(microscopic) CARDIO VASCULAR SYSTEM (CIRCULATORY SYSTEM)

Indriati Dwi Rahayu

The situation…..

KBK

Daftar Penyakit ; ~ Tingkat kemampuan yang harus dicapai: • Tingkat Kemampuan 1: mengenali dan menjelaskan gambaran klinik penyakit   rujukan yang paling tepat  menindaklanjuti sesudah kembali dari rujukan. • Tingkat Kemampuan 2: mendiagnosis dan merujuk Lulusan dokter mampu membuat diagnosis klinik  dst. • Tingkat Kemampuan 3: mendiagnosis, melakukan penatalaksanaan awal, dan merujuk 3A. Bukan gawat darurat mampu memberikan terapi pendahuluan  dst 3B. Gawat darurat mampu memberikan terapi pendahuluan pada keadaan gawat darurat  dst.

(……..lanjutan) • Tingkat Kemampuan 4: mendiagnosis, melakukan penatalaksanaan secara mandiri dan tuntas

(……..lanjutan)

Daftar Keterampilan Klinis

 Tingkat kemampuan 1 (Knows): Mengetahui dan menjelaskan  Tingkat kemampuan 2 (Knows How): Pernah melihat atau didemonstrasikan  Tingkat kemampuan 3 (Shows): Pernah melakukan atau pernah menerapkan di bawah supervisi. Mhsw

berkesempatan untuk melihat dan mengamati keterampilan tersebut dalam bentuk demonstrasi atau pelaksanaan langsung pada pasien/masyarakat, serta berlatih keterampilan tersebut pada alat peraga dan/atau standardized patient.  Tingkat kemampuan 4 (Does): Mampu

melakukan secara mandiri /pada pasien. s/d pengendalian komplikasi.

STANDAR KOMPETENSI DOKTER INDONESIA AREA KOMPETENSI

Keterampilan Klinis 1. Prinsip dan keterampilan anamnesis 2. Prinsip dan keterampilan pemeriksaan fisik 3. Prinsip pemeriksaan laboratorium dasar 4. Prinsip pemeriksaan penunjang lain 5. Prinsip keterampilan terapeutik (lihat daftar keterampilan klinik) 6. Prinsip kewaspadaan standar (standard precaution) 7. Kedaruratan klinik

Landasan Ilmiah Ilmu Kedokteran

1. Struktur dan fungsi A.Struktur dan fungsi pada tingkat molekular, selular, jaringan, dan organ B.Prinsip homeostasis C. Koordinasi regulasi fungsi antar organ atau sistem: CVS, GIT, dst (termasuk tumbuh kembang) 2. Penyebab penyakit a. Lingkungan: biologis, fisik, dan kimia b. Genetik c. Psikologis dan perilaku d. Nutrisi e. Degeneratif

5.3. Patomekanisme penyakit a. Trauma b. Inflamasi c. Infeksi d. Respons imun e. Gangguan hemodinamik (iskemik, infark, thrombosis, syok) f. Proses penyembuhan (tissue repair and healing) g. Neoplasia h. Pencegahan secara aspek biomedik i. Kelainan genetik j. Nutrisi, lingkungan, dan gaya hidup 5.4. Etika kedokteran 5.5. Prinsip hukum kedokteran 5.6. Prinsip2 pelayanan kesehatan (primer, sekunder, dan tersier) 5.7. Prinsip2 pencegahan penyakit 5.8. Prinsip2pendekatan kedokteran keluarga 5.9. Mutu pelayanan kesehatan 5.10 Prinsip pendekatan sosio-budaya

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE

LYMPH VESSEL Conduction – innervations

Functions :

O2, nutrient,

• transport

metabolism waste,

• Homeostatic distribution

body fluid, temperature, immune system

Subsystem : - Cardiovascular - lymph vessel

• Cardiovascular (CVS) – closed tube system – for blood circulation, with the help of heart as pump – components : ♣ cor (heart) ♣ vessel : * capillary * artery * vein

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE

LYMPH VESSEL Conduction – innervations

Gambaran umum sistem tabung tertutup

Tdd 3 lapisan utama - Endothelial lining

- Musculature - Connective tissue / jaringan ikat

HEART WALL: - endocardium - myocardium - Epicardium

PERICARDIUM

Cardiac skeleton – Consist of Dense connective tissue – As the insertion of cardiac muscle fibers Components: – the fibrous framework of dense collagen forms four fibrous rings, which surround the orifices of the valves. – TRIGONA fibrous: the mass of dense connective tissue form a triangle, between the 2 groups fibrous annuli – Septum membranaceum: dense fibrous tissue disc, forming the top of the muscular interventricular septum

