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Physiology of The Heart

M. Djauhari Widjajakusumah Departemen Fisiologi Fakultas Kedokteran Universitas Indonesia

Impulse Transmission AV delay AV node conduction: Penetrating portion of AV bundle: PR segment Atrial impulse conduction SA node Internodes AV node: PR interval

0.09 sec 0.04 sec


------------------------------------

0.13 sec 0.03 sec


------------------------------------

0.16 sec

Conduction Velocity Myocardium Atrium: Ventricle:

0.3 m/sec 0.5 m/sec 1 m/sec 0.02 m/sec 0.05 m/sec

Special Conducting System Internodal pathways: Transitional fibers: AV Node: Purkinje fibers (Bundles of His, terminal fibers):

1.5 - 4.0 m/sec

AV Node Slow Conduction Small cells Thin cell membrane slow conduction velocity Resting Em < Myocardium resting Em Small amplitude of action potential slow conduction velocity Few intercalated disc Great intercellular electrical resistance slow conduction velocity

Purkinje Fiber

Fiber diameter > myocardium diameter Conduction velocity > conduction velocity in myocardium
Smaller intercalated disc electrical resistance Conduction velocity > conduction velocity in myocardium

Refractory Period

Atrium Absolute refractory period 0.15 sec

Ventricle 0.25 - 0.30 sec

Relative refractory period

0.03 sec
------------------------------------

0.05 sec
--------------------------------------------------------------

0.18 sec

0.30 - 0.35 sec

Effects of [K+] on Cardiac Rate and Rhythm


Hyperkalemia Myocardium action potential: Lowers the resting membrane potential (resting Em ) Inactivates Na+ channels Na+ fast inward current action potential upstroke and amplitude slow conduction velocity widening of QRS complex the rate and extent of K+ channels accelerates repolarization shortens the plateau phase and duration of action potential peaked T waves slightly shortened Q-T interval Pacemaker (SA node) action potential: Lowers the resting membrane potential (resting Em ) phase 4 slope no change in sinus rate (heart rate)

Intrinsic and Extrinsic Control of Stroke Volume


Stroke volume + + Extrinsic control Strength of cardiac contraction +

Intrinsic control

Sympathetic activity (and epinephrine) Extrinsic control Vasoconstriction (veins) +

End-diastolic volume +

Intrinsic control

Venous return

Sherwood 2004: Human Physiology, From Cells to System 5th ed

Control of Cardiac Output


Peripheral resistance vasoconstriction arterioles + Heart rate _ + Stroke volume Extrinsic control + Contractility Intrinsic control Parasympathetic activity Sympathetic activity (and epinephrine) End-diastolic volume + Cardiac output + +

+
Extrinsic control
Sherwood 2004: Human Physiology, From Cells to System 5th ed

Intrinsic control + Venous return

Factors that Increase Cardiac Output


Cardiac output = Stroke Volume X Heart Rate SA Node

Cardiac muscle

End-Diastolic Volume

Epinephrine & Norepinephrine

Acetylcholine

Venous return

Adrenal Med & Sympathetic Nerve Activity

Parasympathetic Nerve Activity

Muscle Pump & Respiratory Pump

Cardio-Accelerator & Vasomotor Centers (Medulla)

Cardio-Inhibitory Center (Medulla)

Exercise

Stress

Low Blood Pressure

Autonomic Nervous System Effects on Mean Arterial Pressure


Parasympathetic stimulation Heart Heart rate Cardiac output Blood pressure

Sympathetic stimulation

Heart rate Heart Cardiac output Contractile strength of heart Stroke volume

Blood pressure

arterioles

vasoconstriction

Total peripheral resistance

Blood pressure

Veins

vasoconstriction

Venous return

Stroke volume

Cardiac output

Blood pressure

Sherwood 2004: Human Physiology, From Cells to System 5th ed

Blood Pressure : Neural Regulation


Blood Pressure Baroreceptors
output

Cardiovascular Centers
sympathetic output parasympathetic output

Blood Vessels
vasoconstriction

Heart
Heart Rate (SA Node) Stroke volume

Heart
Heart Rate (SA Node)

Blood Pressure

Blood Pressure : Hormonal Regulation


Baroreceptors In kidneys Secretion of renin Blood pressure Baroreceptors In arch of aorta & carotid sinuses. Output

