INTEGRATED CARDIOVASCULAR

PHYSIOLOGY:
A LABORATORY EXERCISE
Rahul D. Patil, Sangeeta V. Karve, and
Stephen E. DiCarlo
Department of Physiology, Northeastern
Ohio Universities, College of Medicine,
• Examining the hemodynamic responses to
exercise provides a unique opportunity to
analyze and integrate cardiovascular
physiology because more is learned about
how a system operates when it is forced to
perform than when it is idle.
• A laboratory exercise that examines the
cardiovascular responses to exercise was
designed in:
– a sedentary individual
– an athlete
– an individual with quadriplegia
– an individual with heart transplantation.
• These special populations were chosen
because of their unique limitations and
adaptations, which directly influence
cardiovascular function.
 BACKGROUND INFORMATION
• Cardiovascular responses during dynamic
exercise are examined in male subjects (age
30 yr, wt 70 kg) with/ without specific
limitations or adaptations.
 The individual with quadriplegia
• He has a transverse spinal lesion at the C7- C8
spinal level -- > loss of sympathetic and motor
control below the level of the lesion
• Parasympathetic innervation to the heart is
maintained.
• His exercise is limited to the arm (arm cycle
ergometry), which directly influences the
maximum work load, venous return, and
cardiovascular function.
The Individual With Heart Transplantation
• The donor heart is void of all sympathetic
innervation and all significant
parasympathetic innervation.
• He has complete motor function -- > has full
use of the muscle venous pump and can take
advantage of the Frank-Starling mechanism
and exercise at a much higher work load
 Sedentary Individual
• The sedentary individual has no significant
limitations -- > has full innervation to the
heart and circulation.
 Trained Endurance Athlete
• With exercise training, the athlete has
significant autonomic adaptations -- > these
autonomic adaptations make him/ her
uniquely suited to perform exercise, while
maintaining homeostasis.
 Heart Rate
• Figure 1 presents the relationship between
heart rate and increasing work load.
• Work load is expressed as the oxygen
consumption required to perform the work.
• Heart rate is under the influence of the
autonomic nervous system.
– Decreases in cardiac parasympathetic efferent
activity
– Increases in cardiac sympathetic efferent activity
increase heart rate.
• At the onset of exercise : a centrally mediated
simultaneous activation of the cardiovascular
and motor centers (central command) -- >
causing an initial rapid increase in heart rate
due to withdrawal of parasympathetic efferent
activity.
• Once heart rate reaches 100 beats/min -- > a
further increase in heart rate due to activation
of cardiac sympathetic efferent activity
 Questions
1) Compare the heart rate response to exercise
in the individuals with quadriplegia and heart
transplantation. How does the absence of
cardiac parasympathetic innervation affect
the heart rate response to exercise?
2) Compare the maximum heart rate response
to exercise in the individuals with quadriplegia
and heart transplantation. What accounts for
the similarity in maximum heart rate?
3) What factors contribute to the increase in
heart rate in the individuals with quadriplegia
and heart transplantation?
4) Compare the heart rate response to exercise in
the individual with heart transplantation with the
sedentary individual. How would the absence of
cardiac innervation affect the heart rate response
to exercise?
5) Compare the resting heart rate, slope of the
increase in heart rate, and maximum heart rate in
the sedentary and athletic individuals. How are
they different? What accounts for this difference?
1)
• Individuals with heart transplantation and
quadriplegia do not have sympathetic
innervation to the heart;
• However, the individual with quadriplegia has
cardiac parasympathetic innervation.
1)
• The individual with heart transplantation does
not have a rapid rise in heart rate at the onset
of exercise because the heart has no
significant autonomic innervation -- > the rise
in heart rate is due to the effect of circulating
catecholamines.
1)
• The individual with quadriplegia has an initial
rapid rise in heart rate due to the withdrawal
of cardiac parasympathetic efferent activity;
however, heart rate does not rise further
because of the absence of cardiac sympathetic
efferent activity.
