I N N 0 V A T I 0 N S A N D I D E A S

INTEGRATED CARDIOVASCULAR PHYSIOLOGY:

A LABORATORY EXERCISE

Rahul D. Patil, Sangeeta V. Karve, and Stephen E. DiCarlo

Department of Physiology, Northeastern Ohio Universities, College of Medicine, Rootstown, Ohio 442 72

xamining the hemodynamic responses to exercise provides a unique opportu-

E nity to analyze and integrate cardiovascular physiology because more is

learned about how a system operates when it is forced to perform than when it
is idle. We designed a laboratory exercise that examines the cardiovascular responses
to exercise in a sedentary individual, an athlete, an individual with quadriplegia, and
an individual with heart transplantation. The special populations were chosen
because of their unique limitations and adaptations, which directly influence
cardiovascular function. Basic anatomic and physiological data about the special
populations are provided, and the students are challenged to analyze and assimilate
information from figures, answer questions, make calculations, and plot graphs. The
answers to the questions are provided in the APPENDIX. This laboratory exercise
should be attempted in a group to foster discussions and interactions. The laboratory
does not require any equipment or software. This exercise should be attempted after
the cardiovascular section of the physiology course so that the students can integrate
and apply the information presented during the course.
AM. J. PWSIOL. 265 (ADV PHYiSIOL. EDUC. IO): S20-S31, 1993.

teaching tool; education

Teaching cardiovascular physiology is a challenge to Studying the cardiovascular responses to exercise

even the most gifted educator. An enormous amount
of information must be disseminated in a relatively
short period of time. Traditionally, each cardiovascu-
lar component is presented independently, and
very little time is scheduled to discuss the interac-
tion between components. In addition, when educa-
tors discuss interactions, the system is most often
presented as a physical model independent of neu-
ral influences. This method of teaching provides
limited experience in evaluating and understanding
the integrated cardiovascular system, and students
do not have the opportunity to apply the concepts.
More emphasis should be placed on the application
of basic science principles, interpretation of picto-
rial or tabular material, and problem-solving skills
(1) .
’ provides a unique opportunity to integrate and
apply the principles of cardiovascular physiology.
More is learned about how a system operates when
it is forced to perform than when it is idle (3).
Therefore, to help students analyze, integrate, and
apply basic concepts, we developed a learning tool
that evaluates cardiovascular responses during exer-
cise in special populations. The special populations
were chosen because of their unique limitations and
adaptations, which directly influence cardiovascular
function. Therefore, individuals with quadriplegia
and heart transplantation were compared and con-
trasted with sedentary and endurance-trained indi-
viduals. Each individual has unique autonomic and
physiological control mechanisms regulating cardio-
vascular function.

1043 - 4046 / 93 - $2:00 - COPYRIGHT o 1993 THE AMERICAN PHYSIOLOGICAL SOCIETY

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 I N N 0 V A T I
To begin this quest of understanding the integrated
cardiovascular system, the students are presented
with basic anatomic and physiological information
about each population. Subsequently, a figure is
presented that shows the response of a specific
cardiovascular variable during exercise (e.g., heart
rate), and the students are challenged to analyze the
cardiovascular changes that occur during exercise,
keeping in mind the limitations and adaptations
present in each individual. The students answer
questions, make calculations, and plot data related
to that figure. The answers to all the questions are
provided in the APPENDIX.
This game should be attempted after completing the
cardiovascular section of the physiology course. At
this time, the students are prepared to integrate the
information assimilated during the section and are
ready to apply the information to special popula-
tions. The answers do not involve difficult calcula-
tions or new information. The purpose of this game
was not to provide new information but to help the
student apply the information already assimilated
and provide insights concerning cardiovascular regu-
lation.
BACKGROUND INFORMATION
The cardiovascular responses during dynamic exer-
cise are examined in four males (age 30 yr, w-t 70 kg)
with specific limitations or adaptations. The individu-
als are different in the extent of innervation to their
heart and blood vessels, the available muscle mass
for exercise, and the efficiency of venous return. The
following narrative will describe the unique charac-
teristics of each individual.
Individual With Quadriplegia
The individual with quadriplegia has a transverse
spinal lesion at the C,- C8 spinal level, resulting in
the loss of sympathetic and motor control below the
level of the lesion. However, parasympathetic inner-
vation to the heart is maintained. This individual is
limited to arm exercise (arm cycle ergometry),
which directly influences the maximum work load,
venous return, and cardiovascular function.
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0 N S A N D I D E A S
Individual With Heart Transplantation
The individual with a heart transplantation can be
directly contrasted with the individual with quad-
riplegia. The donor heart is void of all sympathetic
innervation and all significant parasympathetic inner-
vation. However, unlike the individual with quad-
riplegia, this individual has complete motor func-
tion. With complete motor function, this individual
has full use of the muscle venous pump and can
therefore take advantage of the Frank-Starling mecha-
nism and exercise at a much higher work load.
Sedentary Individual
The sedentary individual has no significant limita-
tions. This individual, of course, has full innervation
to the heart and circulation and therefore has
cardiovascular responses different from the individu-
als with quadriplegia and heart transplantation.
Trained Endurance Athlete
The athlete has significant autonomic adaptations
associated with exercise training. Exercise training
is associated with a higher stroke volume, cardiac
output, and oxygen consumption during exercise
with no change in the maximum heart rate. In
addition, there is a lower heart rate and higher
stroke volume at rest. These autonomic adaptations
make him uniquely suited to perform exercise,
while maintaining homeostasis.
THE GAME
Heart Rate
Figure 1 presents the relationship between heart
rate and increasing work load. work load is ex-
pressed as the oxygen consumption required to
perform the work. Heart rate is under the influence
of the autonomic nervous system. Decreases in
cardiac parasympathetic efferent activity and/or in-
creases in cardiac sympathetic efferent activity in-
crease heart rate. At the onset of exercise, there is a
centrally mediated simultaneous activation of the
cardiovascular and motor centers (central com-
mand), causing an initial rapid increase in heart rate
due to withdrawal of parasympathetic efferent activ-
ity. Once heart rate reaches - 100 beats/min, there
IN PHYSIOLOGY EDUCATION - DECEMBER 1993
s21
 I N N 0 V A T I 0 N S A N D I D E A S

