2. The cardiac cycle
In the normal heart, cardiac activity is repeated in a regular cyclical manner.
With a resting heart rate of 75 beats/min, the duration of each cardiac cycle is 0.8 second.
For the ventricles, the cycle consists of 0.3 second in systole and 0.5 second in diastole.

3. The cardiac cycle * Atrial systole, * Ventricular systole, then
* Diastole of the whole heart
Atrial and ventricular systoles do not occur at the same time, but their diastoles occur at the same time during the diastole of the whole heart.

4. The cardiac cycle * Atrial systole * Ventricular systole
Isometric (isovolumetric) contraction phase
Rapid ejection phase
Slow ejection phase
    * Diastole of the whole heart
Protodiastole
      Isometric (isovolumetric) relaxation phase
     Rapid filling phase
Slow filling phase

5. ISOMETRIC VENTRICULAR
LATE DIASTOLE
DIASTOLE
ATRIAL
SYSTOLE
VENTRICULAR
EJECTION
ISOMETRIC VENTRICULAR
CONTRACTION

6. ISOVOLUMETRIC RELAXATION RAPID INFLOW DIASTASIS ATRIAL SYSTOLE
EJECTION
ISOVOLUMETRIC
CONTRACTION
ISOVOLUMETRIC RELAXATION
RAPID INFLOW
DIASTASIS
ATRIAL SYSTOLE
AORTIC
PRESSURE
PRESSURE (mmHg)
ATRIAL
PRESSURE
VENTRICLE
VOLUME (ml)
ECG
PHONO-
CARDIOGAM
SYSTOLE DIASTOLE SYSTOLE

7. S1 CARDIAC CYCLE S2 Aortic opens Aortic closes Mitral opens Mitral
Reduced Ejection
Reduced Ventricular
Filling
Atrial Systole
Rapid Ejection
Isovolumic Relax.
Rapid Ventricular
Filling
Isovolumic contract.
Atrial Systole
Aortic
opens
Aortic
closes
Mitral
opens
Mitral
Closes S1
CARDIAC CYCLE S2

8. Heart Sounds Outline: Audible and inaudible heart sounds.
First and second heart sounds:
- Relation to cardiac cycle
- Causes, characters, site of hearing & significance
Third and Fourth heart sounds:
Further Reading:
Guytin: Textbook of Medical Physiology
Ganong: Review of Medical Physiology

10. HEART SOUNDS
During each cardiac cycle 4 heart sounds are produced due to physiological vibration in the heart:
The 1st & 2nd heart sounds are audible i.e. normally heard when a stethoscope is applied to the chest wall.
The 3rd heart sound is usually inaudible (different to be heard); however, it can be sometimes heard in some children.
The 4th heart sound is normally inaudible.

11. The heart sounds
The first heart sound occurs at the beginning of systole and sounds like the word LUP.
The second heart sound occurs at the beginning of diastole and sounds like the word DUP.
The interval between the first and second sound is shorter than the interval between the second and the next first heart sound.

12. FIRST HEART SOUND
It occurs at the beginning of ventricular systole i.e. isometric contraction phase and it extends into the phase of maximum( rapid ) ejection.
Causes:
1) Sudden closure of the AV valves ( mitral & tricuspid ) at the start of the ventricular systole which produces vibrations in the cusps of the AV valves (valvular factor).

13. 2) Contraction of the ventricular muscle which causes vibrations in the muscle itself and vibration in the chorda tendinae ( ventricular) factors.
3) Ejction of blood from the venticles into the aorta and pulmonary artery which causes vibrations in these walls ( vascular factors).
Charcters
Soft and law pitched
It’s duration is about 0.15 second.
It is heard as the ward ((lup)), by the stethoscope.

14. Site of hearing:
- it is best heard at the mitral area= 5th left intercostl space about 10 cm from the midline
Tricuspid area= lower part of the sternum (at the 6th right stenocostal junction).
Significance:
1)it indicates the start of ventricular systole.
2)It gives an idea about the condition of the AV valves.
3) Its intensity and duration indicates the condition of the cardiac muscle (Myocardium).

15. 2) Second heart sound:
It occurs at the onset of ventricular diastole isometric relaxation phase of the cardiac circle
-Causes:
Sudden closure of the semi lunar valves ( aortic and pulmonary valves) and the vibrations that follow in their cusps (= valvular) factors.
vibration in the walls of the aorta and pulmonary artery due to vibration in the aortic and pulmonary valves (= Vascular factors).

