129-134

 This dramatic  in pressure occurs = arteriole constitute a ↑ resistance to flow.

 Total blood flow is constant at all levels of the cardiovascular system, as resistance ↑,
downstream pressure must necessarily  (Q = ΔP/R, or ΔP = Q × R).
 In the capillaries, pressure  further for 2 reasons:
o frictional resistance to flow
o filtration of fluid out of the capillaries
 When blood reaches the venules and veins, pressure has  even further.
 Pressure in the vena cava is only 4 mm Hg and in the right atrium is even lower at 0–2 mm Hg.

Arterial Pressure in the Systemic Circulation

 Mean pressure in the arteries is high and constant, there are oscillations or pulsations of arterial
pressure.
 These pulsations reflect the pulsatile activity of the heart:
o ejecting blood during systole
o resting during diastole
o ejecting blood, resting, and so forth.
 Each cycle of pulsation in the arteries = one cardiac cycle.
 Diastolic pressure is the  arterial pressure measured during a cardiac cycle and is the pressure
in the arteries during ventricular relaxation when no blood is being ejected from the left
ventricle.
 Systolic pressure is ↑arterial pressure measured during a cardiac cycle. It is the pressure in the
arteries after blood has been ejected from the left ventricle during systole.
 Dicrotic notch is the “blip” in the arterial pressure curve. It is produced when the aortic valve
closes.
 Aortic valve closure produces a brief period of retrograde flow from the aorta back toward the
valve, briefly  the aortic pressure below the systolic value.
 Pulse pressure is the difference between systolic pressure and diastolic pressure.
 If all other factors are equal, the magnitude of the pulse pressure reflects the volume of blood
ejected from the left ventricle on a single beat, or the stroke volume.
 Pulse pressure can be used as an indicator of stroke volume because of the relationships
between pressure, volume, and compliance.
 Mean arterial pressure is the average pressure in a complete cardiac cycle and is calculated as
follows:
o Mean arterial pressure = Diastolic pressure + 1/3 Pulse pressure
 Mean arterial pressure is not the simple mathematical average of diastolic and systolic
pressures. This is because a greater fraction of each cardiac cycle is spent in diastole than in
systole. Thus the calculation of mean arterial pressure gives more weight to diastolic pressure
than systolic pressure.
 Pulsations in large arteries are > than the pulsations in the aorta.
 Systolic pressure and pulse pressure are ↑ in the large arteries than in the aorta.
 Ejection of blood from the left ventricle, the pressure wave travels at a higher velocity than the
blood itself travels.
 The direction of blood flow must be from ↑ to 
 The driving force for blood flow in the arteries is the mean arterial pressure, which is influenced
more by diastolic pressure than by systolic pressure.
 This damping and loss of pulse pressure occur for two reasons.
o (1) The resistance of the blood vessels, particularly the arterioles, makes it difficult to
transmit the pulse pressure.
o (2) The compliance of the blood vessels, particularly of the veins, damps the pulse
pressure—the more compliant the blood vessel, the more volume that can be added to
it without causing an increase in pressure.
 Several pathologic conditions alter the arterial pressure curve in a predictable way:
o Arteriosclerosis
 o Aortic stenosis
o Aortic regurgitation

Venous Pressures in the Systemic Circulation

 By the time blood reaches the venules and veins, pressure is less than 10 mm Hg;
pressure will decrease even further in the vena cava and the right atrium.
 The reason for the continuing decrease in pressure is now familiar: The resistance
provided by the blood vessels at each level of the systemic vasculature causes a fall in
pressure.

Pressures in the Pulmonary Circulation

  The entire pulmonary vasculature is at much pressure than the systemic vasculature.
 The pattern of pressures within the pulmonary circulation is analogous to the systemic
circulation.
 Blood is ejected from the right ventricle  pulmonary artery, where pressure is ↑. Thereafter,
the pressure  as blood flows through the pulmonary arteries arterioles capillaries
venules veins  back to the left atrium.
 Pulmonary vascular resistance is much  than systemic vascular resistance.
 The total flow through the systemic and pulmonary circulations must be equal.
 Because pressures on the pulmonary side are much lower than pressures on the systemic side,
to achieve the same flow, pulmonary resistance must be lower than systemic resistance

CARDIAC ELECTROPHYSIOLOGY

 Cardiac electrophysiology includes all of the processes involved in the electrical activation of the
heart:
o The cardiac action potentials; the conduction of action potentials along specialized
conducting tissues; excitability and the refractory periods; the modulating effects of the
autonomic nervous system on heart rate, conduction velocity, and excitability; and the
electrocardiogram (ECG)
 To serve as a pump, the ventricles must be electrically activated and then contract.
 Electrical activation is the cardiac action potential, which normally originates in the sinoatrial
(SA) node.
  “Sequence” is especially critical because the atria must be activatedand contract before the
ventricles, and the ventricles must contract from apex to base for efficient ejection of blood.

