Cardiac output

 Describe the factors affecting CO.

Distinguish intrinsic and extrinsic CO regulation

Describe the variation in cardiac output in different

physiological conditions

List the methods of measuring CO and describe the

principles underlying the common methods
 Physiological factors affecting CO
 Age

 Less in the elderly

 Due to ↓ in HR and SV - body activity and mass of some tissues (e.g., skeletal
muscle) diminish

 Sex

 For young, healthy men, resting cardiac output averages about 5.6 L/min

 For women, this value is about 4.9 L/min

 Physiological factors affecting CO
 Exercise

 ↑ due to sympathetic stimulation

↑ HR

↑ contractility

↑ venoconstriction

may increase the cardiac output up to 700% depending upon the vigorousness of
exercise

 Pregnancy

 45–60% ↑ due to increase in ECF volume which increases blood volume

 Physiological factors affecting CO
 After eating

 ↑ due to ↑ metabolism up to 30%

 Posture

 Sitting or standing from lying down position may decrease the cardiac output
by 20–30%

 due to pooling of blood in the lower limbs

 Physiological factors affecting CO
 Diurnal variation

 In the early morning cardiac output is low

 ↑ in the day time depending upon the basal condition of the individual.

 Anxiety and excitement

 ↑ CO by 50–100%

 Due to sympathetic activity

 Physiological factors affecting CO
 Environmental temperature

 CO affected by extreme temperature changes

 A high environmental temperature is associated with an increase in CO

 High altitude

 ↑ at a high altitude due to release of adrenaline as a consequence to

hypoxia
 Pathological factors affecting CO
 Increase in cardiac output is seen in the following conditions:

Fever - due to increased oxidative processes

 Anaemia - due to hypoxia

Hyperthyroidism - due to increased metabolism

 Pathological factors affecting CO
 Decrease in cardiac output may occur in the following conditions:

 Rapid arrhythmias - due to incomplete filling

 Congestive cardiac failure - due to weak contractions of heart

 Cardiac shock - due to poor pumping and circulation

 Incomplete heart block - to defective pumping action of the heart

 Haemorrhage - because of decreased blood volume

 Hypothyroidism - due to decreased basal metabolism

 Cardiac output

 Describe the factors affecting CO.

Distinguish intrinsic and extrinsic CO regulation

Describe the variation in cardiac output in different

physiological conditions

List the methods of measuring CO and describe the

principles underlying the common methods
 Cardiac output
 CO can be measured using direct and indirect methods

 Direct methods include placement of electromagnetic flow meter in

ascending aorta or by using a cardiometer
 Indirect methods used alternatively;

 Methods based on Fick’s principle

 Indicator or dye dilution method

 Thermodilution method

 Doppler technique echocardiography

 Fick’s method
 The Fick’s principle states that the amount of a substance taken up by an
organ (or by the whole body) per unit of time is equal to the arterial level
of the substance (A) minus the venous level (V) times the blood flow (F),
i.e.

 Q = (A − V) F

 This principle is applicable only in situations in which the arterial blood is

the sole source of the substance taken up
 Fick’s method
 In this method CO is determined by measuring the pulmonary blood flow:

 Pulmonary blood flow/min= right ventricular output.

 Right ventricular output = left ventricular output (cardiac output).

 Measurement of pulmonary blood flow can be made by;

 measuring the amount of O2 taken by the blood from the lungs

 O2 concentration of the venous blood from pulmonary artery (PAO2)

 O2 concentration of the arterial blood from the pulmonary vein (PVO2)

 Fick’s method
 Amount of O2 uptake/min is determined with the help of a spirometer,

 PAO2 is measured from the venous blood sample taken from the pulmonary
artery directly with the help of a cardiac catheter.

 The cardiac catheter is inserted into a vein at the forearm and is then guided up
under fluoroscopic control through the venous channels into the right atrium, right
ventricle and pulmonary artery.

 PVO2, because of practical difficulty in taking sample from pulmonary vein, is

measured from the arterial blood sample taken from any peripheral artery, e.g.
brachial artery
 Fick’s method
 According to Fick’s principle;
 Fick’s method
 Disadvantages of Fick’s principle

 It is an invasive technique, so there are risks of infection and haemorrhage.

 The cardiac output estimated may be higher than normal as the patient
becomes conscious of the whole technique.

 A fatal complication like ventricular fibrillation may occur if the indwelling

catheter irritates the ventricular walls, especially when the cardiac output is
being measured during heavy exercise.
 Indicator or dye dilution method
 Principle

 A known amount of the dye is injected into a large vein or preferably into the
right atrium by cardiac catheterisation.

 By its passage through heart and pulmonary circulation it will be evenly

distributed in the blood stream.

 Its mean concentration during the first passage through an artery can be
determined from the successive samples of blood taken from the artery.
 Indicator or dye dilution method
 The blood flow in litres/min (F) is given by the following formula;
 Indicator or dye dilution method
 Prerequisites for an ideal indicator

 It should be non-toxic

 It must mix evenly in the blood

 It should be relatively easy to measure its concentration

 It should not alter the cardiac output or haemodynamics of blood flow

 Either it must not be changed by the body during mixing period or the amount
changed must be known.

 The dye commonly used in humans for determining the cardiac output is Evans blue
(T-1824) or radioactive isotopes.
 Indicator or dye dilution method
 Procedure

 A few ml of venous blood is withdrawn from the a peripheral vein and it is mixed with
5 mg Evans blue dye.

 The blood containing dye is then injected rapidly into the vein

 Serial samples of the arterial blood from the brachial artery are taken every 2 s and
the dye concentration is determined

 When the dye concentration is plotted as a function of time, a curve is obtained.

 The curve shows that the dye concentration reaches a peak and then steadily
declines only to rise again (CD part of the curve) owing to recirculation of the dye
Indicator or dye dilution method
 Indicator or dye dilution method
 Procedure

 Time duration of first passage of dye through the artery (t) is determined by the
extrapolation of the descending limb (BC) of the curve to the time scale axis.

 The point (E) on the time scale where the extrapolated limb meets it, tells the time
(AE) of first circulation of dye in seconds.

 The mean concentration (C) of the dye is determined by representing the triangle
area ABE as a rectangle AEFG with same area and one of its arm being AE.

 The height of the rectangle (AG) tells the mean concentration (C) of dye

 Calculation made
Indicator or dye dilution method
 Thermodilution method
 Principle

 It is also an indicator dilution technique in which instead of a dye, ‘cold saline’ is used as
an indicator.

 The CO is measured by determining the resultant change in the blood temperature in the
pulmonary artery

 A known volume of sterile cold saline is then injected into the inferior vena cava.

 Temperature of the blood entering the heart from the inferior vena cava and that of the
blood leaving the heart via pulmonary artery is determined by the thermistors.

 Change in temp. is inversely proportional to blood flowing through pulmonary artery

 Echocardiography
 refers to the ultrasonic evaluation of cardiac functions.

 It is a noninvasive technique that does not involve injections or insertion of a catheter.

 It involves ultrasound at a frequency of 2.25 MHz using a transducer which also acts as a
receiver of the reflected waves.

 The recording of the echoes displayed against time on an oscilloscope provides a

record of:

 The movement of the ventricular wall and septum, and valves during the cardiac
cycle.

 When combined with the Doppler techniques, echocardiography can be used to

measure velocity and volume of flow through the valves.

 it is particularly useful in evaluating EDV, ESV, CO and valvular defects

Cardiac output