CARDIAC CYCLE

BY DR. MUDASSAR ALI ROOMI (MBBS, M. PHIL)

DEFINITION OF CARDIAC CYCLE:

Period between start of one beat to start of next. It consists of one complete heart beat. It consists of one systole & one diastole.

INITIATION OF CARDIAC CYCLE:

Initiated by Cardiac Impulse, which originates from SA node.

EVENTS THAT OCCUR IN THE

CARDIAC CHAMBERS DURING CARDIAC CYCLE

Pressure Changes. Volume Changes. Production of Heart Sounds. Closure & Opening of Cardiac Valves. Electric Changes (ECG recording).

VENTRICULAR SYSTOLE (Peak of R wave of QRS complex to the end of T wave) ISO-VOLUMETRIC CONTRACTION MAXIMUM EJECTION (2/3)

0.31 sec

0.06 sec 0.11 sec

REDUCED EJECTION (1/3)

VENTRICULAR DIASTOLE (End of T wave to the peak of R wave of QRS complex) PROTODIASTOLE ISO-VOLUMETRIC RELAXATION 0.52 sec

0.14 sec

0.04 sec 0.06 sec

RAPID INFLOW
SLOW INFLOW / DIASTASIS ATRIAL SYSTOLE (after P wave)

0.11 sec
0.2 sec 0.11 sec

8 Phases of CARDIAC CYCLE

0.8 sec

PRESSURE CHANGES:
A) Pressure changes in left ventricle during cardiac cycle. B) Pressure changes in right ventricle during cardiac cycle. C) Pressure changes in atria.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 1 of cardiac cycle / Isovolumetric contraction of ventricle: At the start of ventricular systole L.V is full of blood (received from left atrium during previous diastole). Pressure in L.V at the start = 1-3 mm Hg. Now L.V begins to contract I.V.P (Intra-ventricular pressure) begins to rise closure of mitral valve / Left AV Valve 1st phase starts: Isometric Contraction Phase Or Isovolumetric Contraction Phase.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 1 of cardiac cycle / Isovolumetric contraction of ventricle (CONT) With closure of mitral valve ventricle is a closed chamber no change in blood volume ISO-VOLUMETRIC, as both valves are closed ISO-METRIC CONTRACTION (no change in length of muscle but rapid increase in I.V.P). When IVP rises just above 80 mm Hg opening of Aortic or Semilunar valve. Duration of I.V.C of Ventricle = 0.06 sec. With opening of Aortic valve, 2nd phase starts: MAXIMAL EJECTION PHASE.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 2 of cardiac cycle / Maximal Ejection Phase (M.E.P) / Rapid Ejection Phase (R.E.P): Ventricle muscle is contracting powerfully with opening of Aortic valve. Blood is ejected from ventricle (2/3 of stroke volume) Aorta (at maximum rate). 70% EMPTYING occurs in first 1/3 of ejection phase. In this phase: I.V.P maximum = 120 mm Hg. Duration of M.E.P = 0.11 sec.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 3 of cardiac cycle / Reduced Ejection Phase (R.E.P): Blood ejection (remaining 1/3 of stroke volume, 30% EMPTYING occurs in last 2/3 of ejection phase) from L.V Aorta, continues but at a reduced rate. I.V.P falls from maximum. This phase ends when I.V.P becomes equal to OR slightly less than AORTIC PRESSURE. Duration of R.E.P = 0.14 sec.

Duration of ventricular systole (3 phases):

1. Isovolumetric contraction = 0.06 sec 2. Maximum Ejection Phase = 0.11 sec 3. Reduced Ejection Phase = 0.14 sec So, Ventricular Systole = 0.31 sec

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 4 of cardiac cycle / Protodiastole: duration = 0.04 sec. At the junction of systole & diastole, but included in diastole. At this stage, I.V.P = Aortic Pressure or I.V.P is slightly less than Aortic pressure, BUT SMALL AMOUNT OF BLOOD CONTINUES TO OOZE, because of momentum. In protodiastole: THIS MOMENTUM IS OVERCOME due to further fall in I.V.P & there is some retrograde flow of Aortic blood in 1st part of Aorta closure of Aortic valve end of Protodiastole.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 5 of cardiac cycle / Isovolumetric Relaxation Phase (I.V.R): Starts with closure of Aortic valve. Why it is called ISOVOLUMETRIC RELAXATION?

