CARDIAC CYCLE

PRESENTER : DR HAIRUL ANUAR BIN MAHAT

 Describe sequence of events that occur
in the heart over one beat

Consists of two phases divided into six

DEFINITIO stages
N
Typically is described as beginning
in late diastole when the myocardium
is relaxed and the ventricles are
passively filling
Phases of cardiac cycle

■ Diastole
– Isovolumetric Ventricular Relaxation
– Rapid Ventricular Filling
– Slow Ventricular Filling
(The cycle begins here).
– Atrial Contraction
■ Systole
– Isovolumetric Ventricular Contraction
– Ejection
 SLOW VENTRICULAR PHASE

■ In slow ventricular filling:

The AV valves are open and the semi-lunar valves are closed
The ventricle is relaxed completely and fills slowly
The ventricles have been mostly filled during rapid ventricular filling and so the pressure gradient is
reducing.
The pressure in each ventricle is almost zero
Arterial pressure is falling, as it is end-diastole
CVP is slowly rising as the ventricle and atria fill
this period occurs after the y descent.
The ECG will show the beginnings of a P-wave at the end of this phase
ATRIAL CONTRACTION

■ The atria contract, and remaining blood in the atria is ejected into the ventricle. This
supplies 10% of the ventricular filling at rest, but up to 40% in tachycardia.
■ In atrial contraction:
■ Arterial pressure is still falling
■ The CVP waveform demonstrates the a wave as atrial contraction also causes blood to
reflux into the SVC
■ The ECG will show the PR interval
ISOVOLUMETRIC CONTRACTION
■ Ventricular pressure rises, and the AV valves close
This gives rise to the first heart sound, S1.
– As ventricular pressure is still less than systemic vascular pressure, the semilunar
valves remain closed
■ Arterial pressure is still falling
■ The CVP waveform shows the C (closure) wave, as the tricuspid valve herniates back
into the RA during ventricular contraction
There is a similar spike in LA pressure as the mitral valve also bulges back into the LA.
■ The ECG will show the remainder of the QRS or the start of the QT interval 
– Atrial repolarisation occurs at this stage, but is typically masked by ventricular
depolarisation
EJECTION

■ Pressure exceeds arterial pressure, the semilunar valves open and ejection occurs. Initial ejection
is rapid, but as ventricular pressure falls and systemic pressure rises the gradient falls ejection
becomes slower.
■ During ejection:
Arterial pressure rises rapidly, and is slightly less than ventricular pressure during this stage
The CVP waveform shows the x descent, as the shortening RV pulls the RA down, rapidly
lowering CVP
The ST segment shows on the ECG as the ventricles are fully depolarised, though the  T wave may
appear in late ejection
ISOVOLUMETRIC RELAXATION

■ When contraction is complete, the ventricles begin to relax. Inertia means that ejection continues for a short time.
■ During isovolumetric relaxation:
■ The semilunar valves close
This gives rise to the second heart sound, S2, and marks the beginning of isovolumetric relaxation.
– This occurs when ventricular pressure falls below vascular pressure
■ Arterial pressure begins to fall, interrupted by the dicrotic notch which is a brief increase in arterial pressure as
the semilunar valves close
■ The v wave is visible on the CVP waveform
Due to atria filling against closed AV valves.
■ The end of the T wave is visible on the ECG as ventricular repolarisation occurs
RAPID VENTRICULAR FILLING

■ filling occurs in this phase. This is because in early ventricular diastole the ventricle is still
relaxing and so a pressure gradient is maintained between the atria and ventricle. 
■ During rapid ventricular filling:
The AV valves open and ventricular filling occurs
This occurs when atrial pressure exceeds ventricular pressure.
Arterial pressure is falling
The y descent occurs when the AV valves open, causing a rapid drop in CVP as the ventricles
fill
No electrical activity is produced - the ECG shows the TP interval
Pressure-volume loop

Peak isovolumetric pressure

Ventricular pressure

Diastolic V-P Curve

End diastolic volume

Pressure-volume loop
200

Ventricular pressure (mm Hg)

c
b
100

d a
0
50 130
End diastolic volume (ml)
Pressure-volume loop
 Pressure-volume loop

Aortic valve closes

Aortic valve opens

Mitral valve opens

Mitral valve closes

End-systolic volume End-diastolic volume

 MYOCARDIAL OXYGEN
CONSUMPTION
 Myocardial oxygen supply is dependent on:
Coronary artery flow
Oxygen content of blood
Oxygen extraction 
Functionally, coronary artery flow is the determinant. This is because:
Oxygen content in individuals without pulmonary disease is maximal
Resting myocardial oxygen extraction is near-maximal (~70%)
This high ER makes the heart less tolerant of anaemia than organs with a low
ER.
RIGHT CORONARY BLOOD FLOW
LEFT CORONARY BLOOD FLOW
 MYOCARDIAL OXYGEN
CONSUMPTION
Myocardial oxygen consumption (MVO ) is 21-27ml.min . The three major determinants are:
2
-

1)Heart rate
A change in heart rate will change the number of tension-generating cycles,
causing a proportional change in MVO2.

2)Contractility
Refers to the rate of tension development as well as its magnitude. Changing ΔPΔt  will change MVO2.
MYOCARDIAL OXYGEN
CONSUMPTION
3)Ventricular wall tension
Ventricular wall tension is pressure work, or the work done by the ventricle to generate pressure but not to eject v
Wall tension is given by the Law of LaPlace
Wall Tension=P.r/2, where:
P = Pressure during contraction
r = Radius
Wall tension is therefore a function of:
Afterload
Increasing afterload will increase the pressure during contraction.
Preload
Increasing preload will increase radius, but to a lesser extent than increasing afterload.
This is because volume and radius are not directly proportional
 Minor Determinants
-External work can also be thought of as volume work, or the energy expended to
eject blood from the ventricle.
-This is encompassed by the area enclosed by the pressure-volume loop
Conversely, internal work is defined as the work required to change the shape
of the ventricle and prepare it for ejection

-On the pressure-volume loop internal work is represented by a triangle between the point o
volume, the end systolic point, and the beginning of rapid ventricular filling.
This is a minor determinant because the majority of ventricular work is generating the p
required to eject blood, not actually move volume
External work is of greater importance at high CO
External work is used to calculate cardiac efficiency, given by the equation:
Cardiac Efficiency=External Work Myocardial /O2 Consumption
 REFERENCES

1)Hall, JE, and Guyton AC. Guyton and Hall Textbook of Medical Physiology. 11th Edition.
Philadelphia,
PA: Saunders Elsevier. 2011. 

2)Chambers D, Huang C, Matthews G. Basic Physiology for Anaesthetists. Cambridge University

Press. 2015.

3)Wigger's Diagram (with some modifictions) from Wigger's Diagram. 21/3/2012.

(Image). By DanielChangMD (revised original work of DestinyQx); Redrawn as SVG by xavax. 
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