Cardiac skeleton

Septum membranaceum

Cardiac skeleton

General Features :

Vessel Wall: - tunica intima  LEI - tunica media 

LEE

- tunica adventitia

General Features of Blood Vessel

….a.d……

Vessel Wall 1. Tunica intima  the innermost layer, adjacent to the lumen  consist of :  endothel (above the thin BL)  subendothel : connective tissue (in the capillary only endothel)  on arteries: separated by a layer underneath : the internal elastica lamina (LEI)

2. Tunica media - consist mainly of VSMC that travelled circularly - thicker in the arteries - identical with the heart at myocardium 3. Tunica adventitia • In the vein: the thickest • In large veins may contain smooth muscle. • May Vasa vasorum inside • Identical to the epicardium in the heart VSMC = vascular smooth muscle cell

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE

LYMPH VESSEL Conduction – innervations

Cells 1. Endothelial Cell (EC) 2. Adventitial cell 3. Vascular Smooth Muscle cell (VSMC) 4. Others : fibroblast, stemcell ------------------------------------------------------------------------------1.

Endothelial cell - size: 0,2 µm - Nucleus protrude into the lumen - cytoplasm : * >> pinocytic vesicles * Organelles & filament around the nucleus

• Membrane : - caveolae [+] - junctional complex • Organelles : * mitochondria, RER, SER, Ribosome, * microfilament : actins * intermediate filament : vimentin * (khas) : Weibel-Palade bodies  tubular vesicles, artery only

 Factor VIII.  korelasi : von Willebrand's disease

Endothel

...(cont. endothelial) function : production of a wide range of factors that regulate vascular tone, cellular adhesion, thromboresistance, smooth muscle cell proliferation, Play role in capillary transport , vessel wall inflammation, etc • Ex :

- Products :

 Cytokine - Disturbance of function  ex: endothelial

dysfunction /activation  clinical cases. Ex :

Atherosclerosis, hypertension, coronary artery disease, chronic heart failure, etc

Suggested reading (available at www.highwire.org): Endothelial dysfunction. Endemann DH, Schiffrin EL. J Am Soc Nephrol. 2004 Aug;15(8):1983-92 Endothelial Dysfunction in Cardiovascular Diseases. The Role of Oxidant Stress. Hua Cai, David G. Harrison. Circ Res. 2000;87:840-844 Recent Advances in Understanding Endothelial Dysfunction in Atherosclerosis. Zhihong Yang, MD and Xiu-Fen Ming, MD, PhD. 2006. Clinical Medicine & Research. Volume 4, Number 1: 53-65 Role of Endothelial Dysfunction in Atherosclerosis. Jean Davignon, MD; Peter Ganz, MD. Circulation. 2004;109;27-32

Clinical Importance of Endothelial Function in arteryosclerosis and Ischemic Heart Disease. Kensuke Egashira, MD. Circ J 2002; 66: 529 –533.

2.

adventitia cell= pericyte

•

small mesenchymal cell, along the capillary

•

attached to the surface of the capillary through the process of the cytoplasm, with adherent junction

•

may contractile can differentiate into other cells

•

may function phagocytosis

PERICYTE

3. Vascular Smooth Muscle Cell - tunica media In heart : Myocyte

Clinical corelation : restenosis

3. others - fibroblast , myofibroblast : in adventitia clinical correlation : injury reaction, chronic inflammatory - stem cell  human blood vessel–derived stem cells (hBVSC)

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE heart blood vessel

classification capillaries arteries vein

DINDING heart

DINDING heart

Endocardium • ~ T. Intima • 1 layer of endothelium. • Subendothel: thin loose connective tissue, with elastic fibers,collagen, and smooth muscle • Myocardial relationship: subendocardia layer 

connective tissue, veins, nerves, and Purkinje fibers

DINDING heart

Valve of the heart • merupakan lipatan endocardium • consist of dense fibrous connective tissue( with colagen & elastic) • endothel coated on 2 sides • base attached to the fibrous annuli

clinical case : Valvular heart disease

Katub heart

Heart wall : myocard

Myocardium • the thickest • contains cardiac muscle cells  spiral • In Atrium  Musculi pectinati, in the form of woven

