CARDIAC CYCLE

Practical class 5
Part I
 CARDIAC CYCLE
The cardiac events that occur from the beginning of one heartbeat to the
beginning of the next one are called the cardiac cycle.

1) SYSTOLE – contraction of atria and ventricles

2) DIASTOLE – relaxation of atria and ventricles
3) TOTAL HEART PAUSE – relaxation of all
chambers of the heart

SYSTOLE DISTOLE VC = VS+VD or AC = AS+AD

CC lasts 0.8 sec if HR is 75 bpm
CC= 60 sec/75 bpm=0.8
TOTAL HEART VC = 0.8 = VS 0.33 + VD 0.47
PAUSE AC = 0.8 = AS 0.1 + AD 0.7

2
To characterize events happening in each
period of cardiac cycle we need to know:

1. Direction of blood flow throughout the heart

chambers
2. State of Valves (closed or opened)
3. Value of pressure in each chamber
 Analysis of cardiac cycle events

HR =75 bpm
Duration of cardiac cycle:
𝟔𝟎 𝒔
= 𝟎. 𝟖 𝒔
𝟕𝟓 𝒃𝒑𝒎

SYSTOLE sec DIASTOLE sec

ATRIAL SYSTOLE 0.1 ATRIAL DIASTOLE 0.7
VENTRICULAR SYSTOLE 0.33 VENTRICULAR DIASTOLE 0.47
I. Period of tension 0.08 I. Protodiastolic period 0.04
1) phase of asynchronous 0.05 II. Period of isometric relaxation 0.08
contraction
2) phase of isometric contraction 0.03 III. Period of filling 0.25
II. Period of ejection 0.25 1) phase of maximal filling 0.08
1) phase of maximal ejection 0.12 2) phase of reduced filling 0.17
2) phase of reduced ejection 0.13 IV. Presystolic period 0.1
4
 Total pause or total diastole of the heart
precedes atrial systole – 0,37 sec

1. Atria and ventricles are relaxed

2. Sphincters of veins are relaxed
3. Blood flows from veins to atria
4. AV valves are opened
5. From atria to ventricles
6. SL valves are closed
7. Pressure about 0
8. Ventricles get about 80 % of EDV before atria
contract
 Atrial systole - 0.1 sec
1. Both atria contract
2. Pressure: RA - 5-8 mm Hg;
3. LA - 10-12 mm Hg
4. Sphincters of veins are closed
5. Blood is not entering atria
6. AV valves are opened
7. SL valves are closed
8. Blood flows from atria to ventricles
9. (active filling of ventricles – 20 % of EDV) – “atrial kick”
S4 – is not audible in normal adults
Ventricles get complete EDV ( about 135 ml)
Amount of blood in the ventricle at the end of diastole is
known as end diastolic volume (EDV)
 Atrial diastole
1. Duration – 0.7 sec
2. Relaxation of atrial myocardium
3. Relaxation of sphincters of veins
4. Blood flows from veins to atrial
5. AV valves will become closed
 Ventricular systole = 0.33 s
I. Period of tension = 0.08 s
1) Phase of asynchronous contraction = 0.05 s
• Depolarization and following contraction of ventricles starts from the
apex toward the basis of the heart
2) Phase of isovolumetric contraction (IVC) = 0.03 s
• Pressure:
• RV – 10-15 mm Hg → RV - 25 mmHg > 8 mmHg (PA)
• LV – 70-80 mm Hg → LV - 120 mmHg > 80 mmHg (Aorta)
• ∆ P forces AV valves to close thus preventing backflow of blood into
atria
• (Ventricular P > Atrial P) producing S1 (systolic) – lub - low-pitched,
muffled (unvoiced) and prolonged
• AV valves just got closed
• SL valves still closed
• 1st phase of all closed valves
 Ventricular systole - Period of ejection = 0.25 s
1) phase of maximal ejection = 0.12 s
2) phase of reduced ejection = 0.13 s
• ∆ P forces the semilunar valves to open → ejection begins
• Blood is ejected from LV to aorta and from RV to pulmonary artery through
opened SL valves
• Ejection is provided by pressure gradient between ventricles and arteries –
peak of ventricular pressure – rapid ejection
• In LV – 120 mm Hg but in aorta – 80 mm Hg
• In RV – 25 mm Hg but in pulmonary artery – 8 mm Hg
• Amount of blood ejected from ventricle to artery in 1 heart beat is called
stroke volume (SV) - 60-80 ml
• Amount of blood remaining in the ventricle after ejection is called end
systolic volume (ESV) – 50-65 ml
• ESV=EDV-SV; SV=EDV-ESV; EDV=ESV+SV
• At the end of this phase the strength of contraction reduces
→pressure starts to decrease → reduced ejection
 Ventricular diastole = 0.47 s

• Isovolumetric relaxation begins with protodiastolic

period
• the ventricles relax and ejection comes to an end
• LVP and RVP is below aortic (120 mm Hg) and pulmonary artery (25 mm
Hg)
• This ