CORONARY

CIRCULATION
By Sridip Haldar
CORONARY CIRCULATION

• Coronary circulation is the circulation of blood in the

blood vessels that supply the heart muscle
(myocardium). Coronary arteries supply oxygenated
blood to the heart muscle. Cardiac veins then drain away
the blood after it has been deoxygenated.
• Cessation of heart functions for more than a couple of
minutes is life threatening. Therefore, it is essential to
maintain an uninterrupted and adequate blood supply to
the heart.
BLOOD SUPPLY

• Arterial Supply

The heart is supplied by right and left coronary arteries that

originate from the root of the aorta behind right and left cusps
of aortic valve respectively
• The right coronary artery principally supplies the right
ventricle and the right atrium, and the left coronary artery
supplies the left ventricle and the left atrium.
• Thus, the coronary arteries are end arteries in human beings
as the territories of blood supply by these arteries do not
overlap.
• The sinuses of Valsalva (small outpouches of the aorta) are Course and branches of right and
present behind the semilunar valves where the eddy currents left coronary arteries.
develop which keep the valve leaflets away from the wall of Note there is no anastomosis
the vessels during systole. between these two arteries.
BLOOD SUPPLY (CONTD.)

• Venous Drainage
• The heart has multiple venous drainage systems. The major system consists of the coronary
sinus and the anterior cardiac veins that drain into the right atrium.
• The minor systems consist of arteriosinusoidal vessels that drain from arterioles to cardiac
chambers, thebesian veins that drain from capillaries to cardiac chambers, and
arterioluminal vessels that directly drain from coronary arteries to heart chambers

Innervation of Coronary Blood Vessels

• The coronary blood vessels are supplied by
sympathetic and parasympathetic fibers.
• Sympathetic innervation: Sympathetic stimulation to the heart causes coronary
vasodilation as coronary arteries are rich in α receptors.
• Parasympathetic innervation: Parasympathetic stimulation to the heart causes
BLOOD SUPPLY (CONTD.)

•Special Features of Coronary Circulation

• Heart receives its major blood supply during diastole. Coronary blood flow decreases during
systole and increases during diastole. The cardiac blood vessels are mechanically compressed
during systole due to contraction of the ventricular muscle. Therefore, blood flow during
systole decreases to the heart muscle.
• The coronary arteries are end-arteries. Therefore, blockage of the coronary arteries results in
ischemia and infarction of the cardiac muscles supplied by the artery.
• The metabolic regulation of coronary circulation is well developed. Therefore, coronary blood
flow is adjusted according to the metabolic need of the myocardium.
• The heart utilizes wide varieties of substrates for its metabolism. These include free fatty
acids, glucose, pyruvate, lactate, ketone bodies, and amino acids. But the major source (about
1/3) of energy supply is free fatty acids.
• Heart muscle extracts about 80% of the oxygen from the arterial blood. Thus, arteriovenous
oxygen difference is very high in heart even at rest. Therefore, major method to increase the
oxygen supply to the heart as required during exercise is to increase the coronary blood flow.
BLOOD SUPPLY (CONTD.)

• Normal Values
• Heart weighs about 300 g. The blood flow to the heart is
approximately 250 mL per minute, which is about 85 mL per 100
gm of the cardiac tissue per minute.
• The rate of coronary blood flow is the second highest in the body,
next to the renal blood flow, which is 420 mL per 100 g of tissue
per minute.
• The coronary blood flow constitutes about 4.7% of the total
cardiac output. However, the rate of oxygen consumption of heart
is highest of all organs of the body, which is 9.7 mL per 100 g of
tissue per minute.
MEASUREMENT OF CORONARY BLOOD FLOW

• Coronary blood flow is measured by direct method or indirect methods. Indirect methods are Fick
method or radionuclide method.

• Direct Method
• Coronary blood flow can be measured directly by placing an electromagnetic flow meter in the
coronary artery. This is used in experimental animals and in humans undergoing open-heart
surgery.

• Using Fick Principle

• In this method, subject inhales a mixture of air and an inert gas (like nitrous oxide) till the gas is
distributed in the tissues according to its partition co-efficient. Then the arterial blood (from any
peripheral artery) and venous samples (from coronary sinus) are collected. The coronary blood
flow is calculated as the ratio of the amount of the inert gas passing through the coronary arteries
in unit time to the average arteriovenous gas concentration difference.
MEASUREMENT OF CORONARY BLOOD FLOW
(contd.)

Amount of inert gas taken up/min

Blood Flow =
Arteriovenous difference of the gas

Radionuclide Methods
• A radioactive substance like thallium (201TI) is injected
intravenously.
• The gamma camera is placed on the chest to monitor the thallium uptake
by the heart. Radioactive xenon (133Xe) can also be used for the purpose.
• By this method, the difference in blood supply through individual arteries
to different parts of the heart can also be measured.
REGULATION OF CORONARY BLOOD FLOW
• Coronary blood flow is regulated by neural factors, metabolic factors, physical factors
and autoregulatory mechanisms.

• Neural Regulation
• Neural regulation is by either sympathetic or parasympathetic fibers.
• Sympathetic Control
• Stimulation of sympathetic fibers produces vasodilation. This is due to the
predominance of beta-receptors in the coronary vessels (stimulation of beta receptors
results in vasodilation). Vasodilation also occurs partly due to the deposition of
metabolites as sympathetic stimulation accelerates cardiac activity that increases
myocardial metabolism.
• Parasympathetic Control
• Parasympathetic (vagal) stimulation causes vasodilation, but there is sparse
parasympathetic innervation of the coronary blood vessel.
REGULATION OF CORONARY BLOOD FLOW
(contd.)

• Metabolic Regulation
• Metabolic regulation of blood flow is well developed in the heart. A close
relationship exists between the coronary blood flow and the oxygen
consumption of myocardium. The metabolic factors that cause coronary
vasodilation are hypoxia, increased local concentration of carbon dioxide,
increased hydrogen and potassium ion concentration, accumulation of
lactate, adenosine, and adenine nucleotide, and increased release of
prostaglandins locally.
• Autoregulation
• An autoregulatory mechanism exists for the coronary blood flow, which
maintains a normal blood flow within the pressure range of 70–110 mm Hg.
REGULATION OF CORONARY BLOOD FLOW
(contd.)

• Physical Factors Blood flow into

left coronary
• The blood flow to the cardiac muscle is artery (LCA) and
right coronary
dependant on the myocardial tension, the artery (RCA)
during systole
pressure that builds up in the muscle and diastole (A).
Note
during contraction. This is the primary that the flow is

factor in determining coronary perfusion. phasic, being less

during systole
The vasocompression during myocardial and significantly
more during
contraction decreases the coronary blood diastole,
especially in the
flow. Coronary blood flow increases LCA, which is
inversely
during diastole proportional to left ventricular pressure as reflected
through aortic pressure recording.
CLINICAL IMPORTANCE

• Coronary Artery Disease

• Decreased blood flow to the heart leads to myocardial ischemia (angina pectoris)
and, if severe and prolonged, results in myocardial infarction (the heart attack).
• This is one of the commonest cause of sudden death, especially in the developed
countries. Recently, the incidence of coronary disease has also increased in
developing nations.
• It usually occurs due to coronary atherosclerosis. Usually, the disease starts with
angina, and infarction occurs when the obstruction occupies at least 75% of the
lumen of the coronary artery.
• The known risk factors for CAD are age (> 40 years), gender (males are more
susceptible), family history, smoking, hypertension, hypercholesterolemia,
diabetes, hemostatic factors (platelet activation, fibrinogen, antiphospholipid
antibody), physical inactivity, obesity, alcohol intake, hyperhomocysteinemia and
stress.
CLINICAL IMPORTANCE (contd.)

• Angina Pectoris
• Angina literally means chest pain. Angina pectoris refers to the chest pain due to
ischemia of the cardiac muscle. The pain is usually felt in the chest below the sternum
toward the left side. The cause of pain is myocardial ischemia due to decreased blood
supply. The pain typically radiates to the ulnar border of the left hand, but it can also
radiate to the back or even to the neck or abdomen.

• Myocardial Infarction
• Infarction (ischemic cell death) occurs when the ischemia is prolonged, following more
than 75% obstruction of the coronary arteries.
• The factors that precipitate acute myocardial infarction (AMI) are spasm of the coronary
artery at the site of atherosclerosis, platelet aggregation at the site of obstruction, and
hemorrhage into the atherosclerotic plaque of the coronary artery.
• Stress is known to induce coronary artery spasm.
• AMI causes severe chest pain that radiates along the ulnar border of the upper arm, arm
CLINICAL IMPORTANCE (contd.)

• Diagnosis
Diagnosis of AMI is based on specific
electrocardiographic changes, elevation of
enzymes specific for myocardial damage, and
typical clinical presentation of the patient.
• Typical ECG changes: The ECG is very useful for
diagnosing and locating areas of infarction. In
acute infarction, the first change to occur is the
ST segment elevation in the ECG leads recorded
with electrodes placed over chest representing
the infarcted area
ECG changes in acute myocardial
infarction. Note, ST elevation is the
prominent feature.
CLINICAL IMPORTANCE (contd.)

• Change in enzymes in the plasma: The damaged myocardium

releases enzymes into the circulation. Detection of elevated level of
these enzymes(creatine kinase,lactate dehydrogenase) plays an
important role in the diagnosis.
• Typical clinical presentation: The severe chest pain associated with
excessive sweating with (or without) radiation to the ulnar border of
the left hand in a person above 40 years is highly suggestive of AMI.
• Coronary angiography: Coronary angiography will show the details
of contour of the coronaries and the site and extent of obstruction in
the arteries
CLINICAL IMPORTANCE (contd.)

• Physiological Basis of Treatment

• The treatment of angina pectoris and acute myocardial infarction
consists of both medical and surgical interventions.
• Medical Treatment
• Treatment for AMI should start at the earliest possible.
• Vasodilators: Nitrates like nitroglycerin produce prompt improvement,
as they are potent vasodilators. They cause arterial dilation that
decreases the afterload, and cause venodilation that decreases the
preload.
• Streptokinase: Streptokinase causes lysis of the intracoronary clot when
injected intravenously. It facilitates conversion of plasminogen to
plasmin that causes fibrinolysis.
CLINICAL IMPORTANCE (contd.)

• Coronary angioplasty: The mainstay of treatment of

myocardial infarction is the removal of obstruction in the
coronary artery at the earliest possible. Therefore (if facilities
are available), immediately following the confirmation of
diagnosis, a catheter containing a balloon is inserted into the
coronary artery and then the balloon is inflated at the site of
obstruction to dilate the constricted artery. This procedure is
called coronary angioplasty.
• Calcium channel blockers: Calcium channel blockers like
verapamil are useful as they produce coronary vasodilation.
• Antiplatelet aggregating agents: The commonly used drug to
prevent platelet aggregation is low dose of aspirin.
CLINICAL IMPORTANCE (contd.)

• Surgical Treatment
• The definitive treatment of myocardial infarction is to bypass the
block in the artery by implanting a vessel in the heart, taken from
other parts of the body (bypass surgery). This is called coronary
artery bypass graft (CABG).
• The grafted artery bypasses the blocked coronary artery. Usually,
the artery is directly connected from aorta to the ventricular
muscle. Therefore, it is called aortic CABG.