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Anatomy and Physiology of the Cardiovascular System

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Anatomy and Physiology of the Cardiovascular System Prepared by Miss Fatima Hirzallah * 1- RHYTHM : regular R-R interval . 2- RATE :(30-40) bpm . 3- P WAVE : absent ... – PowerPoint PPT presentation

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Title: Anatomy and Physiology of the Cardiovascular System


1
Anatomy and Physiology of the Cardiovascular
System
  • Prepared by
  • Miss Fatima Hirzallah

2
  • The heart is a hollow, muscular organ situated in
    the space between lungs(mediastinum) , its about
    12 cm in length about 9 cm in width

3
Cardiac Muscle
  • Contract as a single unit
  • Simultaneous contraction due to depolarizing at
    the same time
  • Automaticity

4
  • The heart is about the size of a clenched fist
    and comprises.
  • The heart composd of four layers
  • Endocardium,
  • Myocardium,
  • Epicardium,
  • and the pericardium..

5
  • 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.

6
  • 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

7
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8
  • The heart consists of four chambers
  • right and left atrium
  • right and left ventricles.

9
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.

10
  • 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.

11
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

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13
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).

14
  • 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.

15
  • 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.

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  • 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.

18
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.

19
  • 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.

20
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

21
Stroke Volume
  • Preload
  • Afterload
  • Contractility

22
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)

23
  • 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

.

24
  • The percentage of the end-diastolic volume that
    is ejected with each stroke is called the
    ejection fraction (EF)
  • (EF) 50-70

25
Patient Assessment Cardiovascular System
26
  • 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
    patients general appearance and evaluates
    hemodynamic status (heart rate and rhythm, BP).

27
  • 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)

28
  • Fatigue (earliest symptom associated with
    several cardiovascularndisorders)
  • Dizziness and syncope or loss of consciousness
    (postural
  • hypotension, dysrhythmias, vasovagal
    effect,cerebrovascular disorders)

29
Physical Exam
  • Inspection
  • General appearance
  • Jugular venous distension (JVD)
  • Skin
  • Extremities
  • Palpation
  • Pulses
  • Point of maximal impulse (PMI)
  • Percussion
  • Auscultation
  • Good stethoscope
  • Positioning
  • Normal tones S1/S2
  • Extra tones S3/S4
  • Murmurs
  • Rubs

30

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33
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.
  • S1First Heart Sound. Closure of the mitral and
    tricuspid valves
  • creates the first heart sound (S1),

S2Second Heart Sound. Closing of the aortic and
pulmonic valves produces the second heart sound
(S2).
34
  • 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,

35
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.

36
Important Cardiac Labs
  • Enzymes CK, CK-MB, LDH
  • Other important cardiac biomarkers that are
    assessed include the myoglobin and troponin T or
    I. Myoglobin

37
  • 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.

38
  • Lipid studies Cholesterol, triglycerides
  • Coagulation studies PTT and PT/INRI
    (nternational
  • Normalized Ratio (INR). The INR provides a
    standard method for reporting PT level
  • Electrolytes Potassium, magnesium, and calcium

39
Invasive Tests
  • Cardiac catheterization
  • Coronary angiography

40
Cardiac Conduction
41
  • 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.

42
  • Before mechanical contraction, an action
    potential travels quickly over each cell membrane
    and down into each cells.

43
  • 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

44
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45
Cardiac Conduction
  • Sinoatrial (SA) node Fires at 60100
    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

46
Action Potential
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49
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

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52
LEADS AND THEIR POSITIONS
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54

LEADS AND THEIR POSITIONS
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56

EXPLAINING P,Q,R,ST
  • 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

EXPLAINING P,Q,R,ST
  • 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

59
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.

60
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.

61

62
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

63
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

64
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
  • Dont treat unless there are symptoms. Can use
    pacing or atropine

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66
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

67
Premature Atrial Contraction (PAC)
  • Can occur at any rate
  • The rhythm is irregular because of the early beat
    but is regular at other times
  • All intervals can be within normal limits
  • There is a P for every QRS and a QRS for every P
  • The P waves all look the same except the P in
    front of the PAC will be different

68
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

69

SUPRAVENTRICULAR TACHYCARDIA
70

SUPRAVENTRICULAR TACHYCARDIA
  • CAUSES
  • 1- hypothyroidism .
  • 2- anxiety .
  • 3- pericarditis .
  • 4- heart failure .
  • 5- structural abnormality .

71
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

72

ATRIAL FIBRILLATION
73
Atrial Fibrillation
  • CAUSES
  • 1- anterior myocardial infarction .
  • 2- inferior myocardial infarction .
  • 3- valvular heart disease .
  • 4- heart failure .