* muscle cells smaller than in the ventricle *>> granul2 contain atrial natriuretic factor * more rhythmic contractions * forward impulse more

Heart wall : myocard

In Ventricle :

muscle cells arranged around the space • Outer: spiral composed from ventricular  M. papillary • Inner : S_shaped circular, through

the septum interventricularis

clinical case : - Cardiomyopathy

Heart wall : myocard

Heart wall : myocard

Purkinje fibers (conduction system) * wider * myofilamen scattered on the edge * diskus intercalatus [+], nucleus : central, 1-2

Ventrikular heart muscle * as syncytium * As the last link impulse conduction

Heart wall : myocard

DINDING heart

Epicardium • Cover the Heart • Mesotel: flat epithelial layer, a layer of connective tissue

• Subepicardium: loose connective tissue, containing veins, nerves, and fat tissue • related to the lining of the visceral pericardium

heart wall - EPICARD

Pericardium consist of : •Fibrous pericard :

- not attached to the heart - lateral : pleura •Serosal pericardium :

- inner/Visceral ~ epicardium - Outer/Parietal : surface of the fibrous pericardium

- apace between: cavum pericardium

Clinical case : Tamponade heart, Pericarditis

INTRODUCTION

CELLS in CVS GENERAL STRUCTURE MICROSCOPIC STRUCTURE blood vessel

classification capillaries arteries vein

heart

blood vessel category ( ~ classification) * arteries - Elastic A/Large A  A. Muscular  arteriole 

metarteriole  capillary  capillary bed  capillary * vein - capillary bed  capillary  postcapillar venule 

venule  medium vein  Large vein

MICROSCOPIC STRUCTURE

blood vessel

heart

classification capillary artery vein

• • • •

A.Elastik/Besar A. Muskular Arteriole Metarteriole

LARGE arteries

•

A.Elastik/Besar

• • •

A. Muskular Arteriole Metarteriole

• = elastic arteries • Ex : Aorta and its large branches • T. Intima : Thick Endothelium. Thick subendothelial , porous LEI • perforated elastic laminae. • T. media : comprised of a lamellar units (consisting of Elastic lamella, smooth muscle, collagen,and elastic fibers). Between the elastic laminae are smooth muscle cells, reticular fibers, proteoglycans, and glycoprotein • No distinct external elastic membrane. • T. Adventitia : connective tissue; vasa vasorum, relatively underdeveloped (thin relative to vessel diameter) clinical case : aortic aneurysm

artery BESAR

MEDIUM arteries • = Muscular arteries = distributing arteries • Endothelium. The intima have a subendothelial layer LEI [+], Refraktil • may contain up to 40 layers of smooth muscle cells. These cells are intermingled with various numbers of elastic lamellae (depending on the size of the vessel) LEE [+] in wider diameter • T. Adventitia : connective tissue; vasa vasorum • Ex : A. Brachialis clinical case : claudicatio

artery SEDANG

artery SEDANG

SMALL artery • Transition : arteriole – medium artery • ~ A. Muscular

artery KECIL

arteriole • Ф < 0,5 mm

• Tunica intima : - Endothelium. Subendothelial layer is very thin - LEI [-] LEI [+] when ø > 40 μm • Tunia media : one to five circularly arranged layers of smooth muscle cells; it shows no external elastic lamina • tunica adventitia : connective tissue; is very thin.

arteriole

arteriole

METarteriole • Branch of the arteriol • +/- precapillary sphincter for Vasoconstriction  Regulates blood flow through capillaries • T. Intima : Endothelium subendothel [-] LEI [-] • T. Media : incomplete single layer of smooth cell • T. Adventitia : indistinguishable connective tissue

Special arteries • A.Duramater & cerebral :

- elastic fibers [-] - T. adventitia less developed, only the collagen bundles - LEI well developed

A. pulmonalis : thin walls, smooth muscle 0,1 mm - s/d large arteriole

MICROCIRCULATION 1. arteriole – metarteriole – capillary – venule 2. Anastomose arteryvein 3. arterial portal system 4. Venous portal system

MIKROSIRKULASI

1. arteriole – metarteriole – capillaries– venule (Capillary bed)

- Surrounded by a discontinuous layer of smooth muscle -

precapillary sphincter [+]

-

Regulates blood flow through capillaries

MIKROSIRKULASI

2. Anastomose arteriol- vein • Direct connection of artery-vein • >> in extremity • contraction  blood to the capillary • Relaxes  to the vein

MICROSIRKULASI

3. arterial portal system • capillary plexus between two arteries • Ex : Glomerulus of kidney (afferent arteriol – capillary plexus– efferent arteriol)

MIKROSIRKULASI

4. Venous portal system • capillary plexus between veins • Ex : hepar (V.porta- sinusoid V.Hepatica)

Vascularization - innervation blood vessel • Vascularization

 difusion  vasa vasorum • innervation * vasomototr :  ANS (serabut efferent)  perivascular

nerves di Tunica adventitia.

