.
 The causes of the turbulence may be a critically
narrowed valve,
 a malfunctioning valve that allows regurgitant
blood flow,
 a congenital defect of the ventricular wall, a defect
between the aorta and the pulmonary artery,
Diagnostic Evaluation

 Laboratory test(Cardiac Labs)

 Chest X-ray
 ECG
 CARDIAC STRESS TESTING
 ECHOCARDIOGRAPHY(ECO)
 Echocardiography is a noninvasive ultrasound test that is
used to examine the size, shape, and motion of cardiac
structures.
Important Cardiac Labs

 Enzymes – CK, CK-MB, LDH

 Other important cardiac biomarkers that are
assessed include the myoglobin and troponin T or I.
Myoglobin

early marker of MI, is a heme protein with a small
molecular weight. This allows it to be rapidly released
from damaged myocardial tissue and accounts for its
early increase, within 1 to 3 hours after the onset of an
acute MI. Myoglobin peaks in 4 to 12 hours and returns
to normal in 24 hours.
 Lipid studies – Cholesterol, triglycerides

 Coagulation studies – PTT and PT/INRI

(international Normalized Ratio (INR).
The INR provides a standard method for reporting
PT level
 Electrolytes – Potassium, magnesium, and calcium
 Invasive Tests

 Cardiac catheterization

 Coronary angiography
Cardiac Electrophysiology

 The cardiac conduction system generates and

transmits electrical impulses that stimulate
contraction of the myocardium.
 To pump effectively, large portions of cardiac muscle
must receive an action potential nearly simultaneously.
 Special cells that conduct action potentials extremely
rapidly are arranged in pathways through the heart.
 Before mechanical contraction, an action potential
travels quickly over each cell membrane and down into
each cell’s.
 Three physiologic characteristics of two
specialized electrical cells, the nodal cells and the
Purkinje cells, provide this synchronization:
 Automaticity: ability to initiate an electrical
impulse
 Excitability: ability to respond to an electrical
impulse
 Conductivity: ability to transmit an electrical
impulse from one cell to another
 Cardiac Conduction
 Sinoatrial (SA) node – Fires at 60–100 beats/minute
 Intranodal pathway
 Atrioventricular (AV) node – Fires at 40-60 beats/minute
 Atrioventricular bundle of His
 Ventricular tissue fires at 20-40 beats/minute and can
occur at this point and down
 Right and left bundle branches
 Purkinje fibers
Action Potential
12-Lead ECG
 Limb leads
 Standard leads: I, II, and III
 Augmented leads: aVR, aVL, and aVF
 Precordial leads
 V1,V2,V3,V4,V5, and V6
 Axis
 The direction of the flow of electricity
53
Friday, 2 March 2018 54
 P wave : atrial depolarization
up to 0.12 second in duration .
QRS complex : ventricular depolarization
normal measure is 0.08-0.12 second
T wave : ventricular repolarization , rounded
upright, not exceeds 0.2 sec of duration
PR interval : the interval between the beginning
of p wave and the beginning of R wave it
measures between ( 0.12-0.2

57
ST segment : the isoelectric line between the end of
QRS and the beginning of T wave
QT interval : the interval between the beginning of
Q wave and the end of T wave , it measures ( 0.32 –
0.40 ) second

58
Normal Timing
PR interval – 0.12 to 0.20 seconds 
QRS interval – less then 0.12 
QT interval – varies with rate. It is usually less then ½ 
the R-to-R distance on the preceding waves
Steps to reading ECGs