ANSWER
Ventricle relaxation without change in volume, because: BOTH VALVES ARE CLOSED no change in blood volume Rapid fall in I.V.P because of relaxation. When (left ventricular pressure) < (left atrial pressure) Opening of left AV valve / mitral valve end of I.V.R phase. Duration of I.V.R = 0.06 sec.

Pressure changes in Left Ventricle (L.V) during cardiac cycle

Phase 6 of cardiac cycle / Rapid Inflow Phase (R.I.P) / Rapid filling phase (R.F.P):
Starts with opening of mitral valve. Blood from Left Atrium rapidly flows into Left Ventricle. 2/3 of ventricular filling occurs in this phase (during first 1/3 of ejection phase) Duration of R.I.P = 0.11 sec.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 7 of cardiac cycle / Slow Inflow Phase / Diastasis:

It appears that: No blood is flowing from Lt. Atrium Lt. Ventricle because: During last phase (R.I.P), most of blood Lt. Vent. Mitral valve is open Lt. atrium & Lt. Ventricle = common chamber whatever blood that returns in small amount from pulmonary veins Lt. Atrium Lt. Ventricle (through open valve) so it appears that no blood is flowing. Only slight filling of Lt. Ventricle in this phase. Duration of diastasis / Slow Inflow Phase = 0.20 sec. THE LONGEST PHASE OF CARDIAC CYCLE.

Pressure changes in Left Ventricle (L.V) during cardiac cycle:

Phase 8 of cardiac cycle / Atrial Systole: Last phase of cardiac cycle Lt. Atrium contracts pushes the blood from its cavity Lt. Ventricle 20% ventricular filling by atrial contraction. Atria contract towards the end of ventricular diastole. With atrial contraction, ventricular filling is complete. Duration: 0.11 sec. AV nodal delay allows atria to contract before ventricles begin to contract, at the end of ventricular filling.

Duration of ventricular diastole (5 phases):

Protodiastole = 0.04 sec Isovolumetric Relaxation = 0.06 sec Rapid Inflow Phase = 0.11 sec Slow Inflow Phase = 0.20 sec Atrial Systole = 0.11 sec Ventricular Diastole = 0.52 sec

Duration of Cardiac Cycle (8 phases):

= Duration of systole + diastole = (0.31) + (0.52) = [0.8 sec]

Pressure Changes in Right Ventricle:

Same phases as for Lt. ventricle. Same duration as for Lt. ventricle.

Only change in pressure levels & in names of valves.

Aortic valve is replaced by pulmonary valve. Mitral valve is replaced by Tricuspid valve.

Pressure Changes in Right Ventricle:

At the beginning of Rt. Vent. Systole: Pressure = 0-1 mm Hg. During I.V.C Pressure increases on the right side just exceeds 8 mmHg opening of pulmonary valve (above 80 mmHg, there was opening of Aortic valve). Maximum increase in pressure in Rt. Vent systole = 25 mmHg (it was120 mm Hg in Lt. vent.)

Pressure Changes in Right Ventricle:

Right ventricle & Pulmonary artery is a low pressure system. Pulmonary artery pressure variation: 8 25 mm Hg Aortic pressure variation: 80 120 mm Hg

Duration of cardiac cycle & heart rate:

Duration of cardiac cycle = 0.8 sec at heart rate = 70 beats / min. When heart rate increases duration of cardiac cycle decreases. Diastole is more affected as compared to systole with rapid heart rate. At heart rate = 180 / min, cardiac cycle duration = 0.33 sec: (systole = 0.18 sec, diastole = 0.15 sec).

QUESTION
At a very rapid heart rate: Cardiac output decreases, Why???

ANSWER
Because diastole becomes too short ventricular filling decreases decrease stroke volume & decrease in cardiac output, in spite of increase in heart rate.

Cardiac output:
Output of heart per unit time = 5 L / min in a resting supine man. Cardiac output = stroke volume x heart rate = 70 ml x 72 beats / min nearly equal to 5 L / min

Stroke volume (S.V):

Difference between End Diastolic Volume (EDV) & End Systolic Volume (ESV). S.V = EDV - ESV S.V = 120 50 = 70 ml When ventricular contraction is forceful ESV decreases (10-20 ml only). Normal is 50 ml. When venous return increases up to 200 ml or more EDV increases (normal = 120 ml)

EJECTION FRACTION:
Fraction of EDV that is ejected in one systole or one stroke = Ejection Fraction. Value of Ejection Fraction = 60% (usually). 65% in some books.

