Sie sind auf Seite 1von 25

Coronary Circulation

and its Regulation


SUFYAN AKRAM
M B BS P h D

Lesson outcomes
Explain haemodynamic basis of fluctuation in
coronary blood flow in the left and right
ventricles during a cardiac cycle
Describe neural and chemical control of
coronary blood flow
Explain the interaction between systemic
regulatory mechanisms (sympathetic nervous
system) and the local auto-regulatory
mechanisms (metabolites) in the control of
coronary blood flow

Introduction
About one third of all deaths in industrialized
countries of the Western world result from
coronary artery disease, and almost all elderly
people have at least some impairment of the
coronary artery circulation
For this reason, understanding normal and
pathological physiology of the coronary
circulation is one of the most important subjects
in medicine

Special features of coronary circulation


O2 extraction from the blood by the myocardium
is near maximum even at rest. There are high
levels of oxygen extraction (6575%), compared
with the average for the whole body (25%), and
during exercise, extraction rates rise to 90%
The coronary circulation has the shortest transit
time (only 68 seconds) and has a very high
density of capillaries, approximately one per
myocyte, which are all perfused continuously
Therefore the only way to supply more O2 when
the O2 demand of the myocardium increases is
by increasing the coronary blood flow

Blood flow in major organs


Organ

%
% cardiac
body
output @
weigh rest
t

Normal flow

Maximal flow

(ml/min per
100 g)

(ml/min per
100 g)

Heart

0.5

80

400

Brain

14

55

150

40

18

60

10

150

0.5

20

400

600

Skeleta
l
muscle
Skin
Kidney
s

Autonomi
c Nervous
System
(direct
and
indirect
effects)

Local

Pressure
changes
in
Ventricula
r walls
during
Cardiac
Cycle

Neural

Haemodynamic

Regulatory Mechanisms
Myocardi
al Oxygen
demand
and Local
Metabolit
es

Haemodynamic
Coronary capillary blood flow in the ventricle
muscle falls to a low value during systole, which
is opposite to flow in vascular beds elsewhere in
the body. The reason for this is strong
compression of the left ventricular muscle
around the intramuscular vessels during systolic
contraction
During diastole, the cardiac muscle relaxes and
no longer obstructs blood flow through the left
ventricular muscle capillaries, so blood flows
rapidly during all of diastole

Haemodynamic
Blood flow through a particular segment of
coronary artery depends on the gradient
between the aortic pressure and that segment
of the coronary artery
The intra-ventricular pressure decreases
progressively as it moves away from the point of
application, compressing maximally the
endocardial arteries and minimally the
epicardial arteries

Note the inverse


relationship of coronary
blood flow to the aortic
pressure
Blood flow through the
coronary capillaries of the
right ventricle also
undergoes phasic
changes during the
cardiac cycle, but
because the force of
contraction of the right
ventricular muscle is far
less, the inverse phasic
changes are only partial

10

Neural
Stimulation of the autonomic nerves to the
heart can affect coronary blood flow both
directly and indirectly
The direct effects result from action of the
nervous transmitter substances acetylcholine
from the vagus nerves and norepinephrine and
epinephrine from the sympathetic nerves on the
coronary vessels themselves.
Indirect effects result from secondary changes
in coronary blood flow caused by increased or
decreased activity of the heart

11

Neural
Parasympathetic
stimulation

Sympathetic
stimulation

Cardiac Muscle

HR,
Contractility

HR,
Contractility

Coronary
Vessels

Dilated (weak
effect)

Constricted ()
Dilated (2)

12

1 and 2
Receptors in
Ventricles

Indirect
Effects:
Vasodilation
of Coronary
Arteries

HR
Force
of
Contractio
n

Sympathetic

How?