What is the rate? Both atrial and ventricular if they are not 
the same.
Is the rhythm regular or irregular? 
Do the P waves all look the same? Is there a P wave for every 
QRS and conversely a QRS for every P wave?
Are all the complexes within normal time limits? 
Name the rhythm and any abnormalities. 
Rate
Look at complexes in a 6-second strip and count the 
complexes; that will give you a rough estimate of rate
Count the number of large boxes between two 
complexes and divide into 300
Count the number of small boxes between two 
complexes and divide into 1500
Estimate rate by sequence of numbers. 
Normal Sinus Rhythm
Rate is between 60 and 100 beats/minute 
The rhythm is regular 
All intervals are within normal limits 
There is a P for every QRS and a QRS for every P 
The P waves all look the same 
Sinus Tachycardia
Rate above 100 beats/minute 
The rhythm is regular 
All intervals are within normal limits 
There is a P for every QRS and a QRS for every P 
The P waves all look the same 
Caused by fever, stress, caffeine, nicotine, exercise, or by 
increased sympathetic tone
Treatment is to take care of the underlying cause 
Sinus Bradycardia
Rate is lower than 60 beats/minute 
The rhythm is regular 
All intervals are within normal limits 
There is a P for every QRS and a QRS for every P 
The P waves all look the same 
Caused by beta-blocker, digitalis, or calcium channel blockers. 
Normal for athletes
Don’t treat unless there are symptoms. Can use pacing or 
atropine
Sinus Arrhythmia
Rate is between 60 and 100 beats/minute 
The rhythm is irregular. The SA node rate can increase or 
decrease with respirations
All intervals are within normal limits 
There is a P for every QRS and a QRS for every P 
The P waves all look the same 
More common in children and athletes 
Ask the patient to stop breathing and the rate will become 
regular
Premature Atrial Contraction
(PAC)
Occur when an ectopic atrial focus discharge an
impulse before the next anticipated sinus node
activation , these ectopic Ps have a bizarre
appearance and can be pointed , inverted or
notched

Friday, 2 March 2018 71

Friday, 2 March 2018 72
Premature Atrial Contraction
(PAC)
1- RHYTHM : regular except for ectopic beat
2-RATE : normal except for ectopic beat 3- P
WAVE :normal ,pointed in atrial ectopic beat
4-PR INTERVAL : normal except for ectopic beat
5- QRS COMPLEX : normal duration

Friday, 2 March 2018 73

 The source of the impulse is some where above
ventricles , but the impulse then spread to the
ventricles so the heart beats faster than normal .

Friday, 2 March 2018 74

Supraventricular Tachycardia
(SVT)

Rate is between 150 and 250 beats/minute 

The rhythm is regular 
QRS intervals can be within normal limits 
There can be a P wave, but more likely it will be 
hidden in the T wave or the preceding QRS wave
Starts and stops abruptly 
Treat with Valsalva maneuver or adenosine IV 
Friday, 2 March 2018 76
 CAUSES : 
1- hypothyroidism .
2- anxiety .
3- pericarditis .
4- heart failure .
5- structural abnormality .

Friday, 2 March 2018 77

 Occurs when multiple irritable focuses in both 
atria started to initiate impulses that resulting in
chaotic , irregular excitation of the atrium .

Friday, 2 March 2018 78

Atrial Fibrillation
Atrial rate is between 350 and 600 beats/minute; 
ventricular rate can vary
The rhythm is irregular 
There is no PR interval; QRS may be normal 
There are many more f waves then QRS 
Unlike flutter where the f wave will appear the same, 
in fib the f waves are from different foci so they are
different
Friday, 2 March 2018 80
Atrial Fibrillation
CAUSES 
1- anterior myocardial infarction .
2- inferior myocardial infarction .
3- valvular heart disease .
4- heart failure .

Friday, 2 March 2018 81

Atrial Flutter
Atrial rate is between 250 and 350 beats/minute. 
Ventricular rate can vary
The rhythm is regular or regularly irregular 
There is no PR interval. QRS may be normal 
2:1 to 4:1 f waves to every QRS 
There are no P waves; they are now called flutter waves 
Problem: Loss of atrial kick and ventricular conduction is 
too fast or too slow to allow good filling of the ventricles
Friday, 2 March 2018 83
 CAUSES : 
1- atrial enlargement .
2- hyper thyroidism .
3- inferior myocardial infarction .
4- anterior myocardial infarction .

