1. Cardiac Output

2. Cardiac output The volume of blood pumped by either ventricle in one minute The output of the two ventricles are equal over a period of time (not necessarily during each minute)

3. Cardiac output Calculation Cardiac output = stroke volume x heart rate Cardiac output of a healthy adult at rest is approximately 5 L/min It does not remain constant in any individual but varies from time to time depending on the needs of the body

4. Cardiac output Significance – 1. It is the total quantity of blood available for providing adequate tissue perfusion Thus CO must be kept at a level which is the same as the requirements of the body Lower than requirement – CVS needs to make adjustments in the distribution of the available output Greater than required – unnecessary workload on heart and increases the pressure within the arteries (leads to damage in the long term

5. Cardiac output Significance – 2. It is a determinant of the pressure in the arteries Low cardiac output – low pressure and reduced force available to drive the blood through the body High cardiac output – high pressure damages blood vessels

6. Measurement of cardiac output Classical methods – Fick principle Dye dilution method

7. Measurement of cardiac output Classical methods – Fick principle If one knows 1. How many boxes have been removed If one also knows 2. How many boxes each truck can carry The number of trucks that arrived can be calculated

8. Measurement of cardiac output LUNGS Venous blood Arterial blood O2 Cardiac output = Total oxygen uptake/ amount of O2 taken by each ml of blood

9. Measurement of cardiac output Classical methods – Dye dilution method Inject a substance (not normally found in blood) into a vein and measure the concentration of the substance over a period of time. Plotting the concentration of the substance over time enables one to calculate cardiac output Time Concn.

10. Measurement of cardiac output 2. Echocardiography Ultrasound waves are used to measure blood flow in the aorta – cardiac output is calculated Cardiac output is not a parameter usually measured in the evaluation of the function of the cardiovascular system in clinical practice. It is more relevant in research

11. Determinants of cardiac output CO = SV x HR = (EDV – ESV) x HR Factors that determine cardiac output are those that influence: EDV ESV HR

12. Determinants of cardiac output Heart InotropyChronotropy 1 2 34 1 2 4 3 Preload Afterload Contractility Heart rate

13. Determinants of cardiac output 1. Preload - Preload can be defined as the initial stretching of the cardiac myocytes prior to contraction and is related to the sarcomere length In the normal heart, ventricular preload is determined by the volume of blood that fills the ventricle at the end of passive filling and atrial contraction - the end-diastolic volume

14. Determinants of cardiac output The effect of preload – Frank-Starling Law “ force of contraction increases when initial length of muscle increases” “Heterometric autoreguation” Force of contraction Initial length of muscle fibre

15. Determinants of cardiac output Preload – A major determinant of preload is the amount of blood returning to the heart through the veins “Venous return” Venous return to the heart is the sum of all the local blood flows from individual segments of peripheral circulation Usually applied to the return to the right heart A concept and not a measurement

16. Determinants of cardiac output Factors which determine ventricular preload by influencing venous return: venous blood pressure venous compliance and tone blood volume gravity muscle pump respiratory pump The venous return will in turn determine the “filling pressure” - the pressure in the atria at the onset of ventricular filling Clinically “central venous pressure” is measured as an indicator of adequacy of venous return

17. Determinants of cardiac output Muscle pump Respiratory pump

18. Determinants of cardiac output Factors other than venous return that affect ventricular preload 1. Ventricular compliance – distensibility of the ventricle, 2. Filling time – duration of ventricular diastole 3. Atrial contraction

19. Determinants of cardiac output 2. Afterload Afterload can be viewed as the "load" that the heart must eject blood against. Higher the afterload, higher the ventricular work. Normally afterload is closely related to the aortic pressure

20. Determinants of cardiac output Afterload Afterload (on the left ventricle) is increased by an increase in Aortic pressure Systemic vascular resistance Aortic valve stenosis

21. Determinants of cardiac output 3. Inotropy Changes in ventricular inotropy (contractility) causes changes in the amount of blood pumped out in one beat (stroke volume) If contractility increases, the stroke volume increases If SV increases, end systolic volume decreases

22. Determinants of cardiac output Inotropy Changes in inotropy produce significant changes in ejection fraction (EF) [EF = SV/EDV %] Increasing inotropy leads to an increase in EF, while decreasing inotropy decreases EF Therefore, EF is often used as a clinical index for evaluating the inotropic state of the heart EF may be determined by echocardiography

23. Determinants of cardiac output Contractility of the myocardium (Inotropy) is influenced by Autonomic nervous activity Circulating catecholamines Oxygen and CO 2 levels H + ion concentration Plasma electrolyte levels Loss of myocardium Drugs

24. Determinants of cardiac output 4. Heart rate The number of times the heart beats per minute influences the amount of blood pumped out per minute When heart rate increases the cardiac output is expected to increase

25. Determinants of cardiac output 4. Heart rate is influenced by Autonomic nervous activity Circulating catecholamines Oxygen and CO2 levels H+ ion concentration Plasma electrolyte levels Drugs

26. Determinants of cardiac output Effect of increased heart rate on cardiac output – Direct effect – increase in CO due to increased number of times the heart pumps Indirect effect – shortening of ventricular diastole causing reduced ventricular filling – tends to reduce EDV and therefore CO The net effect on CO depends on which of the above predominates

27. Determinants of cardiac output Cardiac output increases with increasing heart rate until a limiting rate which is around 200 for adults Beyond this the CO falls CO HR  200

28. Determinants of cardiac output Preload Venous return – filling pressure (affected by many factors) ventricular distensibility filling time atrial contraction Afterload aortic pressure systemic arteriolar resistance Inotropy autonomic nervous system circulating catecholamines functioning myocardium oxygen supply to the heart Heart rate autonomic nervous system

29. Regulation of cardiac output Preload Venous return – filling pressure (affected by many factors) ventricular distensibility filling time atrial contraction Afterload aortic pressure systemic arteriolar resistance Inotropy autonomic nervous system circulating catecholamines functioning myocardium oxygen supply Heart rate autonomic nervous system