In Myocardial disease / heart failure Ejection Fraction decreases.

Pressure changes in Atria during the Cardiac Cycle:

Atrial systole duration = 0.11 sec Atrial diastole duration = 0.70 sec Atrial systole + Atrial diastole = 0.8 sec = cardiac cycle. Atrial diastole > Atrial systole, because basic function of atria is to receive blood from large veins & it can receive blood only when it is relaxed. 3 waves can be recorded from atria which represent atrial pressure changes: a-wave, c-wave & v-wave (Seen as Jugular Venous Pulse, not a true pulse, but a reflection of pressure changes in right atrium.

Pressure changes in Atria during the Cardiac Cycle:

a-wave: Due to increase in atrial pressure during atrial systole.

Pressure changes in Atria during the Cardiac Cycle:

c-wave: Recorded at beginning of contraction of ventricle. During isovolumetric contraction, ventricular pressure increases Cusps of AV valves are pushed into atrial cavity pressure rises in atria ascent of c-wave.

Pressure changes in Atria during the Cardiac Cycle:

The top of c-wave coincides with opening of semi-lunar valves (Aortic & Pulmonary). With opening of semi-lunar valves, 2nd phase starts, which is maximum ejection phase. It is later on followed by iso-volumetric relaxation of ventricle muscle length increases now AV valve is pulled to ventricular cavity atrial cavity increases pressure falls in the atria descent of c-wave.

Pressure changes in Atria during the Cardiac Cycle:

v-wave: Due to gradual increase in atrial pressure, resulting from venous filling of blood (from the venae cavae) into the atria, with closed AV valves ascent of vwave. Top of v-wave coincides with opening of AV valves rapid inflow phase decrease pressure in atria descent of vwave.

Right atrial pressure = Central Venous Pressure.

During most of cardiac cycle, this pressure remains almost zero. During wave a, c & v pressure rises. Otherwise remains almost zero. 4-6 mm Hg Rt. Atrium (during a, c, v) 7-8 mm Hg Lt. Atrium (during a, c, v)

JUGULAR VENOUS PULSE: (a, c, v waves)

Normally arteriolar pulse ends in arterioles & in veins no pulsation. But we can record pulsation in jugular vein, which is not a true pulse. It is just backward transmission of pressure changes in Rt. Atrium (a, c. v waves) transmitted in neck veins.

Significance of J.V.P:
ac interval coincides with PR interval of ECG.

ac interval increases in delayed AV conduction.

Significance of J.V.P:
a waves are absent in: ATRIAL FIBRILLATION. (a wave) > (c wave) in COMPLETE AV BLOCK. Giant a waves in TRICUSPID & PULMONARY STENOSIS.

Pulsating Neck Veins in CCF (Congestive Cardiac Failure).

Volume changes in Ventricles during Cardiac Cycle:

Beginning of ventricular systole: Ejection Phases: (Maximum Ejection Phase & Reduced Ejection Phase) Iso-volumic Relaxation Phase: Rapid Inflow Phase: Diastasis / Slow Inflow Phase: Atrial Systole:

Beginning of ventricular systole:

Ventricle is full of blood (collected during previous diastole, EDV = 120 ml) at the onset of ventricular systole.
This much volume is there at the start of ventricular systole. With this volume onset of Isovolumic / Isometric Contraction, with no change in blood volume.

Ejection Phases: (Maximum Ejection Phase & Reduced Ejection Phase)

Maximum Ejection Phase: 2/3 of Stroke Volume (total = 70 ml) is ejected out. Reduced Ejection Phase: Remaining 1/3 is ejected out.

After ejection phases, the volume of blood left behind is ESV = 50 ml.

Iso-Volumic Relaxation Phase:

No change in blood volume occurs.

Rapid Inflow Phase:

2/3 of ventricular filling.

Diastasis / Slow inflow phase:

Only slight filling occurs.

Atrial Systole:
Remaining 1/3 filling (30%). Now filling of ventricles is complete & EDV of 120 ml is left.

EJECTION FRACTION:
Fraction of EDV that is ejected in one systole or one stroke = Ejection Fraction.

Value of Ejection Fraction = 60% (usually). 65% in some books.

In Myocardial disease / heart failure Ejection Fraction decreases.