2501

180-

z160-

$140- 175-
! '
E 120- 3 150-

d loo- 7:
, 125-

5 80- y 100

2 60- 0
K 75

40-

20-

0: - 9 - 1 - 8 - ’ - ‘7 ’ -1
0 1 2 3 4 5 6 7

OXYGEN CONSUMPTION (Umin)

FIG. 1
Relationship between heart rate and increasing work load.
Work load is expressed as oxygen consumption required to
perform the work. 0, athlete; 0, sedentary; 0, cardiac trans-
plant; H, quadriplegia.
the sedentary and athletic individuals. How are they
is a further increase in heart rate due to activation of
different? What accounts for this difference?
cardiac sympathetic efferent activity.
Stroke Volume
Individuals with heart transplantation and quadriple-
gia do not have sympathetic innervation to the Figure 2 presents the stroke volume response to
heart; however, the individual with quadriplegia has increasing work loads in the four individuals. Stroke
cardiac parasympathetic innervation. volume is a function of venous return, cardiac
sympathetic efferent activity, circulating catechol-
Questions amines, and afterload. During exercise, venous re-
turn increases because of an increase in the activity
I> Compare the heart rate response to exercise in
of the muscle venous pump. Consequently, end-
the individuals with quadriplegia and heart trans-
diastolic volume increases and causes a stronger
plantation. How does the absence of cardiac para-
systolic contraction of the ventricle, in accordance
sympathetic innervation affect the heart rate re-
with the Frank-Starling law. During exercise, cardiac
sponse to exercise?
sympathetic efferent activity also increases. Stroke
volume increases during exercise, reaching a maxi-
2) Compare the maximum heart rate response to
mum at 40-45% of the oxygen uptake at maximum
exercise in the individuals with quadriplegia and
exercise @o 2max). Finally, stroke volume can also
heart transplantation. What accounts for the similar-
increase slightly because of the effect of circulating
ity in maximum heart rate?
catecholamines activating P,-adrenergic receptors
on the myocardium.
3) What factors contribute to the increase in heart
rate in the individuals with quadriplegia and heart
Questions
transplantation?
6) Compare the stroke volume responses in the
4) Compare the heart rate response to exercise in individuals with quadriplegia and heart transplanta-
the individual with heart transplantation with the tion. How are they different and what accounts for
sedentary individual. How would the absence of this difference?
cardiac innervation affect the heart rate response to
exercise? 7) Compare the stroke volume response in the
sedentary individual with the response in the indi-
5) Compare the resting heart rate, slope of the vidual with heart transplantation. What accounts for
increase in heart rate, and maximum heart rate in the similarity in stroke volume?

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 I N N 0 V A T I 0 N S A N D I D E A S

401 Questions
10) Compare the cardiac output responses to exer-
cise in the individuals with quadriplegia and heart
transplantation. How are they different and what
accounts for this difference?

