Cardiovascular physiology

Page i Fundamentals of Anaesthesia and Acute Medicine Cardiovascular Physiology Second edition Edited by Hans-Joachim Priebe Professor of Anaesthesia, University Hospital, Freiburg, Germany and Karl Skarvan Professor of Anaesthesia, University of Basel, Switzerland Page ii © BMJ Books 2000 BMJ Books is an imprint of the BMJ Publishing Group www.bmjbooks.com All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers First published in 1995 by the BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR Second edition published in 2000 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-7279-1427-8 Typeset in Great Britain by Apek Digital Imaging, Nailsea, North Somerset Printed and bound in Great Britain by J.W.Arrowsmith Ltd, Bristol Page iii Contents Contributors Foreword RONALD M JONES, ALAN R AITKENHEAD, PIERRE FOËX Preface HANS-JOACHIM PRIEBE, KARL SKARVAN Cardiac cellular physiology and metabolism HEINRICH TAEGTMEYER, ANNE B TAEGTMEYER Ventricular performance KARL SKARVAN Cardiac electrophysiology JOHN L ATLEE Coronary physiology HANS-JOACHIM PRIEBE The pulmonary circulation KEITH SYKES Regulation of the cardiovascular system NIRAJ NIJHAWAN, DAVID C WARLTIER Cerebral circulation DAVID K MENON Renal, splanchnic, skin, and muscle circulations NGUYEN D KIEN, JOHN A REITAN Microcirculation JAMES E BAUMGARDNER, ALEX L LOEB, DAVID E LONGNECKER 10 Anaesthesia and the cardiovascular system WOLFGANG BUHRE, ANDREAS HOEFT Index Page v vii viii 27 73 119 171 213 240 278 307 331 375 Page iv FUNDAMENTALS OF ANAESTHESIA AND ACUTE MEDICINE Series editors Ronald M Jones, Professor of Anaesthetics, St Mary’s Hospital Medical School, London, UK Alan R Aitkenhead, Professor of Anaesthetics, University of Nottingham, UK Pierre Foëx, Nuffield Professor of Anaesthetics, University of Oxford, UK Titles already available: Cardiovascular Physiology (second edition) Edited by Hans Joachim Priebe and Karl Skarvan Clinical Cardiovascular Medicine in Anaesthesia Edited by Pierre Coriat Intensive Care Medicine Edited by Julian Bion Management of Acute and Chronic Pain Edited by Narinder Rawal Neuro-Anaesthetic Practice Edited by H Van Aken Neuromuscular Transmission Edited by Leo HDJ Booij Paediatric Intensive Care Edited by Alan Duncan Forthcoming: Pharmacology of the Critically Ill Edited by Maire Shelly and Gilbert Park Anaesthesia for Obstetrics and Gynaecology Edited by Robin Russell Page v Contributors John Atlee III, MD Professor of Anesthesiology Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA James E Baumgardner, PhD, MD Assistant Professor of Anesthesia and Bioengineering Department of Anesthesia, University of Pennsylvania, Philadelphia, USA Wolfgang Buhre, MD Department of Anaesthesia, Georg-August Universität, Göttingen, Germany Andreas Hoeft, PhD, MD Professor of Anaesthesia and Chairman Department of Anaesthesia, Rheinische Friedrich-Wilhelms Universität Bonn, Germany Nguyen D Kien, PhD Professor of Anesthesiology Department of Anesthesiology, School of Medicine, University of California, Davis, USA Alex L Loeb, PhD Assistant Professor of Anesthesia and Pharmacology Department of Anesthesia, University of Pennsylvania, Philadelphia, USA David E Longnecker, MD Robert Dunning Dripps Professor and Chairman Department of Anesthesia, University of Pennsylvania, Philadelphia, USA David K Menon, MD, FRCP, FRCA Lecturer in Anaesthesia, University of Cambridge Director, Neurosciences Critical Care Unit, Department of Anaesthesia, Addenbrooke’s Hospital, Cambridge, UK Page vi Niraj Nijhawan, MD, MS Assistant Professor of Anesthesiology Zablocki Veterans Administration Medical Center, Milwaukee, Wisconsin, USA Hans-Joachim