16. -Characters
Sharp and high pitched
Its duration is about 0.12 seconds
Its heard as the spoken ward “Dup” by the stethoscope
Site of hearing:
It is best heard at:
Aortic area ( = 2nd right stennocostal junction).
Pulmonary area ( = 2nd left intercostal space near the sternum).

17. -Significance:
It indicates the end of ventricular systole and the start of ventricular diastole
It gives an idea about the condition of the semi lunar valves.
Its intensity is directly proportional with the arterial blood pressure.
-N.B.
The duration between the 1st and 2nd heart sounds represents clinically the time of ventricular systole and that between the 2nd & 1st heart sounds as the time of ventricular diastole.

18. THIRD HEART SOUND
It occurs during ventricular diastole; during maximum
(rapid) filling phase of ventricular diastole. So, it comes
after the 2nd heart sound.
Causes:
vibrations of the relaxed ventricular walls due to rush of blood from the atria into the ventricles during rapid ventricular filling.
Characters:
Soft and low pitched
Its duration is about 0.1 second.
It is usually inaudible. It can be sometimes heard in children or persons with very thin chest wall.
Significance:
it indicates opening of the AV valves during ventricular diastole and rapid ventricular filling.

19. FOURTH HEART SOUND
It occurs during the phase of atrial systole; therefore,
it is called atrial heart sound.
Causes:
Vibrations in the relaxed ventricular walls due to rush of blood from the atria into the ventricles under the effect of atrial contraction.
Characters:
It is a faint low pitched sound.
Its duration is about 0.5 second.
It is normally inaudible but can be recorded or detected by the phonocardiogram.
Significance:
it indicates atrial systole (=late ventricular filling = late ventricular diastole).

20. MURMURS
Cardiac murmurs are abnormal heart sounds in the form of noises resulting from turbulent blood flow,
Murmurs may be:
Systole murmurs, if they occur during systole.
Diastolic murmurs, if they occur during diastole
Causes:
The main factors causing cardiac murmurs include:
Stenosis (narrowing) of heart valves
Incompetence of heart valves
Increase of blood flow or decrease of blood viscosity (as in anemia).

21. Pressure changes during the cardiac cycle
Outline:
Aortic pressure changes during the cardiac cycle
Arterial pulse curve (radial pulse curve).
The arterial pulse and its importance.
The pulse pressure and water-hammer pulse.
Atrial pressure changes during the cardiac cycle.
The jugular venous pulse waves
Jugular pulse curve and its importance.
Further Reading:
Guyton: Textbook of Medical Physiology
Ganong: Review of Medical Physiology

22. PRESSURE CHANGES DURING THE CARDIAC CYCLE AORTIC PRESSURE CHANGES
At the beginning of the ventricular systole and when the aortic valves opens (i.e. during the maximum or rapid ejection phase of the cardiac cycle), the aortic pressure is rapidly increases to reached a maximum called systolic blood pressure (about 120 mm Hg).
During the reduced ejection phase and the protodiastole phase, there is a fall in the aortic pressure due to slow ejection and the flow of blood from the aorta into the peripheral arteries.
During ventricular diastole, there is a gradual decrease of aortic pressure due to continued flow of blood from the aorta into the systemic peripheral vessels. The aortic pressure decreases to a diastolic valve of about 80 mmHg.

23. The arterial pressure wave = (Radial pulse curve)
This reflects the aortic pressure changes during the cardiac cycle.
Recording of the arterial pressure wave (using a special apparatus called sphygmograph), gives a curve which consists of an ascending limb called the anacrotic limb and a descending limb called the catacrotic limb.
The anacrotic limb is due to sudden distension (expansion) of the artery during ejection of blood from the left ventricle (i.e. during ventricular systole).
The catacrotic limb is due to flow of blood from the artery into more peripheral vessels during the late part of ventricular systole and during ventricular diastole.
Over the catacrotic limb, there is an irregularity in the form notch (called diacrotic notch or incisura) followed by a wave (called dicrotic wave).