11) Compare the cardiac output responses in the

sedentary individual and the individual with heart
transplantation. How are they different and what
accounts for this difference?
2 3 4 5 6 7
OXYGEN CONSUMPTION (Umin) 12) Compare the cardiac output responses in the
FIG. 3 sedentary and athletic individuals. How are they
Plot the relation between cardiac output and oxygen con- different and what accounts for this difference?
sumption (quesHort 9).
Calculating Oxygen Consumption:
8) Compare the stroke volume responses in the The Fick Principle
sedentary and athletic individuals. How are they The Fick principle (Adolph Fick, 1870) can be
different and what accounts for this difference? written

9) With the use of Figs. 1 and 2, calculate the cardiac i70, = CO X (a-v)02
output response during exercise in the four individu- where to2 is oxygen consumption, CO is cardiac
als. Plot these results in Fig. 3. output, and (a-v)02 is the arteriovenous oxygen
difference. This equation is used to calculate cardiac
Cardiac Output output or blood flow to any organ. It can also be
Figure 4 presents the cardiac output response to used to calculate the oxygen consumption of the
exercise in the four individuals. The increase in entire body or any organ, provided the flow rate and
cardiac output is due to an increase in heart rate and the oxygen content of blood samples are known.
stroke volume. Increases in stroke volume contrib- Thus oxygen consumed by the body is determined
ute by measuring cardiac output and the oxygen con-
. to increases in cardiac output up to 40-45% of
vo 2max* Further increases in cardiac output are due tent of the arterial and mixed venous blood. The
to increases in heart rate. oxygen saturation of arterial blood with a PO, of 100
mmHg is -98%, whereas that of mixed venous
blood with a PO, of 40 mmHg is - 75%. One gram of
hemoglobin (Hb) can combine with 1.34-1.36 ml of
g 35-
E .
oxygen. Because normal blood has - 15 g Hb/lOO
2 30- ml, the oxygen capacity of arterial blood is - 20.8 ml
% 25- oxygen/l00 ml blood, and the oxygen capacity of
k
3 20- venous blood is - 15.6 ml oxygen/l00 ml blood.
0 * Accordingly, oxygen consumed by the body is the
5: 15. product of cardiac output and the arteriovenous
E lo- oxygen concentration difference.
2 *
o 5-
Question
2 3 4 5
OXYGEN CONS UMPTION (Umin) 13) Using Fig. 4 and the Fick principle, calculate the
FIG. 4 arteriovenous oxygen difference response to exer-
Cardiac output response to exercise in the 4 individuals. 0, cise in the four individuals. Plot these results in
athlete; l , sedentary; q , cardiac transplant; n , quadriplegia. Fig. 5.

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 N N 0 V A T I 0 N S A N D I D E A S

0:. ’ - “1. ’ - ’ - ’ - ’
=o! - ’ - ’ - ’ - ’ = ’ - 1’ ’
0 1 2 3 4 5 6 7
0 1 2 3 4 5 6 7
OXYGEN CONSUMPTION (Umin)
OXYGEN CONSUMPTION (Umin)
FIG. 5 FIG. 7
Plot the relation between arteriovenous (a-v) oxygen differ- Relationship between arteriovenous oxygen difference in
ence and oxygen consumption (question 13). coronary circulation and increasing work loads in the 4
individuals. 0, athlete; l , sedentary; q , cardiac transplant;
Arteriovenous Oxygen Difference 0, quadriplegia.

Figure 6 presents the relationship between arterio-

venous oxygen difference and increasing work loads.
At rest, oxygen consumption is -250 ml oxygen/
min. The arterial (20.8 ml/100 ml)-venous (15.0
ml/100 ml) oxygen difference is therefore - 5 ml
oxygen/100 ml blood. As the work intensity in-
creases, oxygen consumption increases. The in-
creased requirements for oxygen are met by increas-
ing cardiac output (delivering more oxygen) and
extracting more oxygen from the arterial blood
(increasing arteriovenous oxygen difference). Oxy-
gen extraction increases more slowly than cardiac
output. The maximum arteriovenous oxygen differ-
ence is comparable in the four individuals (- 16-18
ml/100 ml blood). Because oxygen requirements of
the exercising muscles increase significantly during
ko! - ’ - ’ - ’
0 1 2 3
OXYGEN
FIG. 6
Relationship between arteriovenous
increasing work loads in the 4 individuals.
sedentary; q I, cardiac transplant;
exercise, oxygen extraction in the circulation to the
active muscles is nearly complete at maximum
exercise.
Questions
14) What accounts for the difference in arteriove-
nous oxygen difference response to exercise in the
sedentary individual and the athlete?
15) What accounts for the difference in maximum
oxygen consumption of the sedentary and athletic
individuals?
Myocardial Oxygen Consumption
Figure 7 presents the relationship between the
arteriovenous oxygen difference in the coronary
circulation and increasing work loads. Oxygen con-
sumption of the whole heart can be determined
using the Fick equation. The oxygen content of
venous blood draining the heart is low relative to
that of other organs, giving a wide arteriovenous
oxygen difference, even under resting conditions.
Although the myocardial oxygen extraction in-
creases during severe exercise, this reserve is quite
small.
- ’ - 1. “1
4 5 6 7
CONSUMPTION (Umin) Question
oxygen difference and 16) Compare arteriovenous oxygen difference re-
0, athlete; l , sponse to exercise in the coronary and systemic
n , quadriplegia. circulations (Figs. 6 and 7). How are the increased

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 I N N 0 V A T I 0 N S A N D I D E A S

g 250
E
vL
200
1- I

Iii .
2
E 150-
E -
8 loo-
0 .
d
0 5o
=
0 .
$0 ~1~l-1’1’1~1~1 I - I - I - I - I - I ’ I
G O 1 2 3 4 5 6 7 1 2 3 4 5 6 7
OXYGEN CONSUMPTION (Umin) OXYGEN CONSUMPTION (Umin)
8 FIG. FIG. 9
Relationship between systolic blood pressure and increasing Diastolic blood pressure response to exercise in the 4
work loads in the 4 individuals. 0, athlete; 0, sedentary; q, individuals. 0, athlete; l , sedentary; q I, cardiac transplant;
cardiac transplant; W, quadriplegia. n , quadriplegia.

19) Compare the systolic blood pressure response

myocardial oxygen requirements during exercise
to exercise in the athlete and the sedentary indi-
fulfilled?
vidual. How are they different and why?

Systolic Blood Pressure Diastolic Blood Pressure

Figure 8 presents the relationship between systolic Figure 9 presents the diastolic blood pressure re-
blood pressure and increasing work loads in the sponse to exercise in the four individuals. Diastolic
four individuals. Systolic blood pressure (pressure blood pressure (pressure during diastole, when the
during systole, when the heart is active) is the heart is at rest) is the pressure exerted by the
pressure generated by stroke volume during ven- volume of blood that remains in the arteries after
tricular systole. Systolic blood pressure is a function the peripheral runoff of blood from the arteries
of left ventricular stroke volume, the peak rate of through the resistance vessels. The arterial blood
ejection, vessel wall compliance, and diastolic blood volume is the net result of the rate of blood flow
pressure. If one assumesthat the compliance of the from the heart to the arteries and the rate of outflow
blood vessels is similar in the four individuals, from the arteries through the resistance vessels.
stroke volume is the major determinant of systolic Therefore, diastolic blood pressure is a function of
blood pressure. Differences in rate of ejection and heart rate and peripheral vascular resistance. In-
diastolic blood pressure also account for the differ- creases in heart rate increase the rate of inflow of
ence in systolic blood pressure response to exercise blood and reduce the time during which outflow
in the four individuals. occurs through the resistance vessels, thereby in-
creasing the diastolic pressure. An increase in the
peripheral vascular resistance also causesa decrease
Questions
in outflow of blood, which results in an increase in
17) Compare the systolic blood pressure response diastolic pressure. Normally diastolic blood pres-
to exercise in the individuals with quadriplegia and sure remains the same or changes only moderately
heart transplantation. How are they different, and during exercise because although heart rate in-
what accounts for this difference? creases, peripheral vascular resistance decreases.
The diastolic blood pressure response to exercise,
18) Why is the systolic blood pressure response in therefore, depends on the magnitude of the in-
the individual with heart transplantation lower than crease in heart rate and decrease in peripheral
that in the sedentary individual? vascular resistance. Diastolic blood pressure in-

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 I N N 0 V A T I 0 N
creases slightly with increasing work loads in the
individuals with heart transplantation and quadriple-
gia, whereas it decreases in the sedentary individu-
als and athletes.
Questions
20) Explain the response of diastolic blood pressure
to exercise in the athlete and the sedentary indi-
vidual.
21) What does the rise in diastolic blood pressure
with exercise signify?
Mean Arterial Pressure Response
Pulse pressure is the difference between the systolic
and diastolic blood pressures. Pulse pressure is a
function of the volume of blood ejected by the left
ventricle during systole (rapid ejection phase) mi-
nus the volume of blood that runs off to the
periphery during diastole. The major factors affect-
ing pulse pressure are stroke volume, vascular
compliance, and the rate of ventricular ejection vs.
the rate of peripheral outflow.
Mean arterial pressure is the average pressure
throughout the cardiac cycle. Because systole is
shorter than diastole, the mean pressure is slightly
less than the value halfway between systolic and
diastolic pressures. This is often described as the
perfusion pressure or the pressure necessary to
maintain adequate blood flow to the tissues. For all
practical purposes it is calculated by the formula
MAP=DP+1/3PP
where MAP is mean arterial pressure, DP is diastolic
pressure, and pulse pressure (PP) equals systolic
pressure minus diastolic pressure.
Question
22) Using Figs. 8 and 9, calculate the mean arterial
pressure response during exercise in the four indi-
viduals. Plot these results in Fig. 10. Compare the
mean arterial pressure response to exercise in the
sedentary individual and the athlete.
work units
Work or the energy required to perform work is
quantified in a variety of units depending on the
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S A N D I D E A S
sI 250
E
OXYGEN CONSUMPTION (L/min)
FIG. 10
Plot the relation between mean arterial pressure and oxygen
consumption (question 22).
situation. It is possible to utilize either units of work,
such as kilopond -meters or joules, or units of
energy expenditure, such as oxygen consumption
(ml/min), kilocalories, or metabolic equivalent terms
(METS), because there is a linear relationship be-
tween these units. Clinicians are encouraged to
understand the relationships between work and
energy expenditure because they will be required to
utilize these facts in a variety of patient populations.
For example, when modifying the activity profile of
patients with myocardial infarction, adjusting the
insulin requirements of individuals with diabetes, or
making nutritional adjustments in obese individu-
als, the physician must convert the activity or work
performed by the patients (activities of daily living)
to units of energy expenditure. This process allows
the physician to prescribe appropriate medications,
dietary restrictions, and activity levels.
Work on a cycle ergometer is conventionally esti-
mated in units of kilopond meter (kp m). A kilo-
l l
pond is defined as the amount of force required to
accelerate a mass of 1 kg by 9.8 m/s* (gravitational
acceleration). Work is force applied over a specific
distance. For example, lifting 1 kg vertically through
1 m results in 1 kg. m or 1 kp m of work. Power is l
work performed per unit time, so it is estimated in
units of kilopond *meter per minute. Work quanti-
tated on a cycle ergometer (or other device) can be
converted to energy consumption by knowing some
basic facts. The oxygen cost of 1 kp- m of work is
equal to 1.8 ml of oxygen. To account for the added
frictional work on a cycle ergometer, the oxygen
IN PHYSIOLOGY EDUCATION - DECEMBER 1993
s26
 I N N 0 V A T I 0 N S A N D I D E A S

cost of 1 kp-m of work is augmented by 0.2 ml

OJ(kp m). Thus, for cycle ergometry, the oxygen
l

cost of work against the applied load is 2 ml of

02/(kp mm). The total oxygen consumption of an
individual working on a cycle ergometer is thus
obtained by adding the oxygen cost of work to
resting oxygen consumption by the body (-250
ml/min). 10

i/-o, (ml/min) = 2 ml/(kp- m) 5

x kp-m/min + 250 ml/min 0

Go2 (L/min)
Thus there is a linear relationship between oxygen I ’ I * 1 - 1 ” . ’ - ’ * ’

consumption and work load (2). 0 4 8 12

METS
15 20 24 28

-I,, . .., . 1 81, 7.. . , . I. ., 1. 1, (7”’ 1. ‘.

0 1000 1500 2000 2500 3ooo

Whole body oxygen consumption increases in a kp.m/min
linear fashion with increasing work. The oxygen FIG. 11
uptake at maximum exercise, termed Vozmax,corre- Relationship between oxygen consumption (Vo2), kp l m/
lates well with the degree of physical conditioning min, kcal/min, and METS.
and has been accepted as an index of total body
fitness. The capacity to consume oxygen is related 30
1
not only to the effectiveness of the lungs but also to
25
1
the ability of the heart and circulatory system to 1

transport the oxygen and to the body tissue’s ability

to metabolize it. The Vozmaxis a reproducible value,
especially when corrected for body weight, and it
increases with the degree of physical conditioning.
10
In exercise physiology, Vozmaxhas been used as a 1
standard of comparison within and across subjects
5
1
to normalize the effects of various absolute work 1,

loads. METS are frequently used to estimate work in 0 ‘l’l’l-8.1-r-l

clinical cardiology. One metabolic equivalent term 0 5 10 15 20 25 30 35

Kcal/min
is equal to the oxygen consumed by a human being
FIG. 12
at rest, i.e., 3.5 ml O2-kg-l -min. Various common Plot the relation between kcal/min and METS (questfon
work loads are quantitated in terms of multiples of 2342).
oxygen consumption or multiples of METS (dressing
and undressing, 2 METS; walking, 3 METS). This
serves to guide the patients regarding the work exercise (assumingR = 0.82)
loads that they perform. Thus units of oxygen
consumption can be directly converted to METS by energy consumed (kcal/min)
understanding the following relationship
= 5 kcal/l O2 x Vo, (l/min)
MET = Vo,/(weight X 3.5 mlkg-lernin-l)
Questions
where Vo* is in milliliters per minute and weight is
in kilograms. 23) Examine the relation between Vo2, (kp -m) /min,
kcal/min, and METS presented in Fig. 11. Using
The work performed (estimated in terms of kcal/ Figs. 12 and 13, plot the relationship between
min) also has a linear relationship with oxygen a) METS and kcal/min (Fig. 12)
consumption at steady-state, submaximal, aerobic b) kp m/min and Vo, (Fig. 13)
l