74
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
  • 21 to 41 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

75

ATRIAL FLUTTER
76

ATRIAL FLUTTER
  • CAUSES
  • 1- atrial enlargement .
  • 2- hyper thyroidism .
  • 3- inferior myocardial infarction .
  • 4- anterior myocardial infarction .

77

JUNCTIONAL RHYTHM
  • 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 .

78

JUNCTIONAL RHYTHM
79
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 .

80

JUNCTIONAL RHYTHM
81
JUNCTIONAL RHYTHM
  • CAUSES
  • 1- acute myocardial infarction .
  • 2- digoxin toxicity .

82

ACCELARATED JUNCTIONAL RHYTHM
  • 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 .

83

ACCELARATED JUNCTIONAL RHYTHM
84

ACCELARATED JUNCTIONAL RHYTHM
  • CAUSES
  • 1- congestive heart failure .
  • 2- cardiogenic shock .
  • NOTE this type of arrhythmia start end
    gradually .

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86
Premature Ventricular Contractions (PVC)
  • Early beat that is wide (gt0.12)
  • 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

87

VENTRICULAR ECTOPIC BEAT
88

VENTRICULAR ECTOPIC BEAT
  • Multi focal means that the ectopic beat has more
    than one foci , that discharge many shapes of QRS
    T .

89

VENTRICULAR ECTOPIC BEAT
  • That means that 2 consequences impulses
    discharged prior to the next anticipated sinus
    rhythm impulse .

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91
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

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93
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

94
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

95

TORSADES DE POINTES
96

IDIOVENTRICULAR RHYTHM
  • 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 .

97

IDIOVENTRICULAR RHYTHM
98


IDIOVENTRICULAR RHYTHM
  • 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 .

99
IDIOVENTRICULAR RHYTHM
  • CAUSES
  • 1- cardiogenic shock .
  • 2- medication effects like adrenaline .

100

ACCELERATED IDIOVENTRICULAR RHYTHM
  • 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 .

101

ACCELERATED IDIOVENTRICULAR RHYTHM
102
ACCELERATED IDIOVENTRICULAR RHYTHM
  • 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

103

ACCELERATED IDIOVENTRICULAR RHYTHM
  • CAUSES
  • 1- Acute myocardial infarctions .
  • 2- digoxin toxicity .

104

ATRIOVENTRICULAR BLOCKS
105

FIRST DEGREE AV BLOCK
  • Occurs when there is a delay in the
    transmission of electrical impulse through the AV
    node to the ventricles .

106

FIRST DEGREE AV BLOCK
107

FIRST DEGREE AV BLOCK
  • 1- RHYTHM regular .
  • 2- RATE 45 bpm lt 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 .

108
SECOND DEGREE AV BLOCK MOBITZ-1
  • Occurs when conduction through the AV junction
    become progressively difficult with each
    successive impulse until finally a ventricular
    depolarization doesnt occur .

109

SECOND DEGREE AV BLOCK MOBITZ-1
110

SECOND DEGREE AV BLOCK MOBITZ-1
  • 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 .

111

SECOND DEGREE AV BLOCK MOBITZ-1
  • 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 .

112
SECOND DEGREE AV BLOCK MOBITZ-1
  • CAUSES
  • 1-rehumatic fever .
  • 2- inferior myocardial infarction .
  • 3- digoxin toxicity .

113

SECOND DEGREE AV BLOCK MOBITZ-2
  • 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 ) ( 31) .

114

SECOND DEGREE AV BLOCK MOBITZ-2
115

SECOND DEGREE AV BLOCK MOBITZ-2
  • 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 .

116

SECOND DEGREE AV BLOCK MOBITZ-2
  • 5- QRS COMPLEX normal, some dropped beats .
  • 6- T WAVE normal , some dropped as QRS
  • 7- CONDUCTION Third atrial impulse is blocked .

117

SECOND DEGREE AV BLOCK MOBITZ-2
  • CAUSES
  • 1- degenerative changes in conduction system
  • 2- anterior myocardial infarction .
  • 3- coronary artery disease .

118

COMPLETE HEART BLOCK
  • 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 .

119

COMPLETE HEART BLOCK
120

COMPLETE HEART BLOCK
  • 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 )

121

COMPLETE HEART BLOCK
  • 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 .

122

COMPLETE HEART BLOCK
  • CAUSES
  • 1-inferior myocardial infarction .
  • 2- digoxin toxicity .
  • 3- degeneration of conduction system .

123

DEXTROCARDIA
124
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