Priebe, MD, FRCA Professor of Anesthesiology University Hospital, Freiburg, Germany John A Reitan, MD Professor of Anesthesiology Department of Anesthesiology, School of Medicine, University of California, Davis, USA Karl Skarvan, MD Professor of Anaesthesia Department of Anaesthesia, University Hospital, Basel, Switzerland Keith Sykes, MB BChir, FRCA Emeritus Professor, Nuffield Department of Anaesthetics, University of Oxford, UK Anne B Taegtmeyer, BM BCh Clinical Research Fellow Cardiothoracic Surgery Division, National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, UK Heinrich Taegtmeyer, MD, DPhil Professor of Medicine Department of Internal Medicine, Division of Cardiology, University of Texas –Houston Medical School, Houston, USA David C Warltier, PhD, MD Professor of Anesthesiology, Cardiology and Medicine and Vice-Chairman of Research Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, USA Page vii Foreword The pace of change within the biological sciences continues to increase and nowhere is this more apparent than in the specialties of anaesthesia, acute medicine, and intensive care Although many practitioners continue to rely on comprehensive but bulky texts for reference, the accelerating rate of biomedical advances makes this source of information increasingly likely to be dated, even if the latest edition is used The series Fundamentals of anaesthesia and acute medicine aims to bring to the reader up to date and authoritative reviews of the principal clinical topics which make up the specialties Each volume will cover the fundamentals of the topic in a comprehensive manner but will also emphasise recent developments or controversial issues International differences in the practice of anaesthesia and intensive care are now much less than in the past, and the editors of each volume have commissioned chapters from acknowledged authorities throughout the world to assemble contributions of the highest possible calibre Three volumes will appear annually and, as the pace and extent of clinically significant advances varies among the individual topics, new editions will be commissioned to ensure that practitioners will be in a position to keep abreast of the important developments within the specialties Not only does the pace of advance in biomedical science serve to justify the appearance of an international series of this nature but the current awareness of the need for more formal continuing education also underlines the timeliness of its appearance The editors would welcome feedback from readers about the series, which is aimed at both established practitioners and trainees preparing for degrees and diplomas in anaesthesia and intensive care RONALD M JONES ALAN R AITKENHEAD PIERRE FOËX Page viii Preface In the few years since the first edition of Cardiovascular Physiology, knowledge in this field has again expanded tremendously This second edition is therefore written to keep the reader updated on progress in this area, and to further improve his/her understanding of basic cardiovascular physiology The understanding of basic cardiovascular physiology is more important than ever The patient population is becoming progressively more elderly and infirm Even the old and sick undergo increasingly complex and stressful procedures More effective prehospital trauma care improves initial survival of previously fatal injuries, but for subsequent long-term survival the cardiovascular system is challenged to the maximum New guidelines on perioperative cardiac evaluation restrict the extent of preoperative testing The concept of “same day surgery” limits the time available for preoperative optimisation of cardiovascular performance Minimally