Friday, 2 March 2018 84

 This type occurs when SA node & the atria are 
unable to discharge an impulse to depolarize
both atria & ventricles , therefore an ectopic
focus in the surrounding junctional tissue take
the responsibility as apace maker at a rate of (
40-60 ) bpm .
The P wave may be absent, inverted & next QRS 
complex ; depends upon its origin .

Friday, 2 March 2018 85

Friday, 2 March 2018 86
JUNCTIONAL RHYTHM
1-RHYTHM : regular . 
2- RATE : 50 bpm , ( 40 – 60 ) bpm . 
3-P WAVE : Absent . 
4- QRS COMPLEX : normal configuration & 
duration .
5- T WAVE : normal . 
6- CONUCTION : the atria is stimulated by the 
junctional tissue after activation after or with the
activation of the ventricles .

Friday, 2 March 2018 87

Friday, 2 March 2018 88
JUNCTIONAL RHYTHM
CAUSES : 
1- acute myocardial infarction .
2- digoxin toxicity .

Friday, 2 March 2018 89

 1- RHYTHM : regular . 
2- RATE : 83 bpm . 
3- P WAVE : after QRS complex . 
4- QRS COMPLEX : normal configuration & 
duration .
5-T WAVE : Normal . 
6- CONDUCTION : atria activated after the 
ventricles so P wave comes after QRS complex .

Friday, 2 March 2018 90

Friday, 2 March 2018 91
 CAUSES : 
1- congestive heart failure .
2- cardiogenic shock .
NOTE : this type of arrhythmia start & end gradually
.

Friday, 2 March 2018 92

Premature Ventricular Contractions
(PVC)
Early beat that is wide (>0.12) 
Originates the ventricles 
No P wave 
Compensatory pause 
Can be defined by couplet or triplet; anything more 
would be considered ventricular tachycardia
Monomorphic or polymorphic 
Friday, 2 March 2018 95
 Multi focal means that the ectopic beat has 
more than one foci , that discharge many
shapes of QRS & T .

Friday, 2 March 2018 96

 That means that 2 consequences impulses 
discharged prior to the next anticipated sinus
rhythm impulse .

Friday, 2 March 2018 97

Ventricular Tachycardia

Rate is between 100 and 200 beats/minute 

The rhythm is regular, but can change to different 
rhythms
No PR interval; QRS is wide and aberrant 
There may be a P wave, but it is not related to the QRS 
Ventricular Fibrillation
Rapid, irregular rhythm made by stimuli from many 
different foci in the ventricula
Produces no pulse, blood pressure, or cardiac output 
Can be described as fine or coarse 
Most common cause of sudden cardiac death 
Torsades De Pointes
Polymorphous ventricular tachycardia 
Caused by long QT syndrome. 
This is an inherited condition or caused by 
antiarrhythmic drugs
Cannot be converted by defibrillation 
Magnesium is the drug of choice 
Overdrive pacing may work also 
Friday, 2 March 2018 105
 This arrhythmia occurs when all supra ventricular 
pace makers ( SA node , AV junction , bundle of
his , bundle branch ) fail to elicit an electrical
impulse ; the ventricles take over as a pace maker ,
firing at their own inherent rate of ( 30 – 40 ) bpm
.

Friday, 2 March 2018 106

Friday, 2 March 2018 107
 1- RHYTHM : regular R-R interval .
2- RATE :(30-40) bpm .
3- P WAVE : absent .
4-QRS COMPLEX : wide & bizarre .
5- CONDUCTION : electrical impulses arises from
the purkinji fibers or ventricular myocardium .

Friday, 2 March 2018 108

 CAUSES : 
1- cardiogenic shock .
2- medication effects like adrenaline .

Friday, 2 March 2018 109

 This arrhythmia occurs when the SA node & AV 
junction fail to initiate impulse the ventricles
take over the role as a pace maker at a rate about (
50-100) bpm .