Cardiac Action Potentials

Origin and Spread of Excitation Within the Heart

 The heart consists of two kinds of muscle cells: contractile cells and conducting cells.
 Contractile cells constitute the majority of atrial and ventricular tissues and are the working cells
of the heart  Action potentials in contractile cells lead to contraction and generation of force
or pressure.
 Conducting cells constitute the tissues of the SA node, the atrial internodal tracts, the AV node,
the bundle of His, and the Purkinje system.
 Conducting cells are specialized muscle cells that do not contribute significantly to generation of
force  function to rapidly spread action potentials over the entire myocardium.

 The action potential spreads throughout the myocardium in the following sequence:
 o SA node - the action potential of the heart is initiated in the specialized tissue of the SA node,
which serves as the pacemaker. After the action potential is initiated in the SA node, there is a
specific sequence and timing for the conduction of action potentials to the rest of the heart.
o Atrial internodal tracts and atria - The action potential spreads from the SA node to the right
and left atria via the atrial internodal tracts. Simultaneously, the action potential is conducted to
the AV node.
o AV node - Conduction velocity through the AV node is considerably slower than in the other
cardiac tissues. Slow conduction through the AV node ensures that the ventricles have sufficient
time to fill with blood before they are activated and contract. Increases in conduction velocity of
the AV node can lead to decreased ventricular filling and decreased stroke volume and cardiac
output.
o Bundle of His, Purkinje system, and ventricles - From the AV node, the action potential enters
the specialized conducting system of the ventricles. The action potential is first conducted to the
bundle of His through the common bundle. It then invades the left and right bundle branches
and then the smaller bundles of the Purkinje system. Conduction through the His-Purkinje
system is extremely fast, and it rapidly distributes the action potential to the ventricles. The
action potential also spreads from one ventricular muscle cell to the next, via low-resistance
pathways between the cells. Rapid conduction of the action potential throughout the ventricles
is essential and allows for efficient contraction and ejection of blood.
 The term normal sinus rhythm has a specific meaning. It means that the pattern and timing of
the electrical activation of the heart are normal. To qualify as normal sinus rhythm, the following
three criteria must be met:
o (1) The action potential must originate in the SA node.
o (2) The SA nodal impulses must occur regularly at a rate of 60–100 impulses per minute.
o (3) The activation of the myocardium must occur in the correct sequence and with the correct
timing and delays.

Concepts Associated With Cardiac Action Potentials

 The membrane potential of cardiac cells is determined by the relative conductances (or
permeabilities) to ions and the concentration gradients for the permeant ions.
 If the cell membrane has a ↑ conductance or permeability to an ion, that ion will flow down its
electrochemical gradient and attempt to drive the membrane potential toward its equilibrium
potential.
 By convention, membrane potential is expressed in millivolts (mV), and intracellular potential is
 expressed relative to extracellular potential; for example, a membrane potential of −85 mV
means 85 mV, cell interior negative.
 The resting membrane potential of cardiac cells is determined primarily by potassium ions (K+).
The conductance to K+ at rest is ↑, and the resting membrane potential is close to the K+
equilibrium potential.
 Na+-K+ ATPase is primarily to maintain Na+ and K+ concentration gradients across the cell
membrane.
  Changes in membrane potential are caused by the flow of ions into or out of the cell.
 Depolarization means the membrane potential has become less negative.
 Hyperpolarization means the membrane potential has become more negative.
 Threshold potential is the potential difference at which there is a net inward current. At
threshold potential, the depolarization becomes selfsustained and gives rise to the upstroke of
the action potential.

Action Potentials of Ventricles, Atria, and the Purkinje System

 Long duration. In each of these tissues, the action potential is of long duration. Action potential
duration varies from 150 ms in atria, to 250 ms in ventricles, to 300 ms in Purkinje fibers. The
longer the action potential, the longer the cell is refractory to firing another action potential.
Atrial, ventricular, and Purkinje cells have long refractory periods compared with other
excitabletissues.
 Stable resting membrane potential. The cells of the atria, ventricles, and Purkinje system
exhibit a stable, or constant, resting membrane potential.
 Plateau. The action potential in cells of the atria, ventricles, and Purkinje system is characterized
by a plateau.
 The phases of the action potential are described subsequently:
o Phase 0, upstroke. In ventricular, atrial, and Purkinje fibers, the action potential begins
with a phase of rapid depolarization, called the upstroke. As in nerve and skeletal
muscle, the upstroke is caused by a transient ↑ in Na+ conductance (gNa).