Lecture 14

Learning objectives
 Factors maintaining cardiac out put
 Definition of heart failure and its causes
 Compensatory mechanisms in heart failure

FACTORS MAINTAINING CARDIAC OUTPUT

Cardiac output is maintained (determined) by four factors:
1. VENOUS RETURN
Venous return is the amount of blood which is returned to heart from different
parts of the body. When it increases, the ventricular filling and cardiac output
are increased. Thus, cardiac output is directly proportional to venous return,
provided the other factors (force of contraction, heart rate and peripheral
resistance) remain constant.
Venous return in turn, depends upon the following factors:
A- Respiratory Pump
Respiratory pump is the respiratory activity that helps the return of blood, to
heart during inspiration. It is also called abdominothoracic pump. During
inspiration, thoracic cavity expands and makes the intrathoracic pressure more
negative and this negative pressure increases the diameter of inferior vena
cava, resulting in increased venous return. At the same time, descent of
diaphragm increases the intra-abdominal pressure, which compresses
abdominal veins and pushes the blood upward towards the heart and thereby
the venous return is increased.
B- Muscle Pump
Muscle pump is the muscular activity that helps in return of the blood to
heart. When muscular activity increases, the venous return is more.
C- Gravity
Gravitational force reduces the venous return. When a person stands
for a long period, gravity causes pooling of blood in the legs, which is
called venous pooling. Because of venous pooling, the amount of
blood returning to heart decreases.
 D- Sympathetic Tone
Venous return is aided by sympathetic or vasomotor tone which
causes constriction of venules. Venoconstriction pushes the blood
towards heart.

2. FORCE OF CONTRACTION
Cardiac output is directly proportional to the force of contraction, provided
the other three factors remain constant.
According to Frank-Starling law, force of contraction of heart is directly
proportional to the initial length of muscle fibers before the onset of
contraction.
This law states that when there is an increased quantities of blood into the
ventricles, this stretches the walls of the heart chambers. As a result of the
stretch, the cardiac muscle contracts with increased force to empty the
expanded chambers.
Factors that affects the force of contraction of the heart
1- Preload
is the stretching of the cardiac muscle fibers at the end of diastole, just
before contraction and this stretching is due to increase in ventricular
pressure caused by filling of blood during diastole. Stretching of muscle
fibers increases their length, which increases the force of contraction
and cardiac output. Thus, force of contraction of heart and cardiac
output are directly proportional to preload.
2- Afterload
is the force against ventricular contraction and blood ejection. The
afterload is determined by the arterial pressure. The afterload for left
ventricle is determined by aortic pressure and afterload for right
ventricular pressure is determined by pressure in pulmonary artery.
The force of contraction of heart and cardiac output are inversely
proportional to afterload.
3- Sympathetic nerve supply
The resting cardiac sympathetic tone increases the force of contraction
then increases the cardiac output to 13-15 litres/minute, and maximal
sympathetic stimulation (e.g. in severe muscular exercise) increases the
cardiac output to about 25 litres/ minute.
 4- Ventricular hypertrophy
This may normally occur in some athletes as a result of prolonged
strenuous exercises, and it can increase the force of contraction of the
heart and the cardiac output.
pathological conditions causing ventricular hypertrophy are:
 aortic stenosis
 hypertension
 hypertrophic cardiomyopathy.

3. HEART RATE
Cardiac output is directly proportional to heart rate provided, the other
three factors remain constant. Moderate change in heart rate does not
alter the cardiac output. If there is a marked increase in heart rate, cardiac
output is increased. If there is marked decrease in heart rate, cardiac
output is decreased.
4. PERIPHERAL RESISTANCE
is the resistance offered to blood flow at the peripheral blood vessels. the
cardiac output is inversely proportional to peripheral resistance. Resistance
is highest at the arterioles so, the arterioles are called resistant vessels.
HEART FAILURE
Heart failure or cardiac failure is the inability of the heart to pump
sufficient amount of blood to all parts of the body.
Heart failure may involve left ventricle or right ventricle or both. It may be
acute or chronic.
Congestive Heart Failure
Congestive heart failure is a general term used to describe the heart failure
resulting in accumulation of fluid in lungs and other tissues causing fluid
retention and pulmonary edema.
CAUSES OF HEART FAILURE
Common causes of heart failure are:
1. Coronary artery disease
2. valvular heart disease
3. Arrhythmia
4. Cardiac muscle disease such as cardiomyopathy
5. Hypertension
6. Congenital heart disease
7. Hyperthyroidism
8. Anemia
9. Inflammation of cardiac muscle (myocarditis) due to viral infection,
drugs, alcohol, etc.
 TYPES OF HEART FAILURE
1. Systolic Heart Failure ( Heart failure with reduced ejection fraction )
Is the heart failure that occurs when systolic function of the heart is
impaired secondary to weak ventricular contraction. Both of the stroke
volume and ejection fraction are reduced. The end-systolic ventricular
volume is increased.
2. Diastolic Heart Failure ( Heart failure with preserved ejection fraction )
is the heart failure that occurs when the ventricles cannot relax
properly due to the stiffening of cardiac muscle.There is reduction in
ventricular filling, stroke volume and the cardiac output.
3. Right Sided Heart Failure
It occurs due to loss of pumping action of the right side of the heart.
Because of loss of pumping action of right ventricle, blood accumulates
in right atrium and blood vessels. It causes edema in the feet, ankles,
legs and abdomen.
4. Left Sided Heart Failure
is due to the loss of pumping action of the left side of the heart. It
causes congestion of lungs.
Compensatory mechanism in heart failure
To compensate the decrease in the cardiac output, there are many
events will occur:
 Increase in the sympathetic discharge
 Increase in the circulatory catecholamine leading to generalized
vasoconstriction.
 Decrease in renal blood flow and increase in sympathetic discharge
lead to increase renin secretion which leads to increase angiotensin
II which represents the powerful vasoconstrictor substance leading
to increase in aldosterone production leads to sodium and water
retention.
 Increase atrial natriuretic peptide(ANP) due to increase in right atrial
pressure leads to natriuresis ( increase Na and water excretion) as a
trail to withstand the failure status.
 Increase in the venous pressure leads to congestion.
 Increase in the after load leads to more decrease in the CO.