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Cardiovascular Physiology







The sino-atrial node in the Electrophysiology of the heart right atrium- the pacemaker cells. to the atrio-ventricular node. to the bundle of His divides into right and left branches - spreads out from the base of the ventricles across the myocardium - Purkinje fibres. The atria then re-fill as the myocardium relaxes.

Neural & hormonal

The SA node by parasympathetic nervous system fibers (CN X: Vagus Nerve) by sympathetic nervous system fibers (T1-4, Spinal Nerves).

Adrenergic receptors and their effects

Receptor type
Alpha-1 Alpha-2 Beta-1

Blood vessels Blood vessels Heart

Vasoconstriction Vasoconstriction Increase heart rate Increase force of contraction Vasodilatation Bronchodilatation


Blood vessels Lungs

aortic pressure (AP) left ventricular pressure (LVP) left atrial pressure (LAP) left ventricular volume (LV Vol) left ventricular end diastolic volume (LVEDV) left ventricular end systolic volume (LVESV) heart sounds (S)










1 mV


P QS Depolarization of atria

T Repolarization of ventricles Depolarization of ventricles

The P wave - atrial depolarisation The Q wave - depolarisation at the bundle of His The R wave - main spread of depolarisation, from the inside out, through the base of the ventricles The S wave - subsequent depolarisation of the rest ventricles upwards from the base. The T wave - repolarisation of the myocard after systole is complete.

Heart Sounds
S1 = closer mitral valve & closer tricuspid valve (split 0.04 sec) S2 = closer aortic & pulmonary valve S3 = tensing of chordae tendineae and AV ring during ventricular relaxation and filling S4 = vibration ventricular wall during atrial contraction

Average, Normal Intracardiac and Vascular Pressure (mmHg)

Right atrium Right ventricle Pulmonary artery 0-4 25 sys / 4 dias 25 /10

Left atrium
Left ventricle Aorta

120 sys / 10 diast 120 sys / 80 dias

Stroke volume = ventricular end diastolic end systolic volume SV = EDV ESV ml In a healthy 70-kg man, EDV is 120 mL and ESV is 50 mL, giving a difference of 70 mL for the stroke volume. N = 55 - 100 ml Cardiac output CO = SV x HR N = 5 L/min


Ejection fraction is blood ejected by the ventricle relative to its filled volume (end diastolic volume) = measure ability of heart to eject blood EF = SV = EDV ESV % / min EDV EDV N = 55 to 70% / min

3 principle determinants SV: the degree of filling of the ventricle = preload the contractility myocard the resistance against which the ventricle has to work, or afterload = SVR Preload is the ventricular volume at the end of diastole. preload leads to an SV dependent on the return of venous blood from the body. Afterload is the resistance to ventricular ejection. = the resistance to flow in the systemic circulation and is the systemic vascular resistance (SVR). The resistance = the diameter of the arterioles & precapillary sphincters

The relationship between VEDV & SV = Starling's law of the heart = energy of contraction of the muscle is related/proportional to the initial length of the muscle fibre.

Mean pressure the average over each complete cardiac cycle. = average pressure that propels the blood to the tissues MAP = diastolic pressure + 1/3 pulse pressure N = 90-100mmHg.

Blood pressure - Force exerted by blood against a vessel wall

= cardiac output (CO) x systemic vascular resistance (SVR) N = 120 / 80 mmHg Blood pressure is controlled by: Sympathetic & parasympathetic nerves adrenaline, noradrenaline, renin, angiotensin, antidiuretic hormone (ADH, vasopressin), aldosterone and atrial naturietic factor (ANF).

ACE = Angiotensin I-converting enzyme

Blood Pressure Depends on Volume of blood forced into the vessel Compliance (distensibility/elasticity) of vessel walls
Systolic pressure Peak pressure exerted by ejected blood against vessel walls during cardiac systole (ventricular contraction) Averages 120 mm Hg Diastolic pressure Minimum pressure in arteries when blood is draining off into vessels downstream, lowest level of arterial pressure during ventricular cycle Averages 80 mm Hg

Dynamics of blood circulation involves: Pressure Flow Resistance Control mechanisms that regulate blood pressure Blood flow through vessels

The differences in BP within the vascular system = driving force - blood move from higher to lower pressure areas