invasive surgical techniques decrease tissue trauma, but they can impose an additional burden on the cardiovascular system Furthermore, current medical practice encourages restriction of blood transfusion and acceptance of low haemoglobin concentrations which often requires an increase in cardiac work to maintain oxygen delivery Early postoperative extubation and rapid hospital discharge can pose additional stress on the cardiovascular system Not surprisingly, therefore, cardiovascular complications remain the dominant cause of overall perioperative morbidity and mortality For all of these and many others a solid understanding of cardiovascular physiology remains a prerequisite for optimum patient care All chapters have been completely revised and updated We gratefully acknowledge the contributions of all authors Without their work and expertise, this monograph would not have been possible HANS-JOACHIM PRIEBE KARL SKARVAN Page 1: Cardiac cellular physiology and metabolism HEINRICH TAEGTMEYER, ANNE B TAEGTMEYER New horizons Cardiac cellular physiology and metabolism have long been considered areas of interest to only a small group of basic scientists Although, in the past, clinicians have laid the foundations for much of the work in this area,1 their research was descriptive and its clinical use limited to the detection of coronary artery disease by the release of lactate or alanine from the ischaemic myocardium.3-5 When, it was shown (by isotopic methods) that lactate release occurred in the presence of net lactate extraction by the normal human heart,6 it appeared that the potential for invasive assessment of cardiac metabolism to detect coronary artery or other forms of heart disease could not be fulfilled A number of technical advances in the diagnosis and treatment of heart disease have reawakened the interest in cardiac cell metabolism by clinical investigators and basic scientists alike The most dramatic recent examples include reports on enhanced myocardial function in transgenic mice overexpressing the β2-adrenergic receptor,7 highly efficient gene transfer into adult ventricular myocytes,8 the grafting of fetal myocytes into adult host myocardium,9 and the transfer of autologous myoblasts into damaged myocardium.10 It seems, however, that the ultimate success of gene therapy for the failing heart continues to be constrained by the inadequate understanding of the underlying pathophysiological events New insights into cellular physiology and pathophysiology have come from the use of positron labelled metabolic tracers or tracer analogues, which are used for non-invasive assessment of regional myocardial blood flow and metabolism as a tool to differentiate between reversible and irreversible myocardial ischaemia.11–13 Other examples also include the use of tomographic nuclear magnetic resonance (NMR) spectroscopy for the early detection of contractile dysfunction in the pressure overloaded left ventricle.14 Cellular mechanisms of adaptations to ischaemia, reperfusion, and reperfusion injury have come into focus when it became possible to reverse the deleterious effects of compromised Page 376 see also antiarrhythmics anaesthetic-induced 112 mechanisms for 91–2, 105–6 arterial chemoreceptors 226–7 arterial oxygen pressure 259 arterial systolic pressure 39–40 arterioles, and vascular resistance 310 ATP-sensitive potassium channels 131–2, 142 atrial booster pump 58 atrial contraction 58–60 atrial natriuretic peptide 232, 284 atrial septal defects 200 atrial/vena caval low pressure baroreceptors 225–6 atrioventricular node 220 auto PEEP 179 automated border detection 36 automatic transmembrane potential 78 automaticity 73, 80, 86–8 abnormal 92–3, 