Clinical Cardiovascular Anatomy & Physiology

Concepts, Definitions, & Principles

Slides developed in collaboration with

Dr. John Green, 2003.
 The Normal Heart - Coronary Artery Anatomy

Left Main CA

Layers of the Arterial Wall

Circumflex

Adventitia
Media
Intima
Right CA

Left Anterior Descending CA Marginal Branch

The Heart as a Pump
Reference: Berne and Levy, Physiology
 Cardiac Muscle Differences
Fibers organized into functional syncytium
branching, interconnected fibers
ends separated by intercalated disks fused to
adjoining fibers by tight junctions; low resistance
all-or-none law applies to entire myocardium
Cannot be tetanized
due to phase 2 (plateau) of action potential
 Left Ventricular Volumes - Definitions

End Diastolic Volume (EDV)

Volume at the end of diastole
(end of ventricular filling)

End Systolic Volume (ESV)

Volume at the end of systole
(end of ventricular contraction)

Stroke Volume (SV) = EDV - ESV

Ejection Fraction is the
Ejection Fraction (EF) = SV best indicator of heart
EDV performance and
disease prognosis
Left ventricular norm: 62%
 Definitions

Cardiac Output (Q) = HR X SV

Cardiac Index = Q / body surface area
Preload: diastolic filling volume of the left ventricle (EDV
reflects stretch of the cardiac muscle cells)
Afterload: resistance to ventricular emptying during systole (the
amount of pressure the left ventricle must generate to squeeze blood
into the aorta
Frank Starling Law of the Heart - the heart will contract with greater
force when preload (EDV) is increased
Myocardial Contractility - the squeezing contractile force that the heart
can develop at a given preload
regulated by:
sympathetic nerve activity (most influential)
catecholamines (epinephrine norepinephrine)
amount of contractile mass
drugs
 Starlings Law of the Heart and Contractility

contractility
SV
normal
contractility
left
ventricular
contractility
performance
(heart failure)

preload (venous return)

 Using Ventricular Pressure Curves as
Indices of Contractility & Cardiac Function

dP/dt = change in pressure per unit of time

dP/dt dP/dt
Normal
120
Heart Failure

Note elevation in
end diastolic
pressure

0
 Contractility
- a change in developed tension at a given
resting fiber length OR an increase in Vmax
increase max dP/dt from LV pressure curve
Positive and negative inotropic effects
Ejection fraction (EF = SV/EDV) used in clinical
practice
increase contractility assumed with increase EF
with Ca, NE, digitalis, exercise; with [K]o,
[Na]o
 Influences on Myocardial Contractility

Contractility related to :
beta-sympathetic adrenergic nerves
catecholamines: epinephrine
norepinephrine
drugs: digitalis
sympathomimetics

Contractility related to:

loss of contractile mass - myocardial Infarction
myocardial muscle disease - cardiomyopathy
drugs: anesthetics, barbiturates
 Definitions
Arteriovenous Oxygen Difference (AVO2D) the difference in oxygen
content between arterial and venous blood
measured in ml% - ml O2 / 100 ml blood

Oxygen Consumption (VO2) - the rate at which oxygen can be used in

energy production and metabolism
absolute measures: L / min , ml / min
relative measures: ml / kg body wt. / min
Fick equation: VO2 = Q X AVO2D

Maximum Oxygen Consumption (VO2max) maximum rate at which a

person can take in and utilize oxygen to create usable energy
defined as plateau of consumption rate increase
often estimated with VO2peak

Myocardial Oxygen Consumption VO2 of the heart muscle (myocardium)

"estimated" by RPP: HR X SBP
mild 27% - 40%
predicted VO2max - attained VO2max moderate 41% - 54%
Functional Aerobic Impairment: marked 55% - 68%
predicted VO2max severe > 69%
 Definitions

Systolic Blood Pressure (SBP) pressure measured in brachial

artery during systole (ventricular emptying and ventricular
contraction period)
Diastolic Blood Pressure (DBP) pressure measured in brachial
artery during diastole (ventricular filling and ventricular
relaxation)
Mean Arterial Pressure (MAP) "average" pressure throughout the
cardiac cycle against the walls of the proximal systemic
arteries (aorta)
estimated as: .33(SBP - DBP) + DBP

Total Peripheral Resistance (TPR) - the sum of all forces that

oppose blood flow
length of vasculature (L)
TPR = ( 8 ) ( V ) ( L )
blood viscosity (V)
( ) ( r 4 )
hydrostatic pressure (P)
vessel radius (r)
 Cardiovascular Hemodynamic Basics

Pressure (MAP) P aorta P vena cava

Flow (Q) = =
Resistance (TPR) (8) (V) (L)
() (r 4)

