CARDIOVASCULAR SYSTEM

CARDIAC PERFUSSION
(CORONARY CIRCULATION )

I Made Muliarta
 CARDIAC PERFUSSION
THE BLOOD FLOW TO THE ALL CARDIAC
PART
EPICARDIUM, MYOCARDIUM, ENDOCARDIUM

THE HEART WORK CONTINUOUSLY :

REST, SLEEP, OR EXCERCISES.,

CONTROL OF CORONARY BLOOD FLOW IS

VERY IMPORTANT:
CONSTANT CORONARY BLOOD FLOW
PIERMARIO MOROSINI
Sudden death during
exercise
 WAMEN MENINGGAL
WAMEN ESDM: MENINGGAL SAAT
MENDAKI GUNUNG TAMBORA,
DIDUGA SERANGAN JANTUNG
MENGAPA BEGITU?
- TEKANAN O2 RENDAH
- SUHU UDARA DINGIN
- USIA 61 TH (SUDAH BIASA MENDAKI
GUNUNG)
 CARDIAC FUNCTION
TO CIRCULATION OF BLOOD TO ALL
CELL OF THE BODY
CARIEED ON: O2, NUTRITION
REMOVE: CO2, WASTE MET.
PRODUCTS
MAINTENANCE OF BODY
TEMPERATURE
CIRCULATION OF HORMON
 Coronary circulation: blood circulation
of the heart muscle (myocardium)
The vessels that deliver oxygen-rich
blood to the myocardium are known as
coronary arteries.
The vessels that remove the
deoxygenated blood: cardiac veins.
 Left and right coronary arteries run
on the surface of the heart:
epicardial coronary arteries.
These arteries, when healthy, are
capable of autoregulation to
maintain coronary blood flow at
levels appropriate to the needs of
the myocardium.
The coronary arteries are classified
as "end circulation:represent the
only source of blood supply
 Coronary circulation: the left main
coronary and the right main coronary
artery
The left main coronary: left anterior
descending and circumflex branches
Originate at the base of the aorta from
openings called the coronary ostia
located behind the aortic valve leaflets.
 The left and right coronary arteries and their branches
lie on the surface of the heart, and therefore are
sometimes referred to as the epicardial coronary
vessels.
These vessels distribute blood flow to different regions
of the heart muscle.
Normally: low vascular resistance vascular
As in all vascular beds, it is the small arteries and
arterioles in the microcirculation that are the primary
sites of vascular resistance, and therefore the primary
site for regulation of blood flow.
 The arterioles branch into numerous
capillaries that lie adjacent to the cardiac
myocytes.
A high capillary-to-cardiomyocyte ratio and
short diffusion distances ensure adequate
oxygen delivery to the myocytes and
removal of metabolic waste products from
the cells (e.g., CO2 and H+).
 Capillary blood venules cardiac
veins coronary sinus (posterior side of
the heart) right atrium.
Anterior cardiac veins and thesbesian
veins cardiac chambers.
Correlation with ECG, verified by
coronary angiograms or other
imaging techniques.
 Important features of
coronary blood flow:
Flow is tightly coupled to oxygen demand.
This is necessary because the heart has a very high
basal oxygen consumption (8-10 ml O2/min/100g) 20-fold
higher than that of skeletal muscle and the highest A-VO2
difference of a major organ (10-13 ml/100 ml).

oxygen extraction so that 7080% of the

arterially delivered oxygen is extracted,
compared with 3040% in skeletal muscle
 Important features of
coronary blood flow:
Coronary perfusion pressure changes due
to changes in aortic pressure.
Adenosine is an important mediator of
active hyperemia and autoregulation. It
serves as a metabolic coupler between
oxygen consumption and coronary blood
flow.
Nitric oxide is also an important regulator of
coronary blood flow.
 Important features of
coronary blood flow:
Activation of sympathetic : transient
vasoconstriction mediated by 1-adrenoceptors.
Followed by vasodilation caused
vasodilator metabolites (active hyperemia) : 1-
adrenoceptor
functional sympatholysis
Parasympathetic stimulation of the heart :
coronary vasodilation (acetylcholine release)
myocardial oxygen demand due to a reduction
in heart rate, then intrinsic metabolic
mechanisms will increase coronary vascular
resistance by constricting the vessels.
 Progressive ischemic coronary artery disease
results in the growth of new vessels (termed
angiogenesis) and collateralization.
Extravascular compression during systole
markedly affects coronary flow; therefore, most
of the coronary flow occurs during diastole.
Tachycardia there is relatively less time
available for coronary flow during diastole to
occur
 In the presence of coronary artery disease,
coronary blood flow may be reduced.
hypoxia and angina.
Atherosclerosis: improved within that vessel
by
placing a stent within the vessel to expand the
lumen,
using an intracoronary angioplasty balloon to
stretch the vessel open
bypassing the diseased vessel with a vascular
graft.
Blood clot (thrombosis) a thrombolytic drug
Vasospasm vasodilators (nitrodilators,
calcium-channel blockers)
 Coronary Blood Flow
Changes in diastole
During systole, the subendocardial
coronary vessels (the vessels that enter
the myocardium) are compressed .
Epicardial coronary vessels remain
patent
Most myocardial perfusion occurs
during diastole
Change in Oxygen demand
The heart regulates the amount of vasodilation
or vasoconstriction of the coronary arteries
based upon the oxygen requirements of the
heart.
Failure of oxygen delivery caused by a decrease
in blood flow in front of increased oxygen
demand of the heart results in tissue ischemia
In addition to metabolism, the coronary
circulation possesses unique pharmacologic
characteristics.
 CORONARY BLOOD FLOW
VIEW AMOUNT DURING VENTRICLE SYSTOLE:
THE BLOOD FROM LEFT VENTRICLE FAST FLOW
THROUGH AORTIC VESSEL
DURING SYSTOLE, CARDIAC MUSCLE CONTRACTION

MORE AMOUNT DURING VENTRICLE DIASTOLE:

THE BLOOD FLOW BACK TO THE VALVE AND THE
CORONARY ARTERY
CARDIAC MUSCLE DILATATION, CORONARY ARTERY
OVEN
 CORONARY BLOOD FLOW
CORONARY BLOOD FLOW DILIVERED TO
THE CARDIAC MUSCLE, 225 ML/MIN

CORONARY BLOOD FLOW DECREASED

DURING MUSCLE CONTRACTION
(SYSTOLE) ESPECIALY IN THE
SUBENDOCARDIAL VESSELS

DURING EXERCISE : INCREASE FOR 3-4

TIME
 CONTROL OF
CORONARY BLOOD FLOW

1. LOCAL METABOLISM (MORE

IMPORTANT),

2. NERVE:
- SYMPATHIS NERVE: CERVICAL
- PARASYMPATHIS NERVE : VAGAL
NERVE
 LOCAL METABOLISM
LOCAL METABOLISM , RELEASE OF
VASODILATOR FACTORS:
- ADENOSINE,
- ADENOSINE PHOSPHATE COMPOUNDS,
- POTASIUM ION,
- HYDROGEN ION,
- CO2,
- BRADYKININ,
- PROSTAGLANDINS,
 NERVE CONTROL
SYMPATHIS NERVE: CERVICAL
ALFA RESEPTOR: CONTRICTION
BETHA RESEPTOR: DIALATION
SUBENDOCARDIAL

PARASYMPATHIS NERVE : VAGAL

NERVE
 MYOCARDIAL PERFUSION
TEST
MYOCARDIAL PERFUSION IMAGING
TEST:

ADMINISTRATERED OF RADIOACTIVE
THALLIUM TO THE HEART
INDICATOR OF MYOCARDIAL BLOOD
FLOW
 Pemendekan PR interval
Dromotropicity positive saat exercise
Myocardial ischemia angina pectoris
Inotropik, kronotropik
 Blood supply to the heart
Coronary circulation
2 main arteries: left and right coronary arteries
Each artery originates from an ostium or opening in the
wall of the aorta, at a point that is just above the aortic
valve
Two majaor branches left main artery: circumflex branch
(serving the lateral posterior wall of the heart) and the
anterior interventricular (or anterior descending) branch
The right coronary artery supplies most of the right
ventricle, as well as the posterior side of the heart in 80-
90% of people
Venous blood flow drain into a very large vein (coronary
sinus)
 Unique feature coronary blood flow
Large amount oxygen extracted by myocardium
Resting: 25%-30% peripheral organ vs 75%
myocardium
Cardiac work increases during exercise , the
demand for increased oxygen is not satisfied by
big increases in O2 extraction
During exercise: coronary blood flow increases
from 250 ml/mnt at rest to 1000 ml ata max
execise
 Chest discomfort during exercise:
Blockage coronary arteries: blood,
oxygen, nutrients are blocked to
myocardium
Myocardial ischemia: temporary, during
activity need more oxygen demand
 Venous return:
during maximal exercise, incresaing
venous return increasing COP (30
L/mnt)
Muscle pump, Respiratory pump and
abdominal pump, venoconstriction
(Controlled by Sympathetic nervous
system)
 Increase HR and Decrease SV due to body
temperature and plasma volume
The increase in cutaneous blood flow helps
lessen, through conduction, convection,
evaporation the increase in body core
temperature less blood is returned to the
heart
During exercise, fluid moves from the blood
into the surrounding cells and tissue less
blood is returned to the heart: need fluid intake
 Post exercise hypotension: 10-12
mmHg below resting systolic value
and 5-7 mmHg below resting
diastolic value
Can remain up to 4 hours after
exercise
 Tasks:
Describe the blood vessels that supply the heart
Describe some features of coronary circulation
Explain about functional sympatholysis
What are the respons of the heart during exercise
List of the coronary arteries that supply some areas
of the heart