Friday, 2 March 2018 110

Friday, 2 March 2018 111
 1-RATE : 60 bpm . 
2- RHYTHM : regular R-R interval . 
3- P WAVE : absent . 
4- QRS COMPLEX : wide & bizarre . 
5- T WAVE : caught up in ST segment . 
6- CONDUCTION : pace maker site is in bundle 
branch , purkinji fibers or myocardium

Friday, 2 March 2018 112

ACCELERATED IDIOVENTRICULAR RHYTHM

CAUSES : 
1- Acute myocardial infarctions .
2- digoxin toxicity .

Friday, 2 March 2018 113

Friday, 2 March 2018 114
 Occurs when there is a delay in the 
transmission of electrical impulse through the AV
node to the ventricles .

Friday, 2 March 2018 115

Friday, 2 March 2018 116
 1- RHYTHM : regular .
2- RATE : 45 bpm < 50bpm
3- P WAVE : normal .
4- P-R INTERVAL : 0.28 seconds
5- QRS COMPLEX : normal .
6- CONDUCTION : follow normal conduction
pathway but there is a delay in the process .

Friday, 2 March 2018 117

 Occurs when conduction through the AV 
junction become progressively difficult with each
successive impulse until finally a ventricular
depolarization doesn’t occur .

Friday, 2 March 2018 118

Friday, 2 March 2018 119
 1-Ventricular and atrial rate :Depends on the 
underlying rhythm
2- RHYTHM : atrial regular , but ventricular 
irregular .
3- P WAVE : normal . 
4-P-R INTERVAL : lengthening with each 
successive beat .
5-QRS COMPLEX :normal . 

Friday, 2 March 2018 120

 6- CONDUCTION : some of the impulses from the 
atria are blocked . P-R interval gets progressively
longer until one P wave is not followed by QRST .

Friday, 2 March 2018 121

 CAUSES : 
1-rehumatic fever .
2- inferior myocardial infarction .
3- digoxin toxicity .

Friday, 2 March 2018 122

 In this arrhythmia 2 or more atrial impulses 
conducted normally , then the next impulse
blocked without warning . Block may occur
occasionally or at regular intervals . ( for every
third beat ) ( 3:1) .

Friday, 2 March 2018 123

Friday, 2 March 2018 124
 1-Ventricular and atrial rate :Depends on the 
underlying rhythm
2- RHYTHM : P-P interval regular , R-R interval 
irregular .
3- P WAVE : normal . 
4- P-R INTERVAL : 0.16 sec , absent in missed beats 
.

Friday, 2 March 2018 125

 5- QRS COMPLEX : normal, some dropped beats . 
6- T WAVE : normal , some dropped as QRS 

7- CONDUCTION : Third atrial impulse is blocked 

.

Friday, 2 March 2018 126

 CAUSES : 
1- degenerative changes in conduction system
2- anterior myocardial infarction .
3- coronary artery disease .

Friday, 2 March 2018 127

 Occurs when the electrical impulses above the 
AV node are blocked , therefore no impulses
conducted to the ventricles , if SA node blocked
the junctional arises , if the block involve the
junctional tissue , the idiodventricular rhythm
arises .

Friday, 2 March 2018 128

Friday, 2 March 2018 129
  1-1-Ventricular and atrial rate :Depends on the
underlying rhythm
 2- RHYTHM : P-P interval regular , R-R interval
regular .
 3-P WAVE : normal .
 4-P-R INTERVAL : absent ( no relation between
atria& ventricles )

Friday, 2 March 2018 130

 5- QRS COMPLEX : depend on the site of pace 
maker , ( wide = purkinji fibers ) ( normal
=junctional tissue )
6- T WAVE : absent . 
7- CONDUCTION : the atria & ventricles have 
independent pacemaker ,so there is no
relationship between both .

Friday, 2 March 2018 131

 CAUSES : 
1-inferior myocardial infarction .
2- digoxin toxicity .
3- degeneration of conduction system .

Friday, 2 March 2018 132

THANKS 