Flow (Q) = () (Pa Pv) (r 4) Normally Resting Q is

(8) (V) (L) about 5 - 6 liters / minute

V = viscosity of fluid (blood) flowing through the pipe

L = length of pipe (blood vessel)
r = radius of the pipe (blood vessel)
Pa = aortic pressure
Pv = venous pressure
 Brain
The Systemic
Circulation
Lungs
Veins (Flexible Arteries (Stiff
Compliant Pipes) Inflexible Pipes)

Precapillary
Sphincters

Liver
Stomach

Pancreas

Intestines
Kidneys

Arterioles
Skin

Muscle
 Microcirculatory Anatomy

Smooth Muscle Arteriole

Precapillary
Sphincter

Anastomosis
(Shunt)
True Capillary
With Single
Layer of
Endothelium

Metarteriole

Venule
 Effects of an Increase in Preload on
Left Ventricular Pressure Volume Loop

Ejection Pressure

Left 120
Ventricular
Pressure
SV
(mmHg)

EDV
EDP
6

40 140
Volume
(ml)
 Effects of an Increase in Afterload on Left
Ventricular Pressure Volume Loop
ESV
ESP

Left 120
Ventricular
Pressure
SV
(mmHg)

40 140
Volume
(ml)
Mechanism of Control of
Cardiovascular and
Respiratory Systems
 Sites of
Cardiorespiratory
Control
 Cardiorespiratory Control

Stroke Volume regulated by Frank Starling mechanism

venous return EDV stroke volume

Cardiac Output (Q) main determinant: body O2 needs

Autoregulated by intrinsic changes in preload, & SV

afterload initial in Q EDV SV back to normal
venous return preload SV

Autoregulated by extrinsic hormonal influences

Norepinephrine release HR and SV
 Cardiorespiratory Control
Exercise Systemic Blood Flow: Autonomic influences
Sympathetic outflow & circulating catecholamines
activation vasoconstriction in non - exercising tissue
Approximate redistribution of blood flow during maximal exercise
NC in brain blood flow 500 ml/min to heart
11,300 ml/min to muscle 400 ml/min to skin
500 ml/min to kidneys 800 ml/min to viscera
200 ml/min to various other parts of the body

Rest Max Exercise

Acute Cardiorespiratory
Responses to Endurance
Exercise
 Acute Responses to Aerobic Exercise
Heart Rate
up to 3 times resting value at peak exercise ( time spent in diastole)

Oxygen Consumption (VO2)

Expressed in both relative and absolute terms
Relative: ml O2/kg/min Absolute: ml/min or L/min
average VO2max for 40 year old male 37 ml/kg/min
Resting metabolic equivalent = 1 MET = 3.5 ml/kg/min
Oxygen consumption linked to caloric expenditure (1 liter of O2 consumed = 5 kcal)
180
160
Heart
Rate 140
100 HR VO2
relationship is
1.0 2.0 3.0
Oxygen Uptake (L / min) linear until about
90% VO2max
50 150 250
Workloads (Watts)
 Cardiac Output (Q)
up to 4 times resting value at peak exercise ( is rapid at onset, then levels off)
Q venous return
Venous return mediated by and related to:
sympathetic venoconstriction
muscle pump
inspiration thoracic pressure
blood flows to an area of reduced pressure
inspiration abdominal pressure
contraction of abdominal muscles
squeezing of abdominal veins Acute Responses
Stroke Volume to Aerobic
up to 1.5 resting value at peak exercise
increase levels off at 40% - 50% VO2 max Exercise
in venous return EDV (Starling mechanism)
ESV eluding to an in myocardial contractility
ejection fraction: rest: 58% max exercise: 83%

120
Stroke 110
Volume
70
(ml/beat
25% 50% 75%
Percentage of VO2 max
 Arteriovenous oxygen difference
Difference in [O2] between arterial and mixed venous blood
Illustrated by the oxyhemoglobin desaturation curve
approximately 3 fold from rest to max exercise
at rest, about 25% of arterial O2 is extracted
at peak exercise 85% of arterial O2 is extracted Acute Responses
to Aerobic
Blood Pressures and Resistance to Flow Exercise
SBP: - failure to signifies heart failure
DBP: slight or slight or NC
MAP: slight
TPR: - mainly due to vasodilation in exercising muscle

Coronary (Myocardial) Blood Flow

4.5% of Q goes to myocardium at rest and at peak exercise
this increase is due to MAP and CA vasodilation

Blood Flow to the Skin

as exercise duration to allow for heat dissipation
at max exercise to meet exercising muscle demands
during exercise recovery, again for heat dissipation
 Acute Responses to Aerobic Exercise

