Primary FRCA Masterclass

Cardiovascular physiology (pt4)

The Cardiac cycle
Dr Ian Shaw
Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Trust

Ian.shaw8@nhs.net
Cardiac cycle
• During a single heartbeat, the cardiac cycle consists
of:
• Electrical events
• Contractile events
• Valvular events
 Cardiac MRI:
transverse view

LV is thick-walled and
circular – generates
greater pressures

Prominent papillary muscles

seen in LV – which anchor
mitral valve leaflets

RV is thin-walled
and crescentic –
lower pressures
Aortic pressure systolic
120 mmHg
aorta
mean ~
120/70 87 mmHg
diastolic
70 mmHg
Dicrotic
notch
MAP approximates to diastolic + ⅓ pulse
pressure: diastole is normally about twice as
long as systole at rest
More correctly = mathematical mean
derived from AUC

0
Cardiac cycle: pressures – left heart
ECG systolic
120 mmHg
aorta
120/70

diastolic
70 mmHg
LV
121/0

LA
7/3 0
 Right atrial pressure (6/2 mmHg)

Equivalent to the …… central venous pressure

central venous pressure waveform (= RAP)
a
c
v
x y

a wave: atrial contraction

c wave: tricuspid valve bulging back into RA
x descent: atrial relaxation
v wave: atrial filling with closed tricuspid valve
y descent: atria empties into ventricle
Cardiac cycle: valves

aortic / pulmonary aortic / pulmonary

open close
aorta
120/70

LV Valves open or close because of

the pressures on either side of
121/0
them

mitral / tricuspid mitral / tricuspid

close open

LA
7/3 0
Cardiac cycle: heart sounds

aortic / pulmonary
close
aorta
120/70

LV 1st heart 2nd heart

121/0 sound sound

mitral / tricuspid Normal heart sounds are

close caused by valve closure

LA
7/3 0
Left sided valves normally close fractionally ahead of the right
Cardiac cycle: contraction

aorta

LV

diastole

systole
LA
0
Cardiac cycle: contraction
isovolumetric isovolumetric
contraction relaxation

aorta

ventricular
ejection
LV

ventricular
filling

LA
0
systole diastole
 Cardiac cycle: pressures – right heart
systolic 25
mmHg
pulmonary artery
25/10

RV
26/0
diastolic
10 mmHg

RA
6/2
0
Cardiac cycle: coronary blood flow
The rise in LV pressure (and wall tension) during systole acts to
Aortic occlude coronary vessels running through it, with most perfusion
pressure therefore occurring in diastole. This is not a major influence in the
lower pressure RV.

L coronary
artery flow
0
R coronary
artery flow
0
systole diastole
Coronary blood flow
• 250 mL/min (5% of cardiac output)
• O2 extraction rate  55-60% at rest
• Autoregulates between MAP of 50-120 mmHg, mediated largely by
metabolites
Coronary Coronary
vasoconstriction vasodilatation
Metabolic PO2  PO2 
PCO2  (alkalosis) PCO2  (acidosis)
Lactate
Adenosine
Neural (minor) 1 stimulation 2 stimulation

Hormonal ADH Prostacyclin

Angiotensin
(minor)
Thromboxane
Pressure-volume relationship in
the LV
 Consider the LV pressures and volumes at
the 4 valve changing points
C: Aortic opening D: Aortic closing
P = 75 mmHg P = 90 mmHg
V = 110 mL V = 40 mL
aorta

LV Plot them on a
Pressure-Volume
chart
B: Mitral closing
P = 6 mmHg A: Mitral opening
V = 110 mL P = 3 mmHg
V = 40 mL
LA
0
 Pressure-volume relationship of the LV
140

LVP (mmHg) LV ejection

120

100 D: Aortic
closing C: Aortic
80 opening

60 Stroke volume
Isovolumetric Isovolumetric
relaxation
40 contraction

20 A: Mitral B: Mitral
opening
LV filling Closing
0
20 40 60 80 100 120 140
LV Volume (mL)
 Work done by LV
140

LVP (mmHg) 120

100 D: Aortic
closing C: Aortic
80 opening

60 LV Work
40

20 A: Mitral B: Mitral
opening Closing
0
20 40 60 80 100 120 140
LV Volume (mL)
Pressure-volume
relationship in the LV – 2
aspects:
 Filling - diastolic compliance
 Ejecting - systolic contraction
 Pressure-volume relationship of the LV:
140

LVP (mmHg) 120

Diastolic
100 compliance
Note: axes reversed from normal compliance plot
80

60

40 A healthy LV is very
compliant
20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Pressure-volume relationship of the LV:
140

LVP (mmHg) 120

100

80

60
Diastolic dysfunction
40

20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Pressure-volume relationship of the LV:
140

LVP (mmHg) 120 Systolic

100 contraction
80
Frank-Starling relationship: assumes
60
afterload constant
40 2 factors explain this:
• Greater contact of actin/myosin interaction
20 • Increased sensitivity of myofibrils to Ca2+ (from SR)

0
20 40 60 80 100 120 140
LV Volume (mL)
 Pressure-volume relationship of the LV:
140 Systolic
contraction
LVP (mmHg) 120

100

80 Diastolic compliance
P-V loop must fall
60
within these
40 curves
20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Result of an increase in preload?
140 Systolic
contraction
LVP (mmHg) 120

100

80 Diastolic
compliance
60 Stroke volume increases

40

20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Result of a fall in contractility?
140 Systolic
contraction
LVP (mmHg) 120

100

80 Diastolic compliance

60 Stroke volume falls

40

20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Result of an increase in afterload?
140 Systolic
contraction
LVP (mmHg) 120
Afterload is represented by
100 P the slope of the line linking
R =
Q the LVEDV and LVESV points
80  DV) compliance
(DPDiastolic
60 DP

40 DV

20

0
20 40 60 80 100 120 140
LV Volume (mL)
 Result of an increase in afterload?
Increased
140 afterload Systolic
contraction
LVP (mmHg) 120

100

80 Diastolic compliance

60 Stroke volume falls

40

20

0
20 40 60 80 100 120 140
LV Volume (mL)
Cardiac cycle: contraction

aorta

LV

diastole

systole
LA
0
Cardiac cycle: contraction
isovolumetric isovolumetric
contraction relaxation

aorta

ventricular
ejection
LV

ventricular
filling

LA
0
systole diastole
 Cardiac cycle: pressures – right heart
systolic 25
mmHg
pulmonary artery
25/10

RV
26/0
diastolic
10 mmHg

RA
6/2
0
Cardiac cycle: coronary blood flow
The rise in LV pressure (and wall tension) during systole acts to
Aortic occlude coronary vessels running through it, with most perfusion
pressure therefore occurring in diastole. This is not a major influence in the
lower pressure RV.

L coronary
artery flow
0
R coronary
artery flow
0
systole diastole