CORONARY CIRCULATION

INTRODUCTION:-
The heart is highly metabolically active and boasts the highest oxygen consumption by mass of any organ.
This demand for oxygen is met by the coronary circulation, which is responsible for delivering blood to the
myocardium and represents approximately 5% of cardiac output. Adequate blood flow through the coronary
vessels is critical to avoid ischemia and maintain the integrity of the myocardial tissue.

Coronary circulation is the circulation of blood in the blood vessels that supply the heart
muscle (myocardium). Coronary arteries supply oxygenated blood to the heart muscle, and cardiac
veins drain away the blood once it has been deoxygenated. Because the rest of the body, and most especially
the brain, needs a steady supply of oxygenated blood that is free of all but the slightest interruptions, the
heart is required to function continuously. Therefore its circulation is of major importance not only to its
own tissues but to the entire body and even the level of consciousness of the brain from moment to moment.
Interruptions of coronary circulation quickly cause heart attacks (myocardial infarctions), in which the heart
muscle is damaged by oxygen starvation. Such interruptions are usually caused by ischemic heart disease
(coronary artery disease) and sometimes by embolism from other causes like obstruction in blood flow
through vessels.

DEFINITION:-
The coronary circulation consists of the blood vessels that supply blood to, and remove blood from, the
heart.

OR

The coronary arteries are the first branches of the aorta, usually taking their origin within the bulbous
expansions of the aortic root proximal to the sinutubular junction known as the aortic sinuses of Valsalva

STRUCTURE:-
Coronary arteries supply blood to the myocardium and other components of the heart. Two coronary arteries
originate from the left side of the heart at the beginning (root) of the aorta, just after the aorta exits the left
ventricle. There are three aortic sinuses (dilations) in the wall of the aorta just superior to the aortic
semilunar valve. Two of these, the left posterior aortic sinus and anterior aortic sinus, give rise to
the left and right coronary arteries, respectively. The third sinus, the right posterior aortic sinus, typically
does not give rise to a vessel. Coronary vessel branches that remain on the surface of the artery and follow
the sulci of the heart are called epicardial coronary arteries.

The left coronary artery distributes blood to the left side of the heart, the left atrium and ventricle, and the
inter ventricular septum. The circumflex artery arises from the left coronary artery and follows the coronary
sulcus to the left. Eventually, it will fuse with the small branches of the right coronary artery. The
larger anterior interventricular artery, also known as the left anterior descending artery (LAD), is the second
major branch arising from the left coronary artery. It follows the anterior inter ventricular sulcus around the
pulmonary trunk. Along the way it gives rise to numerous smaller branches that interconnect with the
branches of the posterior inter ventricular artery, forming anastomoses. An anastomosis is an area where
vessels unite to form interconnections that normally allow blood to circulate to a region even if there may be
partial blockage in another branch. The anastomoses in the heart are very small. Therefore, this ability is
somewhat restricted in the heart so a coronary artery blockage often results in myocardial
infarction causing death of the cells supplied by the particular vessel.

The right coronary artery proceeds along the coronary sulcus and distributes blood to the right atrium,
portions of both ventricles, and the heart conduction system. Normally, one or more marginal arteries arise
from the right coronary artery inferior to the right atrium. The marginal arteries supply blood to the
superficial portions of the right ventricle. On the posterior surface of the heart, the right coronary artery
gives rise to the posterior inter ventricular artery, also known as the posterior descending artery. It runs
along the posterior portion of the inter ventricular sulcus toward the apex of the heart, giving rise to
branches that supply the inter ventricular septum and portions of both ventricles.

IMPORTANT FEATURES OF CORONARY BLOOD FLOW:

 Flow is tightly coupled to oxygen demand. This is necessary because the heart has a very high
basal oxygen consumption (8-10 ml O2/min/100g) and the highest A-VO2 difference of a major
organ (10-13 ml/100 ml). In non-diseased coronary vessels, whenever cardiac activity and oxygen
consumption increases there is an increase in coronary blood flow (active hyperemia) that is nearly
proportionate to the increase in oxygen consumption.