24. - The diacrotic notch occurs during closure of the aortic valves at the end of the protodiastolic phase (=beginning of the ventricular diastole).
The diacrotic wave occurs during ventricular diastole (isometric relaxation phase) and it is due to the elastic recoil of the arterial wall.
THE ARTERIAL PULSE
During ventricular systole (rapid ejection phase), the expansion of the aortic wall which is rapidly propagated through the arterial walls can be felt using the middle three fingers as a pulsation.
Palpitation of the radial pulse (=arterial pulse) gives information about:
Heart Rate; its regularity, the presence of missed beats or extra systoles. a

25. The force of ventricular contraction e. g
The force of ventricular contraction e.g. full pulse in muscular exercise and weak pulse in hemorrhage.
The condition of the arterial wall which indicates the arterial elasticity e.g. normal arterial wall is soft and in arteriosclerosis it is rigid.
PULSE PRESSURE
Pulse pressure is the difference between systolic blood pressure and diastolic blood pressure.
It increases in conditions that increase systolic BP and/ or decrease the diastolic BP e.g.
Aortic regurgitation.
Arteriosclerosis
big pulse pressure produces marked arterial pulsations (water-hammer pulse).

26. N.B: ATRIAL PRESSURE CHANGES
Pressure changes in the pulmonary artery during the
cardiac cycle are similar to those in the aorta but they differ
in magnitude (the systolic BP is mm Hg and the
diastolic BP is 8-10 mm Hg).
ATRIAL PRESSURE CHANGES
During each cardiac cycle, atrial pressure is increased during the following phases:
Atrial systole
Isometric (isovolumetric) contraction of the ventricles due to bulging of the AV valves towards the atria which results from increased ventricular pressure.
Protodiastolic phase and isometric relaxation of the ventricles due to accumulation of blood in the atria while the AV valves are closed.

27. JUGULAR VENOUS PULSE WAVES = (Jugular pulse curve)
The pressure changes in the right atrium during the cardiac cycle are transmitted to the external jugular vein producing similar changes in the venous pressure of this vein  venous pulse waves.
This is because there are no valves between the vena cava and the right atrium.
The jugular venous pulse waves can be recorded using a special apparatus called phlebograph.
The record shows 3 positive waves (a, c, v) and 3 negative waves (x, x1, y):
The a-wave is due to atrial systole which causes increase in the intra-atrial pressure.
The x-wave is due to atrial diastole.

28. The C-wave occurs at the beginning of the ventricular systole i. e
The C-wave occurs at the beginning of the ventricular systole i.e. during the isometric contraction of the ventricles.
It is due to bulging of the tricuspid valve towards the right atrium which causes increase of the right atrial pressure (which is conducted to the external jugular vein).
The X-wave is due to downward displacement of the A-V valve (tricuspid valve) and the AV ring during maximum ejection phase of ventricular contraction.
The V-wave is due to accumulation of venous blood in the right atrium  increase of atrial pressure during the late part of the ventricular systole (protodiastolic phase) and also during the isometric relaxation of the ventricles.

29. SIGNIFICANCE OF THE JUGULAR
The Y-wave is due to opening of the AV valve (tricuspid valve) during maximal ventricular filling phase i.e. rush of blood from the atria into the ventricles  decrease of atrial pressure.
SIGNIFICANCE OF THE JUGULAR
VENOUS PULSE CURVE
The “a-c” interval represents conductivity in the S-V bundle.
- The “a-c” interval is measured from the beginning of the a-wave to the beginning of the c-wave.
- Since the a-wave is due to atrial systole and c-wave is due to ventricular systole, the a-c interval measures
the time of conduction of the cardiac impulse from the
right atrium to the ventricles.
- The a-c interval corresponds to the P-R interval of the ECG. It is normally about 0.12 second.

30. -. The “a-c” interval is prolonged in cases of delayed
- The “a-c” interval is prolonged in cases of delayed conductivity in the AV bundle which is an early sign of heart block.
In partial heart block, the number of “a” waves is greater than the number of the “c” or “v” waves.
In atrial fibrillation, the “a” wave is absent.
N.B:
When the jugular pulse curve is simultaneously recorded with the radial pulse curve, this is called polygram.
The wave preceding the ascending limb of the radial pulse curve is the c-wave.

31. S1 CARDIAC CYCLE S2 Aortic opens Aortic closes Mitral opens Mitral
Reduced Ejection
Reduced Ventricular
Filling
Atrial Systole
Rapid Ejection
Isovolumic Relax.
Rapid Ventricular
Filling
Isovolumic contract.
Atrial Systole
Aortic
opens
Aortic
closes
Mitral
opens
Mitral
Closes S1
CARDIAC CYCLE S2