106 altered normal 107 modulation of 88 Purkinje fibre 88 sinus node 86–8 subsidiary (latent) pacemakers 88 autonomic hyperreflexia 228–9 autonomic insufficiency 225 autonomic nervous system 217–22, 260 circulatory effects 220–2 parasympathetic nervous system 219–20 sympathetic nervous system 217–19 autoregulation 137–44, 153, 234, 255–8 adenosine 140 ATP-sensitive potassium channels 142 left ventricular 143–4 of local blood flow 311–12 metabolic hypothesis of 310–11 myogenic control 142–3 nitric oxide 140–1 oxygen/carbon dioxide tension 141–2 pressure 234–6 renal circulation 281–3 right ventricular 144 splanchnic circulation 290–1 AV nodal re-entry tachycardia 102 AV node re-entry 102–3 with accessory pathways 103–5 Bainbridge reflex 225 baroreceptor reflex 222–5 anaesthetic effects on 338–41 beta-adrenergic receptors 134 beta-agonists, and pulmonary circulation 194 Bezold–Jarisch reflex 226 blood volume distribution, anaesthetic effects on 365–7 blood–brain barrier 244–6 Bowditch’s positive staircase response 50 bradykinin 128, 184, 185, 290, 315 calcitonin gene-related peptide 135, 294 calcium channel blockers, and pulmonary circulation 194, 197 calcium homeostasis capillaries 310 in gas exchange 313 recruitment 122–3, 242 capillary transit time 313 carbon dioxide tension 141–2, 258–9 cardiac control centre 215–17 cardiac output 40, 54, 64 cardiac pacing 50–1 carotid sinus 222 catabolism 9–10 catecholamines 229 see also individual catecholamines anaesthetic effects on 335–8 cellular physiology/metabolism 1–26 catabolism of substrates 9–10 clinical relevance of myocardial metabolism 13–20 energy transfer in heart muscle 2–5 metabolic pathways and moiety conserved cycles 5–9 nutrition and myocardial protein turnover 10 substrate competition 11–13 thermodynamic aspects of energy transfer cerebral blood volume 242–3 cerebral circulation 240–77 control mechanisms 268–70 in disease states 263–8 functional anatomy 240–4 measurement of cerebral blood flow 246–54 microcirculatory transport and blood–brain barrier 244–6 pharmacological modulation 260–3 Page 377 regional cerebral blood flow 255–60 cerebral perfusion, determinants of 244 chamber compliance 59 chamber stiffness 59 cholecystokinin 290 cholinergic receptors 134 chronotropism 220 circle of Willis 241 circulatory system, function of 309 circus movement 95 CNS ischaemic reflex 227–8 cold reflex 227 collateral circulation 123–4 computed tomography 37 conduction 89–90 conduction block 105 contractility 33, 43–50, 110 corner vessels 175–6 coronary anatomy 119–22 coronary blood flow regulation 124–58 anaesthetic effects on 359–60 autoregulation 137–44 coronary flow reserve 155–8 endothelial control 125–30 flow–function relationship 154–5 metabolic control 130–2 neurohumoral control 132–7 pressure–flow relationships 152–4 variations in myocardial perfusion 144–51 coronary flow reserve 155–8 coronary physiology 119–70 coronary anatomy 119–22 coronary collateral circulation 123–4 coronary microcirculation 122–3 coronary/myocardial blood flow 158–62 regulation of coronary blood flow 124–58 coronary vascular resistance 148–51 cranial nerves 219 critical closing pressure 153 Cushing reflex 228 cutaneous circulation 293–6 anaesthetic effects on 295–6 anatomy 293–4 control of 294 cyclic GMP 185 cyclo-oxygenase inhibitors, and pulmonary circulation 194, 197 defibrillation threshold 110 delayed after depolarisations 95 delayed relaxation period 57–8 depressed fast response 84, 91, 106 depressor reflex 223 desflurane 262, 335, 336 and myocardial efficiency 357 and noradrenaline levels 338 diazepam, and baroreceptor reflex 338–9 distribution of ventilation 178, 179 dobutamine 46, 47, 53, 196 dopamine, and