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 I N N 0 V A T I 0 N S A N D I D E A S

3500- APPENDIX: ANSWERS TO GAME QUESTIONS

3000-
2500-
.I
E 2000-
5
2 1500-
1000 -
500-
0 - ' = ' - " 1"
0 1 2 3
OXYGEN CONSUMPTION
FIG. 13
Plot the relation between kp *m/mix-~
tion (question 236).
DISCUSSION
This laboratory exercise was attempted by faculty
and students at our institution. The subjects worked
in groups of four. In addition, we presented this
game at the Experimental Biology ‘93 meeting in
New Orleans. From these experiences we know that
the laboratory requires - 3 h to complete. The
students were excited about the opportunity to
apply information assimilated over the entire cardio-
vascular section of the physiology course to specific
populations. The practical application of basic sci-
ence principles was greatly appreciated. The stu-
dents also enjoyed reading graphs and using rulers
and pencils to plot data. The physiology faculty
appreciated the fact that it did not require any
equipment or computers (in an era of educational
budget cuts). The faculty were also impressed with
the level of discussion that the exercise stimulated,
and they appreciated the goals of having students
analyze graphical data. According to the clinical
faculty, the strength of this learning tool was that the
students applied basic science information to clini-
cal situations.
The general consensus about the weakness of this
laboratory exercise was that the time to solve this
exercise was too long (- 3 h). We acknowledge this
concern; however, we feel that the faculty could edit
this learning tool to suit their individual curriculum.
Heart Rate
1) The individual with heart transplantation does
not have a rapid rise in heart rate at the onset of
exercise because the heart has no significant auto-
nomic innervation. The rise in heart rate is due to
the effect of circulating catecholamines. The indi-
vidual with quadriplegia has an initial rapid rise in
heart rate due to the withdrawal of cardiac parasym-
- " 1
4 5 6 7 pathetic efferent activity; however, heart rate does
(Umin) not rise further because of the absence of cardiac
sympathetic efferent activity.
and oxygen consump-
2) The maximum heart rate responses in the indi-
vidual with quadriplegia and heart transplantation
are similar because the maximum increase in heart
rate in both individuals is due to the effect of
circulating catecholamines.
3) Factors that contribute to the increase in heart
rate in the individual with quadriplegia are with-
drawal of the parasympathetic tone and the effect of
circulating catecholamines, whereas only the circu-
lating catecholamines contribute to the increase in
heart rate in the individual with heart transplanta-
tion. At this point it is important to note that
circulating catecholamines (norepinephrine and epi-
nephrine) increase heart rate by activating PI-
adrenergic receptors on the sinoatrial node.
4) The sedentary individual has an initial rapid
increase in heart rate due to withdrawal of cardiac
parasympathetic efferent activity and a further in-
crease to an age-dependent maximum due to an
increase in cardiac sympathetic efferent activity.
There is no rapid rise in heart rate at the onset of
exercise in the individual with heart transplantation
because of absence of cardiac parasympathetic inner-
vation; the rise in heart rate occurs because of the
effect of circulating catecholamines.
5) Autonomic adaptations associated with chronic
endurance training result in an enhanced cardiac
parasympathetic efferent activity, and therefore the
athlete has a resting bradycardia. Note that the heart
rate response at similar work loads is lower in the
athlete compared with the sedentary individual;

