Coronary Circulation: Dr. Syma Rizwan

CORONARY CIRCULATION
Dr. Syma Rizwan
Heart Anatomy
Approximately the size of your fist Location
Superior surface of diaphragm Left of the midline Anterior to the vertebral column, posterior to the sternum
Heart Anatomy
Figure 18.1
Coverings of the Heart: Anatomy

Pericardium a double-walled sac around the heart composed of:
A superficial fibrous pericardium A deep two-layer serous pericardium
The parietal layer lines the internal surface of the fibrous pericardium The visceral layer or epicardium lines the surface of the heart They are separated by the fluid-filled pericardial cavity
Coverings of the Heart: Physiology

The pericardium:
Protects and anchors the heart Prevents overfilling of the heart with blood Allows for the heart to work in a relatively friction-free environment
Pericardial Layers of the Heart
Figure 18.2
Heart Wall
Epicardium visceral layer of the serous pericardium Myocardium cardiac muscle layer forming the bulk of the heart Fibrous skeleton of the heart crisscrossing, interlacing layer of connective tissue Endocardium endothelial layer of the inner myocardial surface
Most people believe that the heart does not need arteries supplying it with blood since blood is passing though it all the time . the truth is that the blood which passes thorough the chambers of the heart does not supply the heart muscle itself because a coating called the endocardium lines the inside of the chambers. But even if this lining did not exist the blood supply provided simply by contact between the passing blood and the inside of the muscle walls would not be nearly enough because the muscle of the heart is the hardest working muscle in the body.
Coronary circulation provides an amazing amount of capillaries to the the cardiomyocytes. There is a capillary near almost every cardiomyocyte. The resting coronary blood flow in the resting human being averages 70 ml/min/100 g heart weight, or about 225 ml/min, which is about 4 to 5 percent of the total cardiac output.
Coronary Circulation
Coronary circulation is the functional blood supply to the heart muscle itself Collateral routes ensure blood delivery to heart even if major vessels are occluded
Coronary Circulation
I. Results of coronary artery disease (CAD)
A. 1/3 of all deaths due to CAD B. 45% of all deaths are cardiovascular (only 22% cancer) II. Risk factors for CAD A. Not Reversible 1. Aging 2. Male Sex 3. Genetic Predisposition
II. Risk Factors for CAD (contd)

B. Reversible 1. Cigarette smoking HDL and doubles chances of dying from heart attack) 2. BP vascular damage 3. Obesity - doubles mortality 4. Left ventricular hypertrophy
II. Risk Ffactors for CAD (contd)

C. Partially reversible 1. Cholesterol or triglycerides (saturated fat in diet cholesterol) 2. Hyperglycemia or diabetes mellitus 3. Low levels of HDL D. Others 1. Physical inactivity 2. Personality type 3. C-reactive protein
External Heart: Vessels that Supply/Drain the Heart (Anterior View)

Arteries right and left coronary (in atrioventricular groove), marginal, circumflex, and anterior interventricular arteries Veins small cardiac, anterior cardiac, and great cardiac veins
R coronary artery From ascending aorta (supplies most of the right ventricle, as well as the posterior part of the left ventricle) Two branches Posterior interventricular artery Supplies R atrium and Ventricle Marginal artery L coronary arteryFrom ascending aorta Two branches Anterior interventricular artery (LAD) Branches to R&L ventricle interventricular septum Circumflex artery Supplies L atrium Coronary sulcus
from the left ventricular muscle by way of the coronary sinus, which is about 75 percent of the total coronary blood flow. from the right ventricular muscle returns through small anterior cardiac veins that flow directly into the right atrium, A very small amount of coronary venous blood also flows back into the heart through very minute thebesian veins, which empty directly into all chambers of the heart.
External Heart: Posterior View
Figure 18.4d
Coronary Circulation: Arterial Supply
Figure 18.7a
Coronary Circulation: Venous Supply
Figure 18.7b
III. Coronary Flow = 225 ml/min