pulmonary circulation 196 Doppler ultrasound 159–60, 253–4, 318 dynamic X ray computed tomography 248 early after depolarisations 94–5 echocardiography 37 effective arterial elastance 43 eicosanoids 315 ejection fraction 30, 35 elasticity 33 electromagnetic flow meters 159 electrophysiology 73–118 abnormal 91–105 antiarrhythmic drug action 106–12 mechanisms for clinical arrhythmias 105–6 normal 73–91 electrotonic effects 84 emphysema 199 end diastolic pressure 31 end diastolic volume 31, 32, 35 end systolic pressure 48, 51–2 endothelin-1 290 endothelins 128, 186, 233–4, 315 endothelium-derived contracting factors 128–30 endothelium-derived hyperpolarising factor 315, 326 endothelium-derived relaxing factor see nitric oxide endotoxin 186 endurance training 65 energy transfer 2–5 rate of thermodynamics of enflurane 260–2, 296, 308 and baroreceptor reflex 339, 340 and blood pressure 351 and heart rate 351 and myocardial efficiency 355 Page 378 and myocardial oxygen consumption 351 negative inotropic effect 346 and organ blood flow 321, 322 and stroke volume index 351 etomidate 262, 333 and baroreceptor reflex 338–9 and blood pressure 350 and heart rate 342, 350 and myocardial efficiency 359 and myocardial oxygen consumption 346 negative inotropic effect 344 and stroke volume index 350 excitability 89 excitable gap 98, 99 exercise testing 64–5 extra-alveolar vessels 175, 177 extrapulmonary vessels 173 extrinsic reflexes 227–8 Fallot’s tetralogy 203 fast response fibre 80 fatty acids 12 fentanyl 352, 355, 359 Fick’s method 35 flow–function relationship 154–5 flow–metabolism coupling 255, 270 fluid balance in lung 204–7 Fourier analysis 40–1 fractional area change 36, 38 Frank–Starling law 35, 53–6, 61 afterload mismatch 55–6 external control mechanisms 55 internal control mechanisms 54–5 free fatty acids 11 functional hyperaemia 236 functional re-entry 100–2 functional residual capacity 177 garden hose effect 155 gas exchange 313–14 glibenclamide 142 glucagon 290 glucose 11, 17 glucose-insulin-potassium 19–20 glycogen loading 19 glycolysis 17 gravity, and pulmonary blood flow 173–6 alveolar vessels 173–5 corner vessels 175–6 extra-alveolar vessels 175 Gregg effect 140, 154–5 Guyton’s diagram 55, 56 haematocrit 259–60 haemorrhagic shock 307 halothane 260–2, 292, 307, 308 and baroreceptor reflex 339, 340 and blood pressure 351 and heart rate 351 and microcirculation 318–21 and myocardial efficiency 355, 359 and myocardial oxygen consumption 351 negative inotropic effect 346 and organ blood flow 321, 322, 323 and stroke volume index 351 head injury 265–6 heart see coronary; myocardial heart muscle energy transfer 2–5 features of length dependent activation 28 ventricular 27–9 heart rate 50–1, 60 anaesthetic effects on 341–2 variability 341 heart transplantation 221 hexobarbitone and blood pressure 350 and heart rate 350 and myocardial oxygen consumption 346 and stroke volume index 350 hibernating myocardium 16 histamine 232–3, 290, 299–300, 315 Hodgkin–Huxley model 75, 77 homoeometric regulation 32 humoral control mechanisms 229–34 atrial natriuretic peptide 232 catecholamines 229 endothelium-derived nitric oxide 230–2 microcirculation 315 renin–angiotensin system 229–30 vasopressin 230 hypercapnia 315 hypertensive encephalopathy 266 hypovolaemia 314, 315 hypoxia 186, 315 hypoxic pulmonary vasoconstriction 183–4 imidazoline receptors 216 Page 379 imidazoline-like substances 216–17 impulse propagation 88–91 conduction 89–90 excitability 89 refractoriness 90–1 indicator dilution techniques 318 inert gas clearance technique 158–9 inertance 33 interferon 186 intra-alveolar vessels, resistance of 177 intrapulmonary vessels 173 intrinsic PEEP 179 intrinsic