ICD-10 Chapter IX: Diseases of the circulatory system

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

The circulatory system is an organ system that moves nutrients, gases, and wastes to and from cells, helps fight diseases and helps stabilize body temperature and pH to maintain homeostasis. This system may be seen strictly as a blood distribution network, but some consider the circulatory system as composed of the cardiovascular system, which distributes blood, and the lymphatic system, which distributes lymph. While humans, as well as other vertebrates, have a closed cardiovascular system (meaning that the blood never leaves the network of arteries, veins and capillaries), some invertebrate groups have an open cardiovascular system. The most primitive animal phyla lack circulatory systems. The lymphatic system, on the other hand, is an open system.

The main components of the human circulatory system are the heart, the blood, and the blood vessels. The circulatory system includes: the pulmonary circulation, a “loop” through the lungs where blood is oxygenated; and the systemic circulation, a “loop” through the rest of the body to provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, which consists of plasma that contains red blood cells, white blood cells, and platelets.

Two types of fluids move through the circulatory system: blood and lymph. The blood, heart, and blood vessels form the cardiovascular system. The lymph, lymph nodes, and lymph vessels form the lymphatic system. The cardiovascular system and the lymphatic system collectively make up the circulatory system.

Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart.

Arteries always take blood away from the heart, regardless of their oxygenation, and veins always bring blood back. In general, arteries bring oxygenated blood to the tissues; veins bring deoxygenated blood back to the heart. In the case of the pulmonary vessels, however, the oxygenation is reversed: the pulmonary artery takes deoxygenated blood from the heart to the lungs, and oxygenated blood is pumped back through the pulmonary vein to the heart. As blood circulates through the body, oxygen and nutrients diffuse from the blood into cells surrounding the capillaries, and carbon dioxide diffuses into the blood from the capillary cells.^[1]

The release of oxygen from red blood cells or erythrocytes is regulated in mammals. It increases with an increase of carbon dioxide in tissues, an increase in temperature, or a decrease in pH. Such characteristics are exhibited by tissues undergoing high metabolism, as they require increased levels of oxygen.

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart.

De-oxygenated blood enters the right atrium of the heart and flows into the right ventricle where it is pumped through the pulmonary arteries to the lungs. Pulmonary veins return the now oxygen-rich blood to the heart, where it enters the left atrium before flowing into the left ventricle. From the left ventricle the oxygen-rich blood is pumped out via the aorta, and on to the rest of the body.

The coronary circulatory system provides a blood supply to the heart.

In the heart there is one atrium and one ventricle for each circulation, and with both a systemic and a pulmonary circulation there are four chambers in total: left atrium, left ventricle, right atrium and right ventricle.

The cardiovascular systems of humans is closed, meaning that the blood never leaves the system of blood vessels. In contrast, oxygen and nutrients diffuse across the blood vessel layers and enters interstitial fluid, which carries oxygen and nutrients to the target cells, and carbon dioxide and wastes in the opposite direction. The other component of the circulatory system, the lymphatic system, is not closed.

The circulatory systems of all vertebrates, as well as of annelids (for example, earthworms) and cephalopods (squid and octopus) are closed, just as in humans. Still, the systems of fish, amphibians, reptiles, and birds show various stages of the evolution of the circulatory system.

In fish, the system has only one circuit, with the blood being pumped through the capillaries of the gills and on to the capillaries of the body tissues. This is known as single circulation. The heart of fish is therefore only a single pump (consisting of two chambers). In amphibians and most reptiles, a double circulatory system is used, but the heart is not always completely separated into two pumps. Amphibians have a three-chambered heart.

Birds and mammals show complete separation of the heart into two pumps, for a total of four heart chambers; it is thought that the four-chambered heart of birds evolved independently from that of mammals.

The open circulatory system is an arrangement of internal transport present in many animals such as molluscs and arthropods, in which fluid (called hemolymph) in a cavity called the hemocoel bathes the organs directly with oxygen and nutrients and there is no distinction between blood and interstitial fluid; this combined fluid is called hemolymph or haemolymph. Muscular movements by the animal during locomotion can facilitate hemolymph movement, but diverting flow from one area to another is limited. When the heart relaxes, blood is drawn back toward the heart through open-ended pores (ostia).

Hemolymph fills all of the interior hemocoel of the body and surrounds all cells. Hemolymph is composed of water, inorganic salts (mostly Na⁺, Cl^–, K⁺, Mg²⁺, and Ca²⁺), and organic compounds (mostly carbohydrates, proteins, and lipids). The primary oxygen transporter molecule is hemocyanin.

There are free-floating cells, the hemocytes, within the hemolymph. They play a role in the arthropod immune system.

Circulatory systems are absent in some animals, including flatworms (phylum Platyhelminthes). Their body cavity has no lining or enclosed fluid. Instead a muscular pharynx leads to an extensively branched digestive system that facilitates direct diffusion of nutrients to all cells. The flatworm’s dorso-ventrally flattened body shape also restricts the distance of any cell from the digestive system or the exterior of the organism. Oxygen can diffuse from the surrounding water into the cells, and carbon dioxide can diffuse out. Consequently every cell is able to obtain nutrients, water and oxygen without the need of a transport system.

• Electrocardiogram — for cardiac electrophysiology
• Sphygmomanometer and stethoscope — for blood pressure
• Pulse meter — for cardiac function (heart rate, rhythm, dropped beats)
• Pulse — commonly used to determine the heart rate in absence of certain cardiac pathologies
• Nail bed blanching test — test for perfusion
• Vessel cannula or catheter pressure measurement — pulmonary wedge pressure or in older animal experiments.

The valves of the heart were discovered by a physician of the Hippocratean school around the 4th century BC. However their function was not properly understood then. Because blood pools in the veins after death, arteries look empty. Ancient anatomists assumed they were filled with air and that they were for transport of air.

Herophilus distinguished veins from arteries but thought that the pulse was a property of arteries themselves. Erasistratus observed that arteries that were cut during life bleed. He ascribed the fact to the phenomenon that air escaping from an artery is replaced with blood that entered by very small vessels between veins and arteries. Thus he apparently postulated capillaries but with reversed flow of blood.

The 2nd century AD, Greek physician, Galen, knew that blood vessels carried blood and identified venous (dark red) and arterial (brighter and thinner) blood, each with distinct and separate functions. Growth and energy were derived from venous blood created in the liver from chyle, while arterial blood gave vitality by containing pneuma (air) and originated in the heart. Blood flowed from both creating organs to all parts of the body where it was consumed and there was no return of blood to the heart or liver. The heart did not pump blood around, the heart’s motion sucked blood in during diastole and the blood moved by the pulsation of the arteries themselves.

Galen believed that the arterial blood was created by venous blood passing from the left ventricle to the right by passing through ‘pores’ in the interventricular septum, air passed from the lungs via the pulmonary artery to the left side of the heart. As the arterial blood was created ‘sooty’ vapors were created and passed to the lungs also via the pulmonary artery to be exhaled.

In 1242, the Arabian physician, Ibn al-Nafis, became the first person to accurately describe the process of blood circulation in the human body, particularly pulmonary circulation, for which he is considered the father of circulatory physiology.^[2] Ibn al-Nafis stated in his Commentary on Anatomy in Avicenna’s Canon:

“…the blood from the right chamber of the heart must arrive at the left chamber but there is no direct pathway between them. The thick septum of the heart is not perforated and does not have visible pores as some people thought or invisible pores as Galen thought. The blood from the right chamber must flow through the vena arteriosa (pulmonary artery) to the lungs, spread through its substances, be mingled there with air, pass through the arteria venosa (pulmonary vein) to reach the left chamber of the heart and there form the vital spirit…”

Contemporary drawings of this process have survived. In 1552, Michael Servetus described the same, and Realdo Colombo proved the concept, but it remained largely unknown in Europe.

Finally William Harvey, a pupil of Hieronymus Fabricius (who had earlier described the valves of the veins without recognizing their function), performed a sequence of experiments and announced in 1628 the discovery of the human circulatory system as his own and published an influential book about it. This work with its essentially correct exposition slowly convinced the medical world. Harvey was not able to identify the capillary system connecting arteries and veins; these were later described by Marcello Malpighi.

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• The Circulatory System, a comprehensive overview
• The InVision Guide to a Healthy Heart An interactive website
• NCP Cardiovascular Medicine A Journal Covering Clinical Cardiovascular Medicine

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