A. Epicardial vessels B. Subendocardial vessels (large plexus)
Epicardial and Subendocardial Vasculature
Figure 21-5; Guyton & Hall
Changes in Coronary Flow during the Cardiac Cycle
CORONARY BLOOD FLOW
SUBENDOCARDIAL FLOW
SUB. EPI.
EPICARDIAL FLOW
SYSTOLE
DIASTOLE
Controllers of Coronary Flow

A. Local Muscle Metabolism the coronary blood flow does increase almost in direct proportion to any additional metabolic consumption of oxygen by the heart Myocardial O2 consumption PDV = pump work B. Adenosine - related to O2 In the presence of very low concentrations of oxygen in the muscle cells, a large proportion of the cell's ATP degrades to adenosine monophosphate;
Others include
adenosine phosphate compounds, potassium ions, hydrogen ions, carbon dioxide, prostaglandins, and nitric oxide.
IV. of Coronary Flow (contd) C.Controllers Nervous stimuli
directly and indirectly (sympathetic). the epicardial coronary vessels have a preponderance of alpha receptors, whereas the intramuscular arteries may have a preponderance of beta receptors 1. Mainly affects epicardial flow (a 2. Little effect of parasympathetics. 3. b sympathetic s subendocardial flow
The indirect effects result from secondary changes in coronary blood flow caused by increased or decreased activity of the heart The indirect effects, which are mostly opposite to the direct effects, play a far more important role in normal control of coronary blood flow.
IV. Controllers of coronary flow (contd)
D. Others 1. K+ 2. CO2 3. Kinins 4. Prostaglandins 5. EDRF
V. Energy supply for heart A. Fat metabolism - 70% B. Glycolysis Within as little as 30 minutes of severe coronary ischemia, as occurs after a myocardial infarct, about one half of the adenine base can be lost from the affected cardiac muscle cells. this loss can be replaced by new synthesis of adenine at a rate of only 2 percent per hour.
VII Causes of Ischemic Heart Disease Causes of Ischemic Heart Disease. Causes A. Atherosclerosis of Ischemic Heart Disease
1. Intimal damage 2. permeability of intima possibly to monocytes 3. Subintimal deposit of cholesterol and fats (foam cells) 4. Necrosis 5. Fibrous repair 6. Calcification
VII. Causes of Ischemic Heart Disease

(contd)
B. Thrombus C. Coronary artery spasm 1. Emotional stress 2. Sympathetics
VIII. Result Results of Ischemic Heart Disease s of Ischemic Heart Disease Results A. Partial obstruction of Ischemic Heart Disease
B. Cannot autoregulate C. Not too noticeable early during rest, but exercise pain D. Mortality 1. Much worse if left main coronary affected 2. LAD is next most critical vessel
VIII. Results of Ischemic Heart Disease

(contd)
E. Angina pectoris 1. Probably due to glycolysis and lactic acid 2. Exacerbated by exercise 3. Dont alarm patient
Coronary bypass operation
Angioplasty

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CORONARY CIRCULATION

Dr. Syma Rizwan

Coverings of the Heart: Anatomy

Coverings of the Heart: Physiology

Pericardial Layers of the Heart

II. Risk Factors for CAD (contd)

II. Risk Ffactors for CAD (contd)

External Heart: Vessels that Supply/Drain the Heart (Anterior View)

External Heart: Posterior View

Coronary Circulation: Arterial Supply

Coronary Circulation: Venous Supply

III. Coronary Flow = 225 ml/min

Epicardial and Subendocardial Vasculature

Figure 21-5; Guyton & Hall

Changes in Coronary Flow during the Cardiac Cycle

CORONARY BLOOD FLOW

Controllers of Coronary Flow

IV. of Coronary Flow (contd) C.Controllers Nervous stimuli

IV. Controllers of coronary flow (contd)

D. Others 1. K+ 2. CO2 3. Kinins 4. Prostaglandins 5. EDRF

VII. Causes of Ischemic Heart Disease

B. Thrombus C. Coronary artery spasm 1. Emotional stress 2. Sympathetics

VIII. Results of Ischemic Heart Disease

Coronary bypass operation

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