reflexes 222–7 ion channels Hodgkin–Huxley model of Na+ channel gating 75, 77 ligand gated 75, 77–8 properties of 74 structure–function relationships 78–9 as targets for antiarrhythmics 108–12 voltage gated 74–5, 76 ischaemia 307 cellular consequences 16–18 cerebral 263–4 low flow 17 metabolic support 18–20 normal flow 17 ischaemia–reperfusion injury, anaesthetic effects on 360–2 isoflurane 260–2, 296, 308, 336 and baroreceptor reflex 339, 340 and blood pressure 351 and heart rate 351 and microcirculation 318–21 and myocardial efficiency 357, 359 and myocardial oxygen consumption 351 negative inotropic effect 346 and organ blood flow 321 and stroke volume index 351 isolated perfused lung preparations 189 isoprenaline, and pulmonary circulation 196 isovolumic relaxation period 57–8 jugular venous oximetry 254 ketamine 263, 307 and blood pressure 350 and heart rate 342, 350 and myocardial efficiency 359 and myocardial oxygen consumption 346 negative inotropic effect 344 and organ blood flow 321, 322, 323 and stroke volume index 350 ketone bodies 11, 12 Kety–Schmidt technique 247, 248, 349 kinins 233, 285 kissing papillary muscles sign 38 lactate 11 Laplace’s Law 39, 42, 66 laser Doppler velocimetry 318 leading circle re-entry 100–1 left atrial pressure 62 left ventricular assistance 63 left ventricular autoregulation 143–4 length dependent activation 28 leukotrienes 186 ligand gated ion channels 75, 78 lignocaine 194, 197 lung volume, and pulmonary vascular resistance 176–82 luxury perfusion 119 magnetic resonance imaging 37, 207, 251 maximal left ventricular power 49 maximum diastolic potential 80 Mayer waves 227 membrane potential, loss of 91, 106 metabolic acidosis 300 metabolic pathways 5–9 in intact heart 14–16 metabolic regulation 311 methohexitone 334, 359 Michaelis constant 12 microcirculation 307–30 anaesthetic effects on 317–27 anatomy 309–10 capacitance 313 cerebral 242 coronary 122–3 exchange 313–14 local control 315–17 neural control 314–15 resistance 310–13 systemic humoral control 315 midazolam 338 and baroreceptor reflex 338–9 and blood pressure 352 and heart rate 341, 352 and myocardial oxygen consumption 352 negative inotropic effect 344 Page 380 and stroke volume index 352 moieties excess of recycling of moiety conservation, principle of moiety conserved cycles 5–9 muscle circulation 296–303 anaesthetic effects on 301–3 anatomy 296–7 control of 297–301 myocardial contrast echocardiography 162 myocardial efficiency, anaesthetic effects on 354–9 myocardial infarction 60 myocardial metabolism, clinical relevance 13–20 acutely ischaemic myocardium 18–20 adaptation and deadaptation 16–18 tracing metabolic pathways 14–16 myocardial oxygen consumption 347–9 anaesthetic effects on 349–54 myocardial perfusion, variations in 144–51 coronary vascular resistance 148–51 phasic myocardial perfusion 145–7 resting myocardial perfusion 145 transmural myocardial perfusion 147–8 myocardial protein turnover 10 myocardial remodelling 107 myocardial stiffness 60 myocardium, anaesthetic effects on 342–62 coronary blood flow 359–60 ischaemia–reperfusion injury 360–2 myocardial contractility 343–7 myocardial efficiency 354–9 myocardial oxygen consumption 347–54 neural control mechanisms 214–29 autonomic nervous system 217–22 CNS cardiovascular centres 214–17 microcirculation 314–15 reflex control of circulation 222–9 neurohumoral control 132–7 alpha-adrenergic 132–4 autonomic 132 beta-adrenergic 134 cholinergic 134 peptidergic control 135–6 neuropeptide K 135 neuropeptide Y 135 nifedipine 197, 311 nitric oxide 125–8, 129–30, 140–1, 185, 221, 230–2 as bronchodilator 203 and cerebral haemodynamics 267–70 inhibition of endothelin-1 formation 290 and