Sensory nerve fibers

Blood Angiotensin II activated Adrenal Cortex Aldosterone released Blood Vessels vasoconstriction

Posterior pituitary ADH released

CV Center sympathetic output

Kidneys water reabsorption

Adrenal Medulla Epinephrine released

Kidneys water reabsorption


Blood pressure

Blood Vessels vasoconstriction

Heart
Heart rate (SA node) Stroke volume (Cardiac muscle)

Determinants of Mean Arterial Pressure


Mean arterial pressure

Cardiac output

Total peripheral resistance Stroke volume Arteriolar radius

Heart rate

Blood viscosity

Parasympathetic activity

Sympathetic activity and epinephrine

Venous return

Cardiac suction effect

Local metabolic control

Extrinsic vasoconstrictor control

Number of red blood cells

Blood volume

Respiratory activity

Skeletal muscle activity

Sympathetic activity and epinephrine

Vasopressin and angiotensin II

Passive bulk-flow fluid shifts between vascular and interstitial-fluid compartments

Salt and water balance

Vasopressin, reninangiotensin-aldosterone system

Pengukuran Tekanan Darah Arteri Secara Tidak Langsung Pada Manusia

Pengukuran Tekanan Darah A. Brakhialis Pd Sikap Berbaring Telentang 1. 2. Orang percobaan berbaring telentang dengan tenang selama 10 Selama menunggu, pasang manset sfigmomanometer pd lengan atas kanan OP.

Apa yang harus diperhatikan pada waktu memasang manset?


3. Carilah dengan palpasi denyut a. brakhialis pada fosa kubiti, dan denyut a. radialis pada pergelangan tangan OP.

Mengapa harus meraba letak denyut a brakhialis dan a. radialis?


4. Setelah OP berbaring 10, pompa manset sambil meraba a. radialis sampai tekanan di dalamnya melampaui tekanan sistolik .

Bagaimana Saudara mengetahui bahwa tekanan dalam manset telah melampaui tekanan sistolik?

Pengukuran Tekanan Darah A. Brakhialis Pd Sikap Berbaring Telentang

5.

Naikkan lagi tekanan dlm manset + 30 mmHg.

6.
7.

Letakkan stetoskop di fosa kubiti, di atas a. brakhialis


Turunkan tekanan dlm manset dgn kecepatan + 2-3 mmHg/dtk, sampai air raksa sfigmomanometer kembali ke 0, sambil mendengarkan bunyi pembuluh (bunyi Korotkow), serta tetapkan tekanan sistolik dan diastolik yang dibaca dari skala sfigmomanometer sesuai dgn bunyi Korotkow Ulangi prosedur ini 2-3 kali. Tiap kali mengulang pengukuran, tekanan manset harus diturunkan sampi 0.

8.

Fase-fase Bunyi Korotkow I. Bunyi seperti ketukan (tapping sound) yang makin lama makin jelas, terdengar sejauh + 10-14 mmHg. Tekanan saat mulai terdengarnya bunyi Korotkow 1 menandai tekanan sistolik.

II.
III. IV.

Bunyi pembuluh berkualitas ketukan bercampur bunyi desis, terdengar sejauh + 15-20 mmHg.
Bunyi yang jelas, tanpa desis, terdengar lebih keras dari Korotkow II; terdengar sejauh + 5-7 mmHg. Bunyi terdengar melemah, sejauh + 5-6 mmHg. Saat bunyi terdengar mulai melemah, menandai nilai tekanan diastolik metode lama (American Heart Association). Berakhir dengan hilangnya bunyi pembuluh. Fase saat bunyi hilang, menandai tekanan diastolik metode baru (AHA)

V.

Fase-fase Bunyi Korotkow


130 mmH 120 mmHg 110 mmHg 106 mmHg 100 mmHg 90 mmHg 84 mmHg 80 mmHg 78 mmHg 70 mmHg --------------------------------------------mulai terdengar bunyi K 1 tek sistolik

Korotkow I

Korotkow II
----------------------------------

Korotkow III Korotkow IV

84 mmHg: + awal Korotkow IV (bunyi mulai melemah) tek diastolik metode lama 78 mmHg: Korotkow V (bunyi hilang) tek diastolik metode baru.

Terima kasih