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Cardiovascular Physiology and Pharmacology

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Cardiovascular Physiology and Pharmacology Cardiovascular Physiology and Pharmacology Peter Paal MD, PD, MBA, EDAIC, EDIC Department of Anaesthesiology and Intensive Care Hospitallers Brothers Hospital, Paracelsus Medical University Salzburg, Austria Honorary Senior Clinical Lecturer, Barts Heart Centre, William Harvey Research Institute, Barts & The London School of Medicine&Dentistry, Queen Mary University of London NO COI CARDIOVASCULAR PHYSIOLOGY Myocardial contraction and Frank- Starling-Relationship Actin-Myosin-Filaments Troponin complex C = Ca2+ binding Protein I = Inhibits interaction between actin and myosin T = Tropomyosin-binding Frank–Starling law of the heart (Starling's law) Stroke volume ↑ in response to end- diastolic volume↑ Volume ↑ stretches ventricular wall more forceful contraction Mechanism: Stretching increases affinity of troponin C for calcium greater number of actin-myosin cross-bridges form Relation of resting sarcomere length on contractile force Maximal force is generated with an initial sarcomere length of 2.2 µm 100 (%) 50 Tension Tension 0 Sensitivity of myofilaments for Ca2+ 15 Control 10 Desensitization 5 % Cell shortening % Cell 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Intracellular Ca2+ concentration (nM) Sensitivity of myofilaments for Ca2+ Sensitization 15 Control 10 5 % Cell shortening % Cell 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Intracellular Ca2+ concentration (nM) Change of myofilament sensitivity to Ca2+ 1,2 1,0 0,8 0,6 Temperature a b Protons Force Development Force 0,4 ADP Phosphate 0,2 Relative Relative 0,0 8 7 6 pCa (–log[Ca]) The cardiac cycle - Relation of Pressure against Volume Left ventricular pressure-volume loop Stroke work = SV x Pressure Sources of errors Does aortic pressure peak at end of systole? Does AV open when ventricular contraction begins? Volume change during isovolumetric contraction? All valves closed at the onset of systole? Systole Different Phases Isovolumetric contraction phase – All valves closed Ejection phase – Rapid ejection – Reduced ejection Diastole Different Phases Isovolumetric relaxation – Ends with MV opening Rapid filling phase Diastasis Atrial systole – Ends with start of systole Phases of cardiac cycle (sec) in adult Isovolumic contraction 0,05 Rapid ejection 0,09 Reduced ejection 0,13 Total systole 0,27 Protodiastole 0,04 Heart Rate 75/min Isovolumic relaxation 0,08 Rapid inflow 0,11 S:D = 1:2 Diastasis 0,19 Atrial systole 0,11 Total diastole 0,53 Katz, Physiology of the Heart 2nd ed., p363; 1992 Raven press Relationship of duration of systole + diastole with increasing heart rate End-systolic and end-diastolic pressure-volume relationship Inotropy Lusitropy Decreased contractility, increased end- diastolic volume Vasoconstriction, fluid retention Increased contractility, increased lusitropy Wiggers Diagram - Relation of Pressures, Volume and ECG over Time Aortic valve closes Wiggers-Diagram Aortic valve opens Mitral valve Mitral valve closes opens Central venous pressure waveform cusps bulge Filling of atria; atrial into atrium as concomitant systole MV closes ventricular systole x y atrial relaxation; MV opens; ventricle contracts, rapid drainage downward move- into ventricle ment of base Simultaneous plotting of ECG and central- venous pressure Myocardial Perfusion, Oxygen Supply, Oxygen Demand Anatomy of the coronary arteries Frank Netter, 1990 SYSTOLE DIASTOLE 120 Arterial Blood Pressure 100 80 Left Coronary Artery Flow 0 Flow Right Coronary Artery Flow 0 Flow Main determinants of myocardial oxygen supply O2-Content of coronary blood – Haemoglobin Coronary perfusion – Coronary resistance – Diastolic aortic pressure – LVEDP – Heart Rate Main natural mechanism to increase supply: – Coronary vasodilation (!) – Coronary oxygen extraction already maximal at rest! Main determinants of myocardial oxygen demand Heart Rate – Tachycardia increases oxygen demand – Bradycardia decreases oxygen demand (e.g. b-Blockers) Relationship of duration of systole + diastole with increasing heart rate Main determinants of myocardial oxygen demand Heart Rate – Tachycardia increases oxygen demand – Bradycardia decreases oxygen demand (e.g. b-Blockers) Myocardial contractility – Inotropes increase oxygen demand (e.g. epinephrine) – b-Blockers decrease oxygen demand Effects of Milrinone or Levosimendan on Myocardial Oxygen Consumption Kaheinen, J Cardiovasc Pharmacol 43:555, 2004 Main determinants of myocardial oxygen demand Heart Rate – Tachycardia increases oxygen demand – Bradycardia decreases oxygen demand (e.g. b-Blockers) Myocardial contractility – Inotropes increase oxygen demand (e.g. epinephrine) – b-Blockers decrease oxygen demand Wall tension of the myocardium – High wall tension