microcirculation 315–16 and pulmonary circulation 194 renal circulation 285–6 nitric oxide synthase 185, 315–16 nitroglycerine dilatation of coronary arterioles 311 and pulmonary circulation 194, 196 nitrous oxide 324, 335, 346 and myocardial contractility 348 L-NMMA 316–17, 324–7 NMR spectroscopy 15 noradrenaline 214, 220, 283, 290, 299, 335 anaesthetic effects 337 and microcirculation 315 obstructive sleep apnoea 200 oculocardiac reflex 227 opiates 262–3, 286, 292, 301 and blood pressure 352 and heart rate 352 and myocardial oxygen consumption 352 negative inotropic effect 345 and stroke volume index 352 organ blood flow anaesthetic effects on 318–23 brain 260–2 heart 124–58, 359–60 local, autoregulation of 311–12 lung 173–6 measurement of 158–62, 318 regional inhomogeneity of 176–7 overdrive suppression 88 oxidative phosphorylation 9–10 oxygen extraction fraction 251 oxygen tension 141–2, 180–2 pacemaker currents 108 pain reflex 227 paired pacing 50–1 parasympathetic nervous system 219–20 parasystole 92 pentobarbitone 307 Page 381 and organ blood flow 321 peptidergic control 135–6 peripheral vascular resistance 40, 41 phasic myocardial perfusion 145–7 phenylephrine 223 photosynthesis platelet activating factor 124 positive end expiratory pressure (PEEP) 179 positron emission tomography 15–16, 161, 207, 248 postganglionic neurons 217 potassium ion channel ATP-sensitive 131–2, 142 blockers 110–12 preganglionic neurons 217, 218 preload 31–2, 37–8 preload recruitable stroke work 48 pressor reflex 223 pressure autoregulation 234–6 pressure volume index 243, 244 pressure–flow curves 152–4, 188 pressure/volume area 52–3 primary hypoventilation syndrome 200 propofol 262, 295, 301, 333–4 and baroreceptor reflex 338–9 and blood pressure 351 and heart rate 351 and myocardial efficiency 355, 358 and myocardial oxygen consumption 351 negative inotropic effect 344 and stroke volume index 351 propranolol 194 prostacyclin 185 prostaglandins 127–8, 186 and microcirculation 315 renal circulation 284 splanchnic circulation 290 prostanoids 128–9, 186 pulmonary circulation 171–212 anatomy and physiology 172–86 effects of drugs on 186–204 fluid balance in lung 204–7 pulmonary embolism 198–9 pulmonary hypertension 197–8 pulmonary oedema 206–7 pulmonary vascular resistance 176–82 and drug effects 187–92 flow distribution methods 192–3 pulmonary vasodilators 201–4 pulmonary vasomotor tone 182 pulmonary venous hypertension 201 pump function graph 34 pump function of heart 33–4 clinical evaluation 34–50 Purkinje fibre automaticity 88 radioactive microsphere technique 158, 318 random re-entry 101–2 rapid filling 58 rate pressure product 348 re–entry of excitation 95–105, 106, 107 anatomical re-entry 98–100 AV re-entry with accessory pathways 103–5 functional re-entry 100–2 SA and AV node re-entry 102–3 slow conduction 96–7 unidirectional conduction block 97–8 reactive hyperaemia 236–7 reciprocation 95 recovery from inactivation 75 rectification 84 reflex circulatory tone 222–9 extrinsic reflexes 227–8 intrinsic reflexes 222–7 spinal shock and autonomic hyperreflexia 228–9 refractoriness 90–1 regulation of cardiovascular system 213–39 humoral control of circulation 229–34 local regulation of circulation 234–7 long term regulation of circulation 237–8 neural control of heart and vasculature 214–29 renal circulation 278–87 anatomy 278–81 control of 281–6 effects of anaesthetics on 286–7 renal nerves 283 renin–angiotensin system 229–30, 283 reperfusion 16–18, 360–2 resting membrane potential 78, 80 resting myocardial perfusion 145 right atrial pressure 62 right ventricular autoregulation 144 right ventricular performance 60–4 SA node re-entry 102–3 semilunar valve 30 Page 382 