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 I N N 0 V A
however, both individuals achieve a similar age-
dependent maximum heart rate.
Stroke Volume
6) The individual with quadriplegia has no motor
control below the level of the lesion (no muscle
venous pump), and therefore venous return does
not increase with exercise. In contrast, the indi-
vidual with heart transplantation is able to increase
stroke volume because of a functioning muscle
venous pump. This illustrates the importance of the
Frank-Starling mechanism. In fact the individual
with heart transplantation has a stroke volume
comparable to that of the sedentary individual.
7) Stroke volume response to exercise is deter-
mined by end-diastolic volume, cardiac sympathetic
efferent activity, circulating catecholamines, and
afterload. The muscle venous pump is functioning
normally in both individuals, and therefore the
stroke volume response to exercise is initially simi-
lar; however, the maximum stroke volume achieved
in the individual with heart transplantation is lower
because of the absence of cardiac sympathetic effer-
ent activity.
8) The athlete has a much higher stroke volume at
similar work loads. The athlete has a larger ventricu-
lar volume and slower heart rate, which allows for a
greater cardiac filling during diastole (greater end-
diastolic volumes); therefore the stroke volume
response in the athlete is much greater compared
with that of the sedentary individual.
Cardiac Output
10) The individual with quadriplegia has a very low
cardiac output because stroke volume does not
increase with exercise (no muscle venous pump). In
addition, because of the reduced muscle mass, the
individual with quadriplegia has a reduced ability to
increase total body oxygen consumption. In con-
trast, the individual with heart transplantation has a
normal muscle venous pump and muscle mass;
therefore venous return is enhanced, and total body
oxygen consumption significantly increased. Note
that both individuals have a limited heart rate
response to exercise (absence of cardiac sympa-
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T I 0 N S A N D I D E A S
thetic efferent activity). The lower cardiac output
response in the individual with quadriplegia is
therefore due to a severely limited stroke volume,
heart rate, and muscle mass.
II) The cardiac output responses to exercise are
initially comparable in the sedentary individual and
the individual with heart transplantation; however,
at work loads above 45% of qozmax, the cardiac
output response is lower in the individual with heart
transplantation because of the poor heart rate re-
sponse to exercise.
12) Cardiac output in the sedentary individual and
the athlete are similar at lower work loads. Even
though the athlete has a lower resting heart rate
(Fig. l), he has a much higher stroke volume (Fig. 2)
at the same work load, and therefore cardiac out-
puts are similar. Note, however, that because of
large stroke volumes in the athlete, he can achieve a
much higher cardiac output (nearly double) com-
pared with the sedentary individual.
Arteriovenous Oxygen Difference
14) up to 75% OfiTOImaxof the sedentary individual,
the arteriovenous oxygen difference of the seden-
tary and athletic individuals is similar. However,
above this work load, the arteriovenous oxygen
difference is lower in the athlete compared with the
sedentary individual because the athlete has much
higher cardiac output. Thus the athlete is able to
meet the increased oxygen requirements of the
body by increasing cardiac output without signifi-
cantly altering arteriovenous oxygen difference ho-
meostasis.
15) Even though the athlete and the sedentary
individual have the same maximum arteriovenous
oxygen difference, the difference in the GoZmaxis
due to the difference in the cardiac output between
the two individuals. Actually cardiac output is the
factor limiting the maximum exercising capacity.
Myocardial Oxygen Consumption
16) Under resting conditions, the arteriovenous
oxygen difference in the coronary circulation is
12-14 ml/l00 ml compared with 4-5 ml/100 ml in
IN PHYSIOLOGY EDUCATION - DECEMBER 1993
S29
 I N N 0 V A
the systemic circulation. In response to exercise the
maximum arteriovenous oxygen difference in both
circulations is similar (16-N ml/100 ml). Thus the
coronary circulation has a very small reserve for
extracting oxygen. Therefore the increased myocar-
dial oxygen demands during exercise are primarily
met by increases in the coronary flow.
Systolic Blood Pressure
17) The systolic blood pressure response in the
individual with quadriplegia is much lower than that
in the individual with heart transplantation because
of the poor stroke volume response to exercise. The
reduced stroke volume response to exercise is due
to the failure of cardiac performance to increase
resulting from an absence of the muscle venous
pump and reduced muscle mass.
18) The systolic blood pressure response to exercise
is lower in the individual with heart transplantation
compared with the sedentary individual because of
a lower stroke volume response to exercise (ab-
sence of cardiac sympathetic efferent activity).
19) The athlete has a much higher systolic blood
pressure response to exercise than the sedentary
individual because of a larger stroke volume and a
more rapid rate of its ejection.
Diastolic Blood Pressure
20) Diastolic blood pressure decreases in response
to exercise (despite the increase in heart rate)
because of a decrease in the total peripheral resis-
tance. Total peripheral resistance will decrease be-
cause of metabolic vasodilatation. Total peripheral
resistance can decrease more in the athlete because
the athlete has an increased cardiac performance
and much higher systolic pressure, which maintains
perfusion pressure. During exercise, perfusion pres-
sure is monitored and maintained by the arterial
baroreflex and muscle metaboreflex. If cardiac per-
formance is not adequate enough to maintain perfu-
sion pressure, the arterial baroreflex and muscle
metaboreflex reflexly increase total peripheral resis-
tance. Because cardiac performance is so high in the
athlete, resulting in a large increase in cardiac
output and systolic blood pressure, these reflexes
are not activated to increase total peripheral resis-
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T I 0 N S A N D I D E A S
tance. Therefore diastolic pressure decreases (meta-
bolic vasodilatation).
21) Normally diastolic blood pressure decreases in
response to exercise. However, in the individuals
with heart transplantation and quadriplegia, the
diastolic pressure rises in response to increasing
work loads because of impaired cardiac perfor-
mance. That is, impaired cardiac performance re-
sults in a reduced systolic blood pressure response
to exercise. The reduced systolic blood pressure
response activates the arterial baroreflex and muscle
metaboreflex, which reflexly increase total periph-
eral resistance. Therefore, to maintain perfusion
pressure, diastolic pressure will not decrease, and in
severe casesit will increase because of an increase in
total peripheral resistance. In addition, the indi-
vidual with quadriplegia has a reduced functioning
muscle mass, and this also contributes to his inabil-
ity to decrease total peripheral resistance because
there is a reduced metabolic vasodilatation.
22) The mean arterial pressure response to exercise
in the sedentary individual and the athlete is the
same. The athlete has a higher systolic blood pres-
sure response to exercise, but he also has a lower
diastolic blood pressure response to exercise; there-
fore, the mean arterial pressure response to exercise
is nearly the same in the athlete and the sedentary
individual. The high systolic pressure response al-
lows diastolic pressure to decrease (metabolic vaso-
dilation without activation of baro- and metabore-
flex) during exercise and still maintains perfusion
pressure. Thus the heart works against a decreased
afterload. This is a major advantage to the athlete.
Work Units
23) It can be seen from Fig. 11 and the equations
following it that there are linear relationships be-
tween the units used to quantify work: oxygen
consumption, METS, kp.m/min and kcal/min. One
liter of oxygen consumed per minute is equivalent
to 426.85 (kp.m)/min, 5 kcal/min, and 4.08 METS.
SUMlMARY
This game was designed as a laboratory exercise to
help students apply basic principles of cardiovascu-
lar physiology, assimilate information from graphs,
IN PHYSIOLOGY EDUCATION - DECEMBER 1993
s30
 I N N 0 V A T I 0 N S A N D I D E A S