increases oxygen demand – Decrease of wall tension decreases oxygen demand Wall tension of the myocardium Laplace‘s Law 푝 푥 푟 T = wall tension T = 2ℎ p = internal pressure r = internal radius h = wall thickness Increase in preload ± afterload increases wall tension e.g. Nitrates decrease wall tension Dilated cardiomyopathy increases wall tension Ventricular hypertrophy decreases wall tension Same pressure, same stroke volume, higher wall stress Cardiovascular Reflexes Cardiovascular reflexes = neural feedback loops Afferent Activity Regulation and CNS Heart modulation of Vasomotor Vasculature cardiac function Center Efferent Activity Cardiovascular reflexes Baroreceptor Reflex Bainbridge-Reflex Bezold-Jarisch-Reflex Valsalva Manoeuvre Baroreceptor Reflex Definition Homeostatic mechanism for maintaining blood pressure – Elevated blood pressure reflexively decreases heart rate + blood pressure – Decreased blood pressure increases heart rate + blood pressure Baroreceptors Afferents Target: Solitary tract nucleus = vasomotor center Pressure sensing results in greater afferent activity which inhibits vasomotor center Baroreceptor Reflex Efferents To heart – Primarily governs rate To kidney To peripheral vasculature – Primarily governs degree of vessel constriction Subdivisions – Carotid baroreceptor reflex - Heart – Aortic baroreceptor reflex - Vascular Bainbridge-Reflex Definition Rapid intravenous infusion of volume produces tachycardia Tachycardia is reflex in origin – Stretch receptors in the right and left atria – Vagus nerve constitutes afferent limb – Withdrawal of vagal tone primary efferent limb Bainbridge, The influence of venous filling upon the rate of the heart. J Physiol 50:65–84, 1915 Bezold-Jarisch-Reflex Definition Inhibition of sympathetic outflow to blood vessels and the heart Mediated by mechano- and chemosensitive receptors located in the wall of the ventricles “Preservation” of the heart – Vasodilation during heart failure – Hypotension – Bradycardia Apnea possible Possible cause of profound bradycardia and circulatory collapse after spinal anesthesia Albert von Bezold (1836 – 1868) and Adolf Jarisch Jr. (1891–1965) The Valsalva Manoeuvre Test of – Sympathetic nerve system function – Parasympathetic nerve system function Straining by blowing into mouthpiece against a pneumatic resistance while maintaining a pressure of 40 mmHg for 15 sec Four phases of the Valsalva Manoeuvre 1. BP ↑ via mechanical factors 2. BP ↓ (due to ↓ venous return); reflex HR ↑ and SVR ↑ return of BP despite SV ↓ 3. BP ↓ via mechanical factors after expiratory pressure is released 4. Venous return ↑ and SV ↑ (back to normal over several min), but PVR and CO cause BP ↑↑ and HR ↓ (reflex) Four phases of the Valsalva Manoeuvre CARDIOVASCULAR PHARMACOLOGY Synthesis of dopamine, norepinephrine and epinephrine (1) Phenylalanine NH2 CH2 – CH2 COOH Tyrosine NH2 CH2 – CH2 COOH HO Dopa NH2 HO CH2 – CH2 COOH HO Synthesis of dopamine, norepinephrine and epinephrine (2) Dopamin HO CH2 – CH2 – NH2 Norepi- HO OH nephrine HO CH – CH2 – NH2 Epi- OH HO nephrine HO CH – CH2 – NH – CH3 HO Dobutamine, Phenylephrine, Efedrine are synthetic! Degradation of catecholamines Example: Dopamine Catecholamines act by stimulating adrenergic receptors b-adrenergic receptors – b1 – Cardiac stimulation (positive inotropic, lusitropic, chronotropic) – Agonists, e.g. Isoprenaline, Dobutamine, Epinephrine – Antagonists, e.g. Esmolol, Metoprolol, Atenolol, Bisoprolol, Carvedilol – b2 – Smooth muscle relaxation, (increased myocardial contractility) – Agonists, e.g. Salbutamol, Terbutalin, Salmeterol – Antagonists, e.g. Propranolol – b3 – Enhancement of lipolysis, smooth muscle relaxation – Agonists + Antagonists, in development e.g. Solabegron Ca2+ b1 -Adrenoceptor Dobutamine, Epinephrine Gs A P C Milrinone PDE ATP cAMP Ca2+ Protein Kinase A Sarc. Ret. TnI Actin Ca2+ 2+ TnC Ca Myosin PL 2+ ATP Ca Ca2+ Catecholamines act by stimulating adrenergic receptors a-adrenergic receptors – a1 – Vasoconstriction, renal sodium retention, decreased gastrointestinal motility – Agonists, e.g. Norepinephrine, Phenylephrine, Etilefrine, Metaraminol, Methoxamine, Epinephrine – Antagonists, e.g. Phentolamine, Phenoxybenzamine, Prazosin, Labetalol, Carvedilol – a2 – Central inhibition of sympathetic activity ( vasodilation, bradycardia) – Agonists, e.g. Clonidine, Dexmedetomidine – Antagonists, e.g. Phentolamine, Tolazoline a1 a2 b Gq Gi Gs Phospho- Adenylate- Adenylate- lipase C cyclase cyclase PIP2 DAG ATP cAMP ATP cAMP IP3 Ca2+ Ca2+ Heart muscle contraction Smooth muscle Inhibition of Smooth muscle Smooth muscle contraction transmitter contraction relaxation release glycogenolysis Dopamine Stimulates Dopamine-Receptors at low doses (1 – 3 µg/kg/min) – Various subtypes of Dopamine-receptors (D1-D5) – High receptor density in the proximal
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