septic shock 308, 313 serotonin 233, 290 sevoflurane 262, 336, 357 single photon emission tomography 248, 251 sinoatrial node 220 sinus node automaticity 86–8 sliding filament model of contraction slow conduction 96–7 slow filling 58 slow response fibre 80 Smyth’s procedure 223 sodium ion channel 109 sodium nitroprusside 223 and pulmonary circulation 194, 196 spinal shock 228–9 spiral wave re-entry 101 splanchnic circulation 287–93 anaesthetic effects on 292–3 anatomy 287–9 control of 289–91 stellate ganglia 221 stress failure 203 stretch-induced contraction 142 stroke volume 30, 32–3, 35, 51–2 anaesthetic effects on 350, 351, 352 stroke work 52–3 subarachnoid haemorrhage 266–7 subsidiary (latent) pacemakers 88 substance P 135 substrate catabolism 9–10 substrate competition 11–13 sufentanil 337, 352, 355, 359 sympathetic nervous system 217–19 anaesthetic effects on 332–42 systolic interdependence 62 systolic wall stresses 42–3 tension time index 348 thallium-201 scintigraphy 161 thermodilution technique 35, 160–1 thermodynamics, laws of thiopentone 262 and baroreceptor reflex 338–9 and blood pressure 350 and heart rate 342, 350 and myocardial efficiency 359 and myocardial oxygen consumption 346 negative inotropic effect 344 and stroke volume index 350 thoracic duct obstruction 203 thrombin 186 thromboxanes 185, 186 and microcirculation 315 torsade de pointes 94–5, 111 transcranial Doppler ultrasonography 253–4 transmembrane potential 80, 82, 83 see also action potential transmural myocardial perfusion 147–8 triggered activity 93–5, 106, 107 delayed after depolarisations 95 early after depolarisations 94–5 tumour necrosis factor 186 unidirectional conduction block 97–8 vagus nerves 219 vascular capacitance 313 vascular endothelium 315–17 vascular resistance 66, 310–13 anaesthetic effects on 321–3, 363–5 vasoactive intestinal peptide 135–6, 290 vasomotor centre 214–15 vasomotor tone 221–2 vasopressin see antidiuretic hormone venous drainage, cerebral 242, 243 ventilation–perfusion ratio 178, 179 ventricular diastolic performance 57–60 atrial contraction 58–60 heart rate 60 isovolumic relaxation period 57–8 rapid filling 58 slow filling 58 ventricular function curves 53–6 afterload mismatch 55–6 external control mechanisms 55 internal control mechanisms 54–5 ventricular hypertrophy 60 ventricular performance 27–72 age-related changes 65–7 during exercise 64–5 global ventricular pump function 34–50 heart as pump 33–4 heart rate 50–1 isolated ventricle 29–31 right ventricle 60–4 ventricle as muscle 27–9 ventricle in situ 31–3 ventricular diastolic performance 57–60 ventricular function curves 53–6 ventriculoarterial coupling 51–3 ventricular reflexes 226 Page 383 ventricular septal defects 200 ventricular systolic pressure 39–40 ventriculoarterial coupling 43, 45, 51–3 venules 310, 311 vis a tergo 63 voltage gated ion channels 74–5, 76 Wagner inert gas technique 193 watershed infarctions 240 wedge pressure 62 Wolff–Parkinson–White syndrome 97, 103 Woodforth’s negative staircase response 50 xenon-133 wash-out 247, 248, 249 zero flow pressure 153 zona occludens 245 ... this area, and to further improve his/her understanding of basic cardiovascular physiology The understanding of basic cardiovascular physiology is more important than ever The patient population... University of Oxford, UK Titles already available: Cardiovascular Physiology (second edition) Edited by Hans Joachim Priebe and Karl Skarvan Clinical Cardiovascular Medicine in Anaesthesia Edited... SKARVAN Cardiac cellular physiology and metabolism HEINRICH TAEGTMEYER, ANNE B TAEGTMEYER Ventricular performance KARL SKARVAN Cardiac electrophysiology JOHN L ATLEE Coronary physiology HANS-JOACHIM