 Good autoregulation between 60 and 200 mmHg perfusion pressure helps to maintain normal
coronary blood flow whenever coronary perfusion pressure changes due to changes in aortic
pressure.

 Adenosine is an important mediator of active hyperemia and autoregulation. It serves as a

metabolic coupler between oxygen consumption and coronary blood flow. Nitric oxide is also an
important regulator of coronary blood flow.

 Activation of sympathetic nerves innervating the coronary vasculature causes only transient
vasoconstriction mediated by α1-adrenoceptors. This brief (and small) vasoconstrictor response is
followed by vasodilation caused by enhanced production of vasodilator metabolites (active
hyperemia) due to increased mechanical and metabolic activity of the heart resulting from β1-
adrenoceptor activation of the myocardium. Therefore, sympathetic activation to the heart results
in coronary vasodilation and increased coronary flow due to increased metabolic activity
 (increased heart rate, contractility) despite direct vasoconstrictor effects of sympathetic activation
on the coronaries. This is termed "functional sympatholysis."

 Parasympathetic stimulation of the heart (i.e., vagal nerve activation) elicits modest coronary
vasodilation (due to the direct effects of released acetylcholine on the coronaries). However, if
parasympathetic activation of the heart results in a significant decrease in myocardial oxygen
demand due to a reduction in heart rate, then intrinsic metabolic mechanisms will increase
coronary vascular resistance by constricting the vessels.

 Progressive ischemic coronary artery disease results in the growth of new vessels (termed
angiogenesis) and collateralization within the myocardium. Collateralization increases myocardial
blood supply by increasing the number of parallel vessels, thereby reducing vascular resistance
within the myocardium.

 Extravascular compression (shown to the right) during systole markedly affects coronary flow;
therefore, most of the coronary flow occurs during diastole. Because of extravascular compression,
the endocardium is more susceptible to ischemia especially at lower perfusion pressures.
Furthermore, with tachycardia there is relatively less time available for coronary flow during
diastole to occur – this is particularly significant in patients with coronary artery disease
where coronary flow reserve (maximal flow capacity) is reduced

CORONARY CIRCULATION:-
Coronary circulation, part of the systemic circulatory system that supplies blood to and provides drainage
from the tissues of the heart. In the human heart, two coronary arteries arise from the aorta just beyond the
semilunar valves; during diastole, the increased aortic pressure above the valves forces blood into the
coronary arteries and thence into the musculature of the heart. Deoxygenated blood is returned to the
chambers of the heart via coronary veins; most of these converge to form the coronary venous sinus, which
drains into the right atrium.

The heart normally extracts 70 to 75 percent of the available oxygen from the blood in coronary circulation,
which is much more than the amount extracted by other organs from their circulations e.g., 40 percent by
resting skeletal muscle and 20 percent by the liver. Obstruction of a coronary artery, depriving the heart
tissue of oxygen-rich blood, leads to death of part of the heart muscle (myocardial infarction) in severe
cases, and total heart failure and death may ensue.

Systemic circulation, in physiology, the circuit of vessels supplying oxygenated blood to and returning
deoxygenated blood from the tissues of the body, as distinguished from the pulmonary circulation. Blood is
pumped from the left ventricle of the heart through the aorta and arterial branches to the arterioles and
through capillaries, where it reaches an equilibrium with the tissue fluid, and then drains through the venules
into the veins and returns, via the venae cavae, to the right atrium of the heart. Pressure in the arterial
system, resulting from heart action and distension by the blood, maintains systemic blood flow. The
systemic pathway, however, consists of many circuits in parallel, each of which has its own arteriolar
resistance that determines blood flow independently of the overall flow and pressure and without necessarily
disrupting these. For example, the blood flow through the digestive tract increases after meals, and that
through working muscles increases during exercise. See also pulmonary circulation.

CONCLUSION:-

The major vessels of the coronary circulation are the left main coronary that divides into left anterior
descending and circumflex branches, and the right main coronary artery. The left and right coronary
arteries originate at the base of the aorta from openings called the coronary ostia located behind the aortic
valve leaflets.