2)
• The maximum heart rate responses in the
individual with quadriplegia and heart
transplantation are similar because the
maximum increase in heart rate in both
individuals is due to the effect of circulating
catecholamines.
3)
• Factors that contribute to the increase in heart
rate in the individual with quadriplegia are
withdrawal of the parasympathetic tone and
the effect of circulating catecholamines,
whereas only the circulating catecholamines
contribute to the increase in heart rate in the
individual with heart transplantation.
3)
• Circulating catecholamines (norepinephrine
and epinephrine) increase heart rate by
activating β1-adrenergic receptors on the
sinoatrial node.
4)
• The sedentary individual has an initial rapid
increase in heart rate due to withdrawal of
cardiac parasympathetic efferent activity and
a further increase to an age-dependent
maximum due to an increase in cardiac
sympathetic efferent activity.
4)
• There is no rapid rise in heart rate at the onset
of exercise in the individual with heart
transplantation because of absence of cardiac
parasympathetic innervation; the rise in heart
rate occurs because of the effect of circulating
catecholamines.
5)
• Autonomic adaptations associated with
chronic endurance training result in an
enhanced cardiac parasympathetic efferent
activity, and therefore the athlete has a
resting bradycardia.
• The heart rate response at similar work loads
is lower in the athlete compared with the
sedentary individual.
• Both individuals achieve a similar age
dependent maximum heart rate
 Stroke Volume
• Figure 2 presents the stroke volume response
to increasing work loads in the four individuals
• Stroke volume is a function of venous return,
cardiac sympathetic efferent activity,
circulating catecholamines, and afterload.
• During exercise, venous return increases
because of an increase in the activity of the
muscle venous pump -- > consequently, end
diastolic volume increases a and causes a
stronger systolic contraction of the ventricle,
in accordance with the Frank-Starling law.
• During exercise, cardiac sympathetic efferent
activity also increases. Stroke volume
increases during exercise, reaching a
maximum at 40-45% of the oxygen uptake at
maximum exercise (VO 2max).
• Finally, stroke volume can also increase
slightly because of the effect of circulating
catecholamines activating β1-adrenergic
receptors on the myocardium.
 Questions
6) Compare the stroke volume responses in the
individuals with quadriplegia and heart
transplantation. How are they different and
what accounts for this difference?
7) Compare the stroke volume response in the
sedentary individual with the response in the
individual with heart transplantation. What
accounts for the similarity in stroke volume?
8) Compare the stroke volume responses in the
sedentary and athletic individuals. How are
they different and what accounts for this
difference?
9) With the use of Figs. 1 and 2, calculate the
cardiac output response during exercise in the
four individuals. Plot these results in Fig. 3.
6)
• The individual with quadriplegia has no motor
control below the level of the lesion (no muscle
venous pump), and therefore venous return does
not increase with exercise. In contrast, the
individual with heart transplantation is able to
increase stroke volume because of a functioning
muscle venous pump. This illustrates the
importance of the Frank-Starling mechanism. In
fact the individual with heart transplantation has
a stroke volume comparable to that of the
sedentary individual.
7)
• Stroke volume response to exercise is determined
by end-diastolic volume, cardiac sympathetic
efferent activity, circulating catecholamines, and
afterload. The muscle venous pump is functioning
normally in both individuals, and therefore the
stroke volume response to exercise is initially
similar; however, the maximum stroke volume
achieved in the individual with heart
transplantation is lower because of the absence
of cardiac sympathetic efferent activity.
8)
• The athlete has a much higher stroke volume
at similar work loads. The athlete has a larger
ventricular volume and slower heart rate,
which allows for a greater cardiac filling during
diastole (greater end diastolic volumes);
therefore the stroke volume response in the
athlete is much greater compared with that of
the sedentary individual.
9) Cardiac Output
• Figure 4 presents the cardiac output response
to exercise in the four individuals. The
increase in cardiac output is due to an
increase in heart rate and stroke volume.
Increases in stroke volume contribute to
increases in cardiac output up to 40-45% of
VO2max. Further increases in cardiac output are
due to increases in heart rate.
