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Coronary circulation

By Prof.
Soheir Helmy

Coronary circulation
It is concerned with the blood supplying
the cardiac muscles.
Coronary vessels: The heart is supplied by 2 coronary
arteries arising from the aorta just above
the aortic valve.
The left coronary artery suppliesthe LT.
atrium, the LT ventricle & the anterior part
of inter ventricular septum

Coronary circulation
The right coronary artery:- supplies the
RT. Atrium ,RT ventricle ,and the post.
Part of inter ventricular septum.
The coronary arteries are functional end
arteries. There are small anastomotic
connection between the 2 coronaries
which are not sufficient to supply the
cardiac muscle with blood if one of
them is occluded.

Coronary circulation

The heart comprise 0.5% of the total body weight...

.
Under resting condition the coronary blood flow is
about 5% of the COP , it is about 250 ml/min.

The coronary capillaries run parallel to the cardiac


muscle fiber ,and there is about one coronary capillary
for each muscle fiber

.All the capillaries are open all the time (there is no


vasomotion).

Most of the O2 is extracted from the blood as it passes


through myocardial capillaries.

O2 consumption of the heart

The heart has a very high basal O2 consumption. About


8-10 ml/100gm.
O2 in coronary artery = 19ml%
O2 in coronary vein = 5ml%
The highest arterio venous oxygen difference of all
organs.
Low venous O2 reserve
This is in contrast to other tissues.

Phasic changes in coronary blood flow

During systole:-

The coronary blood flow falls to a low value ,which is


opposite to the flow in all other beds in the body. Due to
strong compression of the ventricular muscles around
the intramuscular vessels.
This decrease in blood flow during systole is
compensated by O2 delivered from myoglobin.

During diastole:-

the cardiac muscle relaxes and


blood flows rapidly into the coronary arteries

Phasic changes in blood flow to the right ventricle are


less pronounced because of the lesser force of contraction.

Perfusion time

Any increase in heart rate affect diastolic time more


than systolic time and reduces the perfusion time.

Coronary blood flow

Regulation of coronary blood flow

Intrinsic mechanism
(autoregulation)

The coronary blood


flow is regulated by
the metabolic need of
the heart.
CBF is increased
when cardiac work
increased &vice versa

Extrinsic mechanism
Nervous factors
Chemical factors
Mechanical factors

Coronary perfusion pressure

During systole, intramuscular blood vessels are compressed and


twisted by the contracting heart muscle and blood flow to the left
ventricle is at its lowest.
In systole, intramyocardial blood is propelled forwards towards the
coronary sinus and retrogradely into the epicardial vessels, which
act as capacitors

During diastole when the muscle relaxes, Flow resumes


The coronary perfusion pressure is the difference between
the aortic diastolic pressure and left ventricular end-diastolic
pressure (LVEDP )
60- 160 mm Hg is the normal range for coronary perfusion

pressure

Intrinsic mechanism(autoregulation)
Oxygen demand is the major factor in local blood flow
regulation.
Oxygen lack (hypoxia) causes vasodilatation HOW?
Decrease O2 tension in the coronary blood has a direct
relaxing effect on the smooth muscles of the wall of the
coronary arteries.
Decrease O2 tension release of vasodilator substances
by the tissues such as adenosine, K , CO2 and bradykinin.

Extrinsic mechanism

1- nervous factors.

2- mechanical factors.

3-chemical factors

Nervous factors
Sympathetic stimulation: V.C by a direct effect
V.D by indirect mechanism through

increase
metabolic activity of the heart ,but the net result is an
increase in coronary blood flow.

Parasympathetic stimulation:Direct V.D effect.


It decrease H.R &the metabolic activity of the heart is
decreased. This lead to V.C and decrease coronary
blood flow.

Chemical factors:
2.

Nitroglycerin.
Long acting nitrates.

3.

Beta blockers e.g

1.

propranolol act by reducing


myocardial O2 consumption ,H.R and cardiac muscle
contractility.

4.

Calcium channel blockers.


All these chemicals produce coronary dilatation and are
important in the treatment of coronary artery diseases.

Anti

platelet drugs, anticoagulants and


lipid lowering drugs

These agents act inside the lumen to prevent


further reduction in the vessel diameter.
Statins inhibit, the enzyme involved in
cholesterol synthesis.
Antiplatelet drugs prevent platelet aggregation,
often the initial step in the formation of an
occlusive thrombus.
Antithrombin agents act at various sites in the
coagulation cascade to inhibit thrombin
formation.

Drugs acting on angiotensin


Angiotensin-converting enzyme inhibitors reduce
conversion of angiotensin I to angiotensin II.
These drugs reduce angiotensin-mediated
vasoconstriction and enhance myocardial perfusion by
vasodilatation without reflex tachycardia.
Over time, it also regulates fibrous tissue formation
after tissue injury.

Mechanical factors:

The heart rate.

Phases of Cardiac cycle.

Arterial blood pressure.

Heart rate
Total coronary flow is greater in diastole
than in systole.
Increased heart rate in normal subject:
Increased cardiac work &decreased
diastolic period >>restrict coronary flow
But at the same time there is an increase
in metabolism>>dilatation of coronary
vessels.

In heart with limited blood flow


Such as in coronary insufficiency
Increased heart rate may cause chest pain
(angina).
Because flow can not increase to meet the
increased O2 demand.

Heart rate

Decrease in the heart rate:-

The metabolic activity of the heart decreased.


The amount of vasodilator metabolic substances
will be decreased so the coronary blood flow
decreases to parallel the decrease in cardiac
metabolism.

Phases of Cardiac cycle.

The left ventricle:-

Gets its blood supply mainly during diastole.


during the contraction phase ,the left ventricular
myocardial fibers squeeze the coronary vessels
between them and stop the blood flow in them.
The right ventricle:

The contraction of myocardial fibers is weaker it


does not stop the flow in RT coronary vessels.
so the flow is continuous through out the cardiac
cycle.

Coronary artery diseases

Angina pectoris:-

Myocardial ischemia due to decreased coronary


blood flow.
It is characterized by short attacks of sever
pericardial pain which is mostly substernal and
usually radiate to the left shoulder and arm.
The attack is brought about by effort
,excitement ,and sudden exposure to cold.
Causes:- coronary spasm, atherosclerosis, aortic
stenosis ,and aortic regurgitation.

Coronary artery diseases


Myocardial infarction: It means necrosis of a part of the
myocardium due to sever prolonged
ischemia or sudden occlusion of a major
coronary artery.
It produce irreversible changes of the
muscle cells.