(P.u unmyelinated, simpatis) * sensoris : myelinated

Vasa vasorum -

the small blood vessels for nutrient artery / vein

- ø > 1 mm - in the Tunica adventitia (Bailey)

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE

LYMPH VESSEL Conduction – innervations

1. SISTEM PEMBULUH LIMFATIK • Lymph fluid; component : * excess tissue fluid * cellular debris * lymphocytes * fat (intestinal) • Is a closed tube system Starting from the capillary lymph vessels  empty to the vein • moving one direction, toward a meeting between the two lymph vessels with a large vein in the neck

ORGANISASI sistem pembuluh capillary Limfatik Lymph vessels Lymph organs

Lymph vessels S Cisterna chyli

D Ductus lymphaticus dextra

Ductus thoracicus

trunkus V. SUBCLAVIA

PEMBULUH LIMFATIK

 types of vessels:

capillary: the end of dead-end, collect lymph from intercellular space lymph vessels: capillary lymphatic collecting lymph 

lymphatic duct: lymph vessels collect lymph from small lymph vessel  V. subclavian



characteristics : – Smooth – RELATIVE wider – More valve – Basal lamina [-]

Allows for absorption of drugs

– Capillaries more permeable – Wider gap between endothel – The flow running very slow: can be manipulated – [-]: the nervous system (including eye) clinical case : -Lymphangitis -Elephantiasis

capillary DARAH

VS

capillary LIMFATIK

capillary LIMFATIK

Pergerakan Cairan Limfe

PEMBULUH LIMFATIK

3 in 1

a = small lymphatic with endothelial lining but no other organized wall. b = small vein (very thin muscle; pale c.t.). c = small artery (pink muscle; yellow c.t.)

INTRODUCTION GENERAL STRUCTURE

CELLS in CVS MICROSCOPIC STRUCTURE

LYMPH VESSEL Conduction – innervations

The rhythm of the heart (conduction system) consist of : * SA node * Av node * Av bundle * Purkinje fiber - Connect with gap-junction

(Sistem Konduksi)

http://people.eku.edu/ritchisong/heartautoareas.gif

(Sistem Konduksi)

SA node : * in the middle wall of the right atrium, close to the opening V. Cava Superior * Set as speed control heart rhythm * modification of cardiac muscle fusiform * smaller cell * fewer myofibril AV node : * similar to the SA node, cytoplasm which branched out into various directions  woven * in the right side of interatrial septum * continues into the AV bundle

(Sistem Konduksi)

AV bundle of His  is a specialized cardiac muscle fibers  from interatrial septum interventricular septum  branching each ventricle (left & right)  Purkinje fibers Purkinje fibers * wider, * myofilamen scattered on the edge * intercalates disc [+], central core, 1-2 Ventricular heart muscle cells * as a syncytium * As the last link conduction impuls

Heart-vascularization and Innervation Vascularisasi – A.coronaria (Aorta branch) myocard – Back flow : sinus coronarius  right Atrium – Ischemia  infark

• Innervasi  plexus cardiacus : * formed by nerve fibers of NX and post-ganglioner truncus simpaticus. * cardiacus plexus located in the pericard  motor fibers autonomic ganglion  Stimulation of the sympathetic HR  ↑  Parasympathetic stimulation  ↓ HR

Specialized sensory mechanisms : (carotid sinus, carotid body, and the aortic bodies) • Sinus carotis  dilatation of the internal carotid Artery  As baroreceptor  to detect changes in blood pressure CNS  thinner T.media  >> nerve ending

• Carotid body dan Aortic body  = chemoreceptor against CO2 and O2 in the blood  Carotid body : near bifurcatio A. Carotid communis  Aortic bodies : wall of the arch of the aorta at the junction of the com-on carotid and subclavian arteries  >> fenestrated capillary  sensitive to low O2 pressure, [CO2] is high, and low arteryal pH

Carotid body dan Aortic body

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Anatomi FKUB