THE CARDIAC OUTPUT (COP)

DEFINITION: Cardiac output:it is the volume of the blood pumped by each ventricle per minute. In adult male with 70Kg body weight, It equals 5-6L/min at resting condition. It is affected by the heart rate & stroke volume . Stroke volume: the volume of the blood pumped by each ventricle per beat. It is about 70 ml/beat. Cardiac output varies with the body size; women have a small output than men, and the cardiac output of the children is less than that of adults. The correlation between cardiac output & the body surface is the cardiac index which is the cardiac output per square meter surface area. The average value is 3.2L/min/m2. End diastolic volume:the volume of blood in each ventricle at the end of diastole. It equals 130ml/beat; it is affected by the venous return End systolic volume:is the volume of blood in each ventricle at the end of systole. It equals 60 ml/beat; it is affected by arterial blood pressure & cardiac contractility (increased arterial blood pressure and decreased cardiac contractility decreases stroke volume & increases end systolic volume).

Ejection fraction: the ratio of stroke volume to end diastolic volume (70/130 = 65%). It reflects the contractile state of the cardiac muscle; it decreases in heart failure due to pump failure.
CARDIAC OUTPUT = STROKE VOLUME (SV) X HEART RATE (HR)

C O = 70ml/beat x 75beats /min 5 L/min

Factors affecting the cardiac output

i. ii. iii. Venous return (preload) The heart rate. Efficacy of cardiac contractility.

iv.

The arterial blood pressure (after load).

I.VENOUS RETURN (PRELOAD) Definition : It is the volume of blood that flows from the veins to the right atrium per min. The preload is the degree by which the myocardial fiber is stretched before it contracts (at the end of diastole). It is influenced by the venous return which affects the end diastolic volume and the tension developed in the ventricular wall (according to Frank Starling law).

Several mechanisms help to return the venous blood back to the right atrium:
1. pressure gradient for venous return: it is the difference between the central venous pressure (in the right atrium) and the peripheral venous pressure 2. gravity: Normally the venous pressure gradient is enough to return the venous blood from the tissues to the heart in the recumbent position. However, on standing it will not be able to do so because the force of gravity will show its effect; thus below the heart the venous return from the lower limbs and abdomen is decreased.. However, many factors come into play to secure an adequate venous return against gravity force. 3. The diameter of arterioles: arteriolar dilation increases venous return, while arteriolar constriction decreases venous return. 4. The capillary tone: it is the number of partially or totally closed capillaries.

It equals 80-90% . So only 10% of the capillaries are opened under the normal resting conditions, this fraction maintains the venous return. However, if all the capillaries are opened at the same time, blood will accumulate in the capillaries and no venous return would occur (as in histamine shock). 5. The skeletal muscle pump: The contraction of voluntary muscles squeezes the blood from the capillaries and small veins that lie between the fibers. Voluntary muscles; therefore act as peripheral hearts, the activity of which is essential for maintaining the circulation against the earths gravity. 6. The venomotor tone: Venomotor tone: is vasoconstrictor sympathetic discharge to the muscular coat of veins, preventing their distention which is very dangerous. Veins have a great capacity and they contain more than 60% of the total blood volume. If the venomotor tone is much lowered, much blood would stagnate in the veins and the venous return and cardiac output are markedly reduced.

7. The thoracic pump: inspiration increases the intra-thoracic pressure negativity and intra-abdominal pressure positivity and this increases the venous return. During expiration the opposite occurs. 8. Contraction of blood reservoirs (pulmonary veins, spleen & veins in the skin and liver sinusoids). 9. Tissue metabolism :when increased , it increases the venous return as during muscular exercise. All these factors increase the venous return, the end-diastolic volume, the stroke volume & the cardiac output. II.HEART RATE

The heart rate has a direct effect on the cardiac output, if it increases, the cardiac output increases. However, Severe tachycardia or bradycardia Causes Decreased cardiac output Too much increase in heart rate shortens the diastolic time, and decreases the end-diastolic volume, force of contraction & stroke volume. Too much decrease in heart rate prolongs the diastolic time, and increases the end-diastolic volume, causing over stretch of myocardium, decreased force of contraction & stroke volume III.CARDIAC CONTRACTILITY (condition of myocardium) The myocardial contractility exerts a major effect on the stroke volume. Increase in the force of myocardial contraction, increases the cardiac output up to 30l/min in healthy hearts. IV.ARTERIAL BLOOD PRESSURE (AFTERLOAD) An increase in the arterial blood pressure decreases the stroke volume & the cardiac output transiently.. When the BP against which the heart pumping is raised, the heart puts out less blood than it receives for several beats. Blood accumulates in the ventricles and the size of the heart increases. The distended heart beats more forcefully (Frank-Starlings Law), and the output returns to its previous level. Conversely, when the resistance is reduced the output rises transiently but the size of the heart decreases, and the output falls to the previous constant level, according to Frank-Starlings Law. Therefore, it follows that changes in the arterial blood pressure in a normal heart have no effect on the output provided the venous return is kept constant. Within a few beats the heart adjusts its diastolic volume to the new level of work it has to perform.