Direct Effects:
Vasoconstricti
on of
Coronary
Arteries

Receptors in
Coronaries

Vasoconstric
tion

Receptors in
Coronaries

Vasodilation

13

Neural
The indirect effects, which are mostly opposite
to the direct effects, play a far more important
role in normal control of coronary blood flow
Thus, sympathetic stimulation increases both
heart rate and heart contractility and increases
the rate of metabolism of the heart. In turn, the
increased metabolism of the heart sets off local
blood flow regulatory mechanisms for dilating
the coronary vessels, and the blood flow
increases approximately in proportion to the
metabolic needs of the heart muscle

14

Autoregulation
The capacity of tissues to regulate their
own blood flow
Well developed in the:
Heart (myocardium)
Brain
Kidneys
Exercising skeletal muscles

Theories of autoregulation:
Myogenic theory
Metabolic theory

15

Local (Autoregulation)
Blood flow through the coronary system is
regulated mostly by local arteriolar vasodilation
in response to the nutritional needs of cardiac
muscle
That is, whenever the vigor of cardiac
contraction is increased, the rate of coronary
blood flow also increases
Blood flow in the coronary arteries usually is
regulated almost exactly in proportion to the
need of the cardiac musculature for oxygen

16

Local (Autoregulation)
The exact means by which increased oxygen
consumption causes coronary dilation has not been
determined
It is speculated by many research workers that a
decrease in the oxygen concentration in the heart
causes vasodilator substances to be released from the
muscle cells
A substance with great vasodilator propensity is
adenosine
In the presence of very low concentrations of oxygen in the
muscle cells, a large proportion of the cells ATP degrades to
adenosine monophosphate; then small portions of this are further
degraded and release adenosine into the tissue fluids of the
heart muscle, with resultant increase in local coronary blood flow

17

Local (Autoregulation)
Adenosine is not the only vasodilator product
that has been identified
Other Vasodilator Metabolites (VDMs) include
adenosine phosphate compounds, potassium
ions, hydrogen ions, carbon dioxide,
prostaglandins, and nitric oxide

18

Overall effect
Sympathetic activity directly causes coronary
vasoconstriction; at the same time, it causes
increased heart rate and contractility raising
cardiac work and metabolism
Increased production of vasodilator metabolites
(VDMs)
The effect of VDMs eventually overcomes the
direct coronary vasoconstrictor effect of
sympathetic nervous system
Thus the net effect of sympathetic activity is
coronary vasodilation secondary to increased
metabolic activity
19

Metabolic factors are the major controllers of


myocardial blood flow. Whenever the direct
effects of nervous stimulation alter the coronary
blood flow in the wrong direction, the metabolic
control of coronary flow usually overrides the
direct sympathetic coronary effects within
seconds

20

Ischaemic Heart
Disease

21

Ischemic Heart Disease


If blood flow to the heart through the coronary
vessels is reduced or the oxygenation of the
blood is insufficient, then the heart muscle will
be damaged. Over two- thirds of deaths from
coronary artery disease occur outside hospitals,
with few prior symptoms and often no warning.
The two most common manifestations of
ischaemic heart disease are angina and
myocardial infarction
The major factor in the development of
ischaemic heart disease is the narrowing of the
coronary arteries by the formation of atheroma

22

Coronary angiography
Coronary angiography
involves the injection of a
radiocontrast dye into
the left and right
coronary arteries. X-ray
images are taken from
various angles in order to
observe fully any
narrowings. This
information may be
useful in assessing the
degree toShows
whichthe
vessels
anatomy of
may be narrowed
coronary vessels

23

Doppler ultrasonography
A non-invasive
alternative, Doppler
ultrasonography,
measures the direction
and speed of blood flow
and has more commonly
been used to evaluate
the degree of impairment
in patients with heart
failure. It can also be
used to evaluate blood
flow in the coronary
vessels.

Shows the flow of


blood in coronary
vessels
24

Thank you

SufyanAkram@imu.edu.m
y
DID: 03 2731 7480
Ext: 2773
Faculty area 2 @ Level
2

25