Pulse pressure = systolic - diastolic N = 40 mmHg Increases when stroke volume or vascular compliance = a pulse to determine heart rate and rhythmicity Central venous pressure (CVP) = right atrial pressure = right ventricular end diastolic volume (preload) N = 3 8 mmHg = 5 10 cm H2O

Oxygen extraction
This oxygen extraction is determined by the ratio of oxygen consumption to coronary blood flow as described by the Fick Principle. Oxygen extraction : the difference between the arterial and venous concentrations of oxygen (CaO2-CvO2). Fick Principle = MVO2 = CBF (CaO2 CvO2) MVO2 = myocard O2 consumption CBF = coronary blood flow

Oxygen extraction

Closed system of vessels consists of:

Arteries - carry blood away from heart to tissues at high pressure Arterioles - smaller branches of arteries Capillaries Smaller branches of arterioles Smallest of vessels across which all exchanges are made with surrounding cells Venules Formed when capillaries rejoin Return blood to heart Veins Formed when venules merge Return blood to heart

15% of the circulating blood volume

70% of the circulating blood volume

Blood flow
Hagen-Poisseuille formula. flow rate: Driving pressure x Radius Length x Viscosity

Venous Return
is influenced by changes in position Venous pressure is driving force for return of blood to the heart. adequate blood return is aided by: Respiratory pump Muscular pump Valves prevent backflow during venous return

Capillary Network Blood flows from arterioles metarterioles - capillary network Venules drain network Smooth muscle in arterioles, metarterioles, precapillary sphincters regulates blood flow Capillary wall consists mostly of endothelial cells True capillaries exchange vessels Oxygen and nutrients cross to cells Carbon dioxide and metabolic waste products cross into blood

Capillary Exchange & Interstitial Fluid Volume Regulation Blood pressure, capillary permeability, & osmosis affect movement of fluid from capillaries A net movement of fluid occurs from blood into tissues bulk flow. Fluid gained by tissues removed by lymphatic system.

Exchange of Fluid between Capillaries &Tissues Distribution of fluid between plasma and interstitial compartments Is in state of dynamic equilibrium. Balance between tissue fluid and blood plasma.

Fisiologi Respirasi


Ventilasi Atmosfer ke alveolus Diffusi Alveolus ke darah Transport Oxygen carriage oleh darah Perfusi

Volume paru statik

1. spirometri Tidal volume Inspiratory reserve vol Expiratory reserve vol Inspiratory capacity = TV + IRV Vital capacity = IC + ERV 2. spirometri+analisis gas Residual vol Functional residual capacity = ERV + RV Total lung = VC + RV

Tekanan dalam sistem pernapasan

Tekanan interpleura
Permukaan luar paru - pleura visceralis Permukaan dalam thorak - pleura parieratalis Antara kedua pleura terdapat cairan sliding Tekanan cairan -10 cmH2O PPL = 6 10 = -4 cmH2O (-3 sd -5)

Inspirasi Tekanan intra-alveolar Tekanan intrapleural Perbedaan tekanan (Pressure Gradient) -3.0 mm Hg -6.0 mm Hg +3.0 mm Hg [ -3 - (-6) = +3 ]

Ekspirasi +3.0 mm Hg -3.0 mm Hg +6.0 mm Hg [ +3 - (-3) = +6 ]

Seluruh tekanan di tabel dibandingkan dengan atmospheric pressure pada lokasi manapun.

Daya kembang thorak dan daya recoil paru

Tegangan permukaan

Atmosfer ke alveolus
Udara atmosfer - 760 mmHg (1 atmosfer = 760mmHg = 101kPa = 15lbs/sq. in). 21% O2 78% Nitrogen CO2, argon and helium. Pada 37oC tekanan kelembaban air trachea : 47 mmHg PO2 trachea - breathing = (760-47) x 21/100 = 150 mmHg PO2 alveoli 100 mmHg Breathing = the removal O2 by the pulmonary capillaries and its continual supply by alveolar ventilation

O2 berdifusi dari alveolus ke kapiler sampai PO2 di kapiler = alveolus Difusi : gerak molekul gas dari tekanan tinggi ke rendah melalui membran semipermeabel

Alveolus ke darah

CO2 berdifusi dari kapiler paru ke alveoli O2 berdifusi dari alveoli ke kapiler paru

Ficks Law The diffusion of gas takes place according to Ficks Law: V gas = A x D x (P1 P2) T V gas = amount of gas diffuses from one point to another A = surface area D = diffusion constant P1 P2 = partial pressure difference T = thickness of the membrane

Tekanan relatif O2 dan CO2 di membran kapiler-alveolar

Venous Blood PvO2 = 40 mm Hg PvCO2 = 45 mm Hg Alveolar Gas PAO2 = 100 mm Hg PACO2 = 40 mm Hg Arterial Blood PaO2 = 100 mm Hg PaO2 = 40 mm Hg

V / Q ratio
Angka ini dari rasio rata-rata = laju ventilasi alveolar normal (4-6 liter/menit) curah jantung normal (5 liter/menit) Keadaan normal dari ventilasi dan perfusi paru-paru yang seimbang mendekati nilai 0,8-1,2. Nilai rata-rata rasio antara ventilasi terhadap perfusi (V/Q) = 0,13.

3 faktor dapat menyebabkan PO2 pulmonary veins < PAO2 alveolar: ventilation/perfusion mismatch shunt slow diffusion

VA / Q ratio

Ventilation/perfusion mismatch
Beberapa alveoli relatif overventilated sedang lain relatif over-perfused. Paru normal - some degree of ventilation/ perfusion mismatch Area atas relatif overventilated sedang area bawah relatif over perfused & under-ventilated.

Shunt sejati/ anatomis VA =0 Q =N V/Q = 0 unchanged PO2 (40 mmHg)

Penyebab: Atelektasis (kolaps alveoli) Konsolidasi paru Pulmonary edema

Ventilation without perfusion

Kebalikan extreme ventilation-perfusion mismatch = physiological dead space (ruang rugi) V =N Q =0 V/Q = kompensasi PaCO2 Penyebab : CO rendah tekanan intra-alveolar tinggi kompresi atau stretching kapiler alveolar (mechanically ventilated patients)


=N =N =N

Efek ruang rugi VA =N Q = tinggi V/Q = tinggi

Efek shunt VA Q V/Q

= rendah =N = rendah

Oxygen di darah
O2 dibawa dalam 2 bentuk Dengan Hb (figure 2b) Di plasma (kecil) Tiap gr Hb: 1.31 ml O2 - fully saturated. Tiap 100 ml darah - Hb 15g/dl membawa 20 ml O2 dg PO2 >100 mmHg = O2 capacity

O2 capacity : jumlah O2 yg terikat Hb scr max di 100 ml darah O2 content : jumlah O2 yg terikat Hb di 100 ml darah pada waktu tertentu (tidak maksimal) Saturation O2 (%): O2 content x 100% O2 capacity

3 faktor mempengaruhi adequacy O2 delivery ke jaringan - konsentrasi Hb - cardiac output - oxygenation

Oxygen delivery
Jumlah O2 yang dibutuhkan tubuh dalam satu menit = CO x arterial O2 content = 5000 ml blood/min x 200 mlO2/1000 ml blood = 1000 ml O2/min. O2 delivery (mls O2/min) = DO2 = CO (litres/min) x Hb concentration (g/litre) x 1.31 (mls O2/g Hb) x % sat

Oxygen consumption
250 ml O2 / min dipakai sewaktu istirahat (O2 consumption) = 25% arterial O2 / min. Hb mixed venous blood = 70% saturated (95% less 25%).

Oxygen stores
Principle stores of oxygen in the body While breathing AIR In the lungs (FRC) In the blood Dissolved or bound in tissues(FRC) Total 450ml 850ml While breathing 100% O2 3000ml 950ml





Transport CO2
Jaringan ke paru Bentuk:

Pusat : - Medula oblongata pons involunter - Cortex volunter Perifer : - Aferen - Eferen

Afferent Supply
(1) Central chemoreceptors cells in the floor of the 4th ventricle - acidity of CSF measured by the pH = jumlah ion H (2) Peripheral chemoreceptors. respond to O2 & CO2 concentrations in arterial blood from carotid body glossopharyngeal nerve (N IX) from the aortic body vagus nerve (N X) (3) Brain (4) Lung --> vagus wall of the bronchi - irritant elastic tissues of the lung and the chest wall stretch blood vessels - stretch

Efferent Supply
N phrenicus (N cervicalis 3-5) diafragma N. X - laryngeal and all pharyngeal muscles N. XI - sternocleidomastoid and trapezius muscles Segmental intercostal nerves vert TI and TI2 intercostal muscles Cervical plexus - accessory muscles in the neck