Far Eastern University NICANOR REYES MEDICAL FOUNDATION

Doctor of Medicine
2019
CARDIOLOGY: NORMAL AND ABNORMAL MYOCARDIAL FUNCTION
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

3 MAIN DETERMINANTS OF MYOCARDIAL MECHANICAL PERFORMANCE

1. Frank-Starling mechanism
2. Contractile state
3. Heart rate

FRANK-STARLING RELATIONSHIP

PRELOAD
- ventricular end diastolic fiber length
- end diastolic volume
- physiologically determined by the venous return, which in turn is
influenced by:
o Body position
o Intrathoracic pressure
o Intrapericardial pressure
o Venous tone - Factors that influences contractility:
o Pumping action of the skeletal muscles a. Adrenergic nerve activitY
- also influence by atrial contraction b. Circulating catecholamines
c. Force-frequency relationship
AFTERLOAD i. Bowditch staircase phenomenon or Treppe
d. Inotropic agents
- load that opposes shortening
e. Physiologic depressants
- determined by the aortic pressure (peripheral vascular resistance)
i. hypoxia, ischemia, acidosis
f. Pharmacologic depressants
ANREP EFFECT i. Ca antagonist, alcohol, anesthesis
- abrupt increase in afterload follows an increase in contractility g. loss of myocytes
- Laplace Law = pressure x radius / 2 x wall thickness
CONTRACTILITY

DETERMINANTS OF STROKE VOLUME

I. VENTRICULAR PRELOAD
a. Blood volume
b. Distribution of blood volume
i. Body position
ii. Intrathoracic pressure
iii. Inrapericardial pressure
iv. Venous tone
v. Pumping action of skeletal muscles
c. Atrial contraction
II. VENTRICULAR AFTERLOAD
a. Systematic vascular resistance
b. Elasticity of arterial tree
c. Arterial blood volume
d. Ventricular wall tension
i. Ventricular radius
ii. Ventricular wall thickness
III. MYOCARDIAL CONTRACTILITY
a. Intramyocardial (CA) ↑↓

lendldeoRNMAN
Page 1 of 2
 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: NORMAL AND ABNORMAL MYOCARDIAL FUNCTION
Alexander D. Ang MD, RFPCP, FPCC
Medicine 3A
Drkhkh

b. Cardiac adrergic nerve activity ↑↓ LOW OUTPUT VS HIGH OUTPUT HEART FAILURE
c. Circulating catecholamines ↑↓ - LOW OUTPUT HEART FAILURE
d. Cardiac rate ↑↓ o characterized by clinical evidence of impairment of
e. Exogenous inotropic agents ↑ peripheral circulation, with systemic vasoconstriction and
f. Myocardial ischemia ↓ cold, pale and sometimes cyanotic extremities
g. Myocardial cell death (necrosis, apoptosis, autophagy) ↓ - HIGH OUTPUT HEART FAILURE
h. Aterations of sarcomeric and sytoskeletal proteins ↓ o the extremities are warm and flushed, and the pulse
i. Genetic pressure is widened or at least normal
ii. Hemodynamic overload
i. Myocardial fibrosis ↓
CAUSES OF HEART FAILURE
j. Chronic overexpression of neurohormones ↓
k. Ventricular remodeling ↓ - Underlying Causes
l. Chronic and/or excessive myocardial hypertrophy ↓ o Ischemic heart disease is responsible for about three
quarters of all cases
o Cardiomyopathies
o Congenital, valvular, and hypertensive heart disease

- Precipitating Causes
o Infections
o Arrhythmias
o Physical, Dietary, Fluid, Environmental, and Emotional
Excesses
o Myocardial Infarction
o Pulmonary Embolism
o Anemia
o Thyrotoxicosis and Pregnancy
o Aggravation of Hypertension
o Rheumatic, Viral, and Other Forms of Myocarditis.
o Infective Endocarditis

HEART FAILURE

SYSTOLIC VS DIASTOLIC CONGESTIVE HEART FAILURE

- SYSTOLIC CONGESTIVE HEART FAILURE
o defect in expulsion of blood
- DIASTOLIC CONGESTIVE HEART FAILURE
o defect in ventricular filling

BACKWARD VS FORWARD HEART FAILURE

- BACKWARD HEART FAILURE
o ventricle fails to discharge its contents, blood accumulates
and pressure rises in the atrium an d the venous system
emptying into it
- FORWARD HEART FAILURE
o inadequate delivery of blood in the arterial system

RIGHT SIDED VS LEFT SIDED HEART FAILURE

- LEFT SIDED HEART FAILURE
o symptoms of pulmonary congestion predominates
- RIGHT SIDED HEART FAILURE
o systemic venous congestion predominates, ankle edema,
congestive hepatomegaly, ascites, pleural effusions

lendldeoRNMAN
Page 2 of 2