Sequence of systole in chambers of heart:

Right atrial systole begins earlier as compared to left atrial systole. Left ventricular systole begins earlier as compared to right ventricular systole. But blood ejection from right ventricle pulmonary artery, starts earlier as compared to ejection from left ventricle aorta, BECAUSE pressure in pulmonary artery < Aortic pressure.

Closure & Opening of Heart Valves:

AV VALVES: Are closed at the beginning of Isovolumic contraction Phase. Are open at the beginning of Rapid Inflow phase. AV valve closure is slow & soft & does not require backward flow of blood.

Cusps of AV valves are soft & thin because they are not subjected to increase in pressure & rapid blood flow.

Closure & Opening of Heart Valves:

SEMILUNAR VALVES: Are closed at the beginning of Isovolumic relaxation phase. Cusps of these valves are thick & heavier (as they are subjected to increased pressure & rapid blood flow). Their closure is rapid & requires backward flow of blood (incisura in case of Aortic valve).

Closure & Opening of both AV & Semilunar Heart Valves:

Forward pressure gradient opening. Backward pressure gradient closure. AV valves prevent, leakage of blood from ventricle atria, during ventricular systole (when pressure rises in ventricle). Semilunar valves prevent leakage of blood from large arteries ventricles, during ventricular diastole (when pressure falls in ventricle)

Heart Sounds:
During each cardiac cycle, 4 heart sounds are produced. These can be recorded in phonocardiogram. By auscultation we can hear / auscultate, 1st & 2nd heart sounds & sometimes 3rd as well. But 4th is Atrial heart sound, which is never auscultated normally. 1st & 2nd heart sounds are called as CLASSICAL HEART SOUNDS (as they are usually auscultated in normal subjects).

4 Auscultatory areas:
Pulmonary Area: Left 2nd intercostal space, sternal border. Aortic Area: Right 2nd intercostal space, sternal border. Apex. 4th intercostal space.

Mitral Area: Tricuspid Area:

4 basic factors affecting Heart Sounds:

Acceleration of blood: Sudden flow. Deceleration: Sudden stoppage of blood flow. Turbulance. Thickness of chest wall effects.

1st Heart Sound:

Characteristics: Long, soft, low pitched. (heard as LUBB) Frequency: 30 50 cycles / sec. Duration: 0.14 sec

1st Heart Sound:

CAUSES: Vibrations due to closure of AV valves, at the beginning of ventricular systole. Vibrations in ventricles & large vessels when ventricular muscle contracts. Vibrations when blood starts ejecting into large artery.

Physiological Splitting of 1st heart sound:

Mechanism: Tricuspid valve may close earlier than mitral.

Intensity of 1st heart sound:

Depends on: Force of ventricular systole. Rate of increase in ventricular pressure, during isovolumic contraction phase.

2nd Heart Sound:

Characteristics: Short, sharp, high pitched. (heard as DUBB) Frequency: 50 200 cycles / sec. Duration: 0.11 sec

2nd Heart Sound:

Minor causes: When blood flows from ventricle to large arteries, there may be turbulance.

Splitting of 2nd Heart Sound:

PHYSIOLOGICAL Increases or Widens during inspiration (0.5 sec) & decreases during expiration (0.02 sec or disappear). PATHOLOGICAL In bundle branch block, mainly right bundle branch block. Intensity of pulmonary component of 2nd heart sound is increased in pulmonary hypertension. Intensity of aortic component is increased in aortic hypertension

Cause of splitting: During inspiration venous return increases more blood returns to right atrium right ventricle more ejection delayed closure of pulmonary valve. Reverse occurs in expiration.

3rd Heart Sound:

Prominent sometimes in children. Can be made prominent by increasing venous return: i) exercise. ii) lying position. Low frequency sound. Duration: 0.04 sec. Best heard at: Apex of heart, in 5th intercostal space (mid-clavicular line). Cause: Vibrations produced in ventricular wall during Rapid Inflow Phase.

4th Heart Sound:

Not normally auscultated but recorded in phonocardiogram. Low frequency, low intensity sound. Produced just before 1st heart sound.

Also called ATRIAL HEART SOUND. Cause: Vibrations of ventricular wall, due to impact of blood pumped from the atrium ventricle, during Atrial Systole. Diseases: In CCF, 4th Heart Sound is auscultated.

MURMURS:
Abnormal heart sounds. Produced when: Valvular stenosis.

Valvular incompetence.
Hyperdynamic circulation: Hyperthyroidism, severe anemia (hemic murmurs)