and understand the integrated cardiovascular sys- 2. Pate, R. R. (Editor). Guidelines for Exercise Testing and
Prescription/American College of Sports Medicine (4th ed.).
tem. It requires pencils, paper, an interest in cardio-
Philadelphia, PA: Lea & Febiger, 1991, p. 290-291.
vascular physiology, and 3 h to complete.
3. Rowe& L. B. Human Circulation Regulation During Pbysi-
cal Stress. New York: Oxford University Press, 1986, p. 3.
We suggest that students work in groups of four or
five to foster discussion and interactions. This would
stimulate an exchange of information, and the ques-
Suggested Readings
tions will make the discussion thought provoking.
1. Blomqvist, C. G., and B. Saltin. Cardiovascular adaptations
We sincerely appreciate the excellent work of Heidi L. Collins in to physical training. Ann. Rev. Pbysiol. 45: 169-89, 1983.
the preparation of this manuscript. 2. Glaser, R. M. Arm exercise training for wheelchair users. Med.
Sci. Sports Exercise 21: S149-S157, 1989.
Address for reprint reyuests: S. E. DiCarlo, Dept. of Physiology,
3. Rowe& L. B. Human Circulation Regulation During Physi-
Northeastern Ohio Universities, College of Medicine, PO Box 95,
cal Stress. New York: Oxford University Press, 1986.
Rootstown, OH 44272.
4. Astrand, P. O., and K. Rodahl. Textbook of Work Physiology.
PhysioZogicaZ Bases of Exercise. New York: McGraw-Hill,
Received 7 January 1993; accepted in final form 16 June 1993.
1986.
5. Shephard, R. J. Responses of the cardiac transplant patient to
References exercise and training. Exert. Sport. Sci. Rev. 20: 297-320,
1. Case, S. M., D. F. Becker, and D. B. Swanson. Relationship 1992.
between scores on NBME basic science subject tests and the 6. Stone, H. L., and I. Y. S. Liang. Cardiovascular response and
first administration of the newly designed NBME part I control during exercise. Am. Rev. Respir. Dis. 129, suppl.:
examination. Acad. Med. 67, Suppl.: S13-S15, 1992. S13-S16,1984.

Teachers and their students may find the following articles from
News in Physiological Sciences useful when exploring the physiol-
ogy of the preceding paper:

Bove, A. A. Hormonal responses to acute and chronic exercise.

NIPS 4: 143-146,1989.

Gorman, M. W., and H. V. Sparks. The unanswered question.

NIPS 6: 191-193, 1991.

Ludbrook, J. Horace Smirk 1902-1991: exercise physiologist.

NIPS 7: 88-89,1992.

Segal, S. S. Communication among endothelial and smooth

muscle cells coordinates blood flow control during exercise. NIPS
7: 152-156,1992.

Stray-Gunderson, J. Unethical alterations of oxygen-carrying

capacity in endurance athletes. NIPS 3: 241-244, 1988.

Tenney, S. M. Athlete’s heart. NIPS 6: 199, 1991.

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