 Questions
10) Compare the cardiac output responses to
exercise in the individuals with quadriplegia and
heart transplantation. How are they different and
what accounts for this difference?
11) Compare the cardiac output responses in the
sedentary individual and the individual with heart
transplantation. How are they different and what
accounts for this difference?
12) Compare the cardiac output responses in
the sedentary and athletic individuals. How
are they different and what accounts for this
difference?
10)
• The individual with quadriplegia has a very
low cardiac output because stroke volume
does not increase with exercise (no muscle
venous pump). In addition, because of the
reduced muscle mass, the individual with
quadriplegia has a reduced ability to increase
total body oxygen consumption.
10)
• In contrast, the individual with heart
transplantation has a normal muscle venous
pump and muscle mass; therefore venous
return is enhanced, and total body oxygen
consumption significantly increased.
• Note that both individuals have a limited
heart rate response to exercise (absence of
cardiac sympathetic efferent activity).
10)
• The lower cardiac output response in the
individual with quadriplegia is therefore due
to a severely limited stroke volume, heart rate,
and muscle mass.
11)
• The cardiac output responses to exercise are
initially comparable in the sedentary
individual and the individual with heart
transplantation; however, at work loads above
45% of qozmax, the cardiac output response is
lower in the individual with heart
transplantation because of the poor heart rate
response to exercise.
12)
• Cardiac output in the sedentary individual and
the athlete are similar at lower work loads.
Even though the athlete has a lower resting
heart rate (Fig. 1), he has a much higher stroke
volume (Fig. 2) at the same work load, and
therefore cardiac outputs are similar. Note,
however, that because of large stroke volumes
in the athlete, he can achieve a much higher
cardiac output (nearly double) compared with
the sedentary individual.
 Systolic Blood Pressure
• Figure 8 presents the relationship between
systolic blood pressure and increasing work loads
in the four individuals. Systolic blood pressure
(pressure during systole, when the heart is active)
is the pressure generated by stroke volume
during ventricular systole.
• Systolic blood pressure is a function of left
ventricular stroke volume, the peak rate of
ejection, vessel wall compliance, and diastolic
blood pressure.
• If one assumes that the compliance of the
blood vessels is similar in the four individuals,
stroke volume is the major determinant of
systolic blood pressure. Differences in rate of
ejection and diastolic blood pressure also
account for the difference in systolic blood
pressure response to exercise in the four
individuals.
 Questions
17) Compare the systolic blood pressure
response to exercise in the individuals with
quadriplegia and heart transplantation. How
are they different, and what accounts for this
difference?
18) Why is the systolic blood pressure response
in the individual with heart transplantation
lower than that in the sedentary individual?
19) Compare the systolic blood pressure
response to exercise in the athlete and the
sedentary individual. How are they different
and why?
17)
• The systolic blood pressure response in the
individual with quadriplegia is much lower than
that in the individual with heart transplantation
because of the poor stroke volume response to
exercise.
• The reduced stroke volume response to exercise
is due to the failure of cardiac performance to
increase resulting from an absence of the muscle
venous pump and reduced muscle mass.
18)
• The systolic blood pressure response to
exercise is lower in the individual with heart
transplantation compared with the sedentary
individual because of a lower stroke volume
response to exercise (absence of cardiac
sympathetic efferent activity).
19)
• The athlete has a much higher systolic blood
pressure response to exercise than the
sedentary individual because of a larger stroke
volume and a more rapid rate of its ejection.
 Diastolic Blood Pressure
• Figure 9 presents the diastolic blood pressure
response to exercise in the four individuals.
Diastolic blood pressure (pressure during
diastole, when the heart is at rest) is the
pressure exerted by the volume of blood that
remains in the arteries after the peripheral
runoff of blood from the arteries through the
resistance vessels.
• The arterial blood volume is the net result of
the rate of blood flow from the heart to the
arteries and the rate of outflow from the
arteries through the resistance vessels.
• Therefore, diastolic blood pressure is a
function of heart rate and peripheral vascular
resistance.