Minute Ventilation
resting average: 6 Liters/min
peak exercise average: 175 Liters/min
respiratory rate: resting 12-18 peak exercise: 45-60
tidal volume: resting .5 liters peak exercise: 2.25 Liters

Plasma Volume
blood plasma in the interstitum of exercising muscle
fluid shift results in a 5% in the hemoconcentration
blood viscosity increases
 Oxygen
Oxygen Debt
DEBT and Deficit
& Oxygen DEFICIT

Steady State Oxygen Deficit Oxygen Debt

VO2 (EPEOC)

VO2 Untrained or people with

certain cardiorespiratory
diseases will have larger
DEBTS and DEFICITS
Rest

Onset EXERCISE TIME Termination

Oxygen Deficit due to:

delay in time for aerobic ATP production to supply energy
Oxygen Debt due to:
resynthesis of high energy phosphates (CP, ATP)
replace oxygen stores
lactate conversion to glucose (gluconeogenesis)
HR, respiration, catecholamines, body temperature
 OBLA Respiratory Compensation
P aO 2 (hyperventilation)
P AO 2

P AC O 2 & P aC O 2

No Change in
VE
Ventilatory and V E
Metabolic VCO2
Changes
During VCO 2
VO 2 m ax
Exercise
VO 2
-
HCO 3

pH

Increasing
workload
Training Adaptations to
Chronic Endurance
Exercise
Resting
NC NC
VO2 = HR x SV x AVO 2diff

due to: due to:

time in diastole preload
afterload
ventricle size
blood volume

Submax Workload (measured at same pre-training workload)

NC NC
VO2 = HR x SV x AVO2diff
Effects of
note: a in afterload (mentioned above)
accompanied by a in HR response translates into Exercise
a myocardial VO2 at rest or at any workload Training on the
Max Workload (measured at peak exercise) Components of
NC the Fick
VO2 = HR x SV x AVO2diff Relationship
some studies show
a slight decrease
 Mean Arterial Pressure
NC at rest or during exercise
Systolic and Diastolic Blood Pressure
usually NC at rest or during exercise
possible at submaximal workload
may at rest in borderline hypertensives
some studies report a mean of about 9 mmHg
Total Peripheral Resistance and Afterload
capillarization (more parallel circuits) TPR
TPR Afterload (slight not of major significance)
Respiratory Variables
Respiratory Rate
Rest: NC
Submax exercise: d
Max exercise: slight
Training Adaptations
Tidal Volume
Rest: NC
Submax exercise: NC or slight
Max exercise: slight
Anaerobic Threshold
Occurs at a higher percentage of VO2 max
Pre-training: 50% VO2max Post-training: 80% VO2max
 Mitochondria
number, size and membrane surface area
Aerobic Enzymes in Exercising Muscle
Krebs cycle enzymes (succinate dehydrogenase)
oxidation enzymes (carnitine acyltransferase)
electron transport enzymes (cytochrome oxidase)
Fatty Acid & Glycogen Utilization
utilization of oxidative pathways to produce ATP
Called the glycogen sparring effect
RER for any given submaximal workload
muscle glycogen stores (with high carbohydrate diet)
Platelet Aggregation
Fibrinolytic Activity
Training Adaptations
Circulating Catecholamines
vagal tone risk of arrhythmia
No Appreciable Change in Resting Metabolic Rate
Exception: training induced in lean muscle mass
Resistance to Pathological Events
smaller infarct size and quicker recovery
Less of a in ventricular function during ischemia
 "Average" Values for Sedentary and
Trained Individuals

Heart Rate
( beats / minute )

200 185 185

150

100 75
60

50

0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Stroke Volume
( ml / beat )

160

150 120

100 80
60

50

0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Cardiac Output
( liters / minute)

40
35 30
30
22
25
20
15
10 5 5
5
0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

A-V O2 Difference
( ml%)

20
16
14
15

10
6 6

0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Oxygen Consumption
( liters / minute)

6
4.5
5
4 3
3
2
1 0.25 0.25
0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Oxygen Consumption
( ml / kg / minute)

55
60
50
38
40
30
20
10 3.5 3.5

0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Systolic Blood Pressure

( mm Hg)

210 206
200
134 130
150

100

50

0
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Diastolic Blood Pressure

( mm Hg)

90
88
86 84
84 82 82
82 80
80
78
76
74
sedentary-rest sedentary-max trained-rest trained-max
 "Average" Values for Sedentary and
Trained Individuals

Minute Ventilation
( liters / minute)
150
160
140 120
120
100
80
60
40
6 6
20
0
sedentary-rest sedentary-max trained-rest trained-max