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Cardiac Cycle
1. Ventricular Systole - Isovolumetric contraction - Ventricular ejection
2. Ventricular Diastole - Isovolumetric ventricular relaxation - Ventricular filling: Rapid inflow Diastasis Atrial systole
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Systolic
Diastolic1. 심실 , 심방 , 동맥내 압력 .2. 심실내 용적변화 .3. 판막의 여닫힘 시기 .4. 심음 , EKG .
CheckpointsBP
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Ventricular volume change during cardiac cycle
- Ejection fraction = SV/EDV : 50 - 60 % 심실근 수축성의 지표
EDV
ESV
SV
- Stroke Volume (SV) = EDV - ESV
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심음 청진 부위
• Normal Heart Sound: S1, S2, (S3)
• Abnormal Heart Sound (Murmur) - timing: systolic/diastolic/continuous - area
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심근수축의 기본 형태
AfterloadPreload
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Preload dependenceEDV 에 해당 , venous return 에 의해 결정됨 .
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Afterload : Aortic Pressure 에 해당
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심장의 작업곡선근수축의
길이 - 장력 관계(length-tension)
심장에서는압력 - 용적 관계(pressure-volume)
로 나타냄
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Animal Experiment Animal Experiment Measurement with Conductance CatheterMeasurement with Conductance Catheter
LV volume
LV pressure
LV volume
LV p
ress
ure
End diastole
End systole
LV p
ress
ure
LV pressure-volume loop
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Regulation of myocardial performance
Intrinsic regulation (autoregulation) - Frank-Starling mechanism - Rate-induced regulation
Extrinsic regulation - Autonomic nervous system - Endocrine control : adrenal medullary hormone thyroid hormone, insulin, glucagon - 기타 : PO2, PCO2, pH
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The effect of increasing preload
LV p
ress
ure
LV volume
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• 용적부하 (preload)증가에 따른 반응
• 압력부하 (afterload)증가에 따른 반응
심장의 자동조절 기전 : Frank-Starling 기전
SV EDV SV
EDV SV
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Contractility Indices
ejection ejection fractionfraction
peak dP/dtpeak dP/dt
systolic systolic ejection rateejection rate
contractilitycontractility
dP/dt/DPdP/dt/DP
Heart Disease, Braunwald, 5th edition
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Heart
Heart
Vagus nerve Muscarinic receptor
-adrenergic receptor
Dorsal motor nucleus(cardioinhibitory center)
Autonomic Nervous Control
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Vagal stimulation
Sympathetic stimulation
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Effect of autonomic nerve stimulation on SAN
Sympathetic stim.
Parasympathetic stim.
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Left RightSympatheticparasympathetic
SVConduction velocity
SV HRHR
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Effect of Autonomic Nervous System
sympathetic parasympathetic
Atrial myocardium
AV Node
SA Node
Ventricular myocardium
Positive chronotropicPositive inotropic
Negative chronotropicNegative inotropic
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Signal transduction of ion channel regulationby autonomic stimulation
sympathetic parasympathetic
Phospholylation of ICa & If Activation of IKACh
-adrenergic receptor
Adenylyl cyclase
cAMP
Protein kinase A
muscarinic receptor
Gs protein Gi protein_
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Ion Channel Mechanism of Nervous System
sympathetic parasympathetic
Atrial myocardium
AV Node
SA Node
Ventricular myocardium
ICa If
ICa
ICa
IKACh ICa
IKACh ICa
IKACh ICa
Na pump
ICa If
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Contractility 증가
교감신경 흥분의 수축력에 대한 효과
교감신경 흥분 , Ca 농도 증가 등의 조건에서 수축력 증가
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CardiacOutput
Heart Rate
MyocardialContractility
Pleload
Afterload
Cardiac factors Coupling factors
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Regulation of the heartbeat
- Baroreceptor reflex- Bainbridge reflex- Chemoreceptor reflex
- Respiratory sinus arrhythmia- Effect of blood or electrolyte solution infusion
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Coronary circulation
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extracoronary resistance
- squeezing effect of the contracting myocardium - left coronary flow : early ventricular systole 에 reverse; early diastole 에 최대
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Autoregulation 발달 - change of perfusion pressure : blood flow 비교적 일정하게 유지 - metabolic demands 증가 vasoactive metabolites released from myocardium coronary resistance 감소 - adenosine hypothesis 가 가장 유력
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Ischemic Heart Disease
관상동맥 막힘
Ischemia( 허혈 ), Infarction( 경색 )
세포내 ATP 감소
KATP Channel 의 활성화
활동전압 duration 짧아짐 , K 의 유출로 세포밖 K 농도 증가
수축 감소로 energy saving 의 효과 (cardioprotective) 동시에 부정맥 발생 위험 증가 (arrhythmogenic)
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Heart Failure- 정의 : Pumping capability of the heart is impaired to the point that the tissues of the body are not adequately perfused.- Acute or Chronic
- In chronic H. F., fluid retention (hypervolemia)
is accompanied. (GFR aldosterone 분비 )
right shift of vascular function curve
C.O 은 정상일 수도 있음 Fig.29-12
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Fig. 29-9Fig. 29-10
The effect of sympathetic stimulation on the equilibrium value of cardiac output and central venous pressure
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Effect of cholinergic blocker (atropine) and adrenergic blocker (propranolol) on heart rate
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Respiratory sinus arrhythmia : inspiration - HR (vagal activity ) expiration - HR (vagal activity )
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Respiratory Center
Change inintrathoracic
pressure
Change invenous return
Bainbridge reflex
Heart Rate
Change inlung volume
(stretch receptor)
Change inArterial pressure
Baroreceptor reflex
CardiacVagal Center
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Intravenous infusion
Right atrial pressure
Atrial receptor stimulated
Bainbridge reflex
Heart Rate
Cardiac output
Arterial pressure
Baroreceptor reflex
+ _
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Cardiac Output (C.O) = Stroke Volume (ml) x Heart Rate (/min)
Fig. 29-16
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Left and Right Heart (Systemic vs. Pulmonary)
Fig. 24-19Fig. 29-14
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Fig. 29-9Fig. 29-10
The effect of sympathetic stimulation on the equilibrium value of cardiac output and central venous pressure