• Increases in heart rate increase the rate of
inflow of blood and reduce the time during
which outflow occurs through the resistance
vessels, thereby increasing the diastolic
pressure. An increase in the peripheral
vascular resistance also causes a decrease in
outflow of blood, which results in an increase
in diastolic pressure.
• Normally diastolic blood pressure remains the
same or changes only moderately during exercise
because although heart rate increases, peripheral
vascular resistance decreases.
• The diastolic blood pressure response to exercise,
therefore, depends on the magnitude of the
increase in heart rate and decrease in peripheral
vascular resistance. Diastolic blood pressure in
 Questions
20) Explain the response of diastolic blood
pressure to exercise in the athlete and the
sedentary individual.
21) What does the rise in diastolic blood
pressure with exercise signify?
20)
• Diastolic blood pressure decreases in response to
exercise (despite the increase in heart rate)
because of a decrease in the total peripheral
resistance.
• Total peripheral resistance will decrease because
of metabolic vasodilatation. Total peripheral
resistance can decrease more in the athlete
because the athlete has an increased cardiac
performance and much higher systolic pressure,
which maintains perfusion pressure.
• During exercise, perfusion pressure is
monitored and maintained by the arterial
baroreflex and muscle metaboreflex. If cardiac
performance is not adequate enough to
maintain perfusion pressure, the arterial
baroreflex and muscle metaboreflex reflexly
increase total peripheral resistance.
• Because cardiac performance is so high in the
athlete, resulting in a large increase in cardiac
output and systolic blood pressure, these
reflexes are not activated to increase total
peripheral resistance. Therefore diastolic
pressure decreases (metabolic vasodilatation).
21)
• Normally diastolic blood pressure decreases in
response to exercise. However, in the
individuals with heart transplantation and
quadriplegia, the diastolic pressure rises in
response to increasing work loads because of
impaired cardiac performance.
• That is, impaired cardiac performance results
in a reduced systolic blood pressure response
to exercise.
• The reduced systolic blood pressure response
activates the arterial baroreflex and muscle
metaboreflex, which reflexly increase total
peripheral resistance.
• Therefore, to maintain perfusion pressure,
diastolic pressure will not decrease, and in
severe cases it will increase because of an
increase in total peripheral resistance.
• In addition, the individual with quadriplegia
has a reduced functioning muscle mass, and
this also contributes to his inability to
decrease total peripheral resistance because
there is a reduced metabolic vasodilatation.
 Mean Arterial Pressure Response
• Pulse pressure is the difference between the
systolic and diastolic blood pressures. Pulse
pressure is a function of the volume of blood
ejected by the left ventricle during systole (rapid
ejection phase) minus the volume of blood that
runs off to the periphery during diastole.
• The major factors affecting pulse pressure are
stroke volume, vascular compliance, and the rate
of ventricular ejection vs. the rate of peripheral
outflow.
• Mean arterial pressure is the average pressure
throughout cardiac cycle. Because systole is
shorter than diastole, the mean pressure is
slightly less than the value halfway between
systolic and diastolic pressures. This is often
described as the perfusion pressure or the
pressure necessary to maintain adequate
blood flow to the tissues.
• For all practical purposes it is calculated by the
formula:
MAP = DP + (1/3)PP

• where MAP is mean arterial pressure, DP is

diastolic pressure, and pulse pressure (PP)
equals systolic pressure minus diastolic
pressure.
 Question
22) Compare the mean arterial pressure
response to exercise in the sedentary
individual and the athlete.
22)
• The mean arterial pressure response to
exercise in the sedentary individual and the
athlete is the same.
• The athlete has a higher systolic blood
pressure response to exercise, but he also has
a lower diastolic blood pressure response to
exercise; therefore, the mean arterial pressure
response to exercise is nearly the same in the
athlete and the sedentary individual.
• The high systolic pressure response allows
diastolic pressure to decrease (metabolic
vasodilation without activation of baro- and
metaboreflex) during exercise and still
maintains perfusion pressure.
• Thus the heart works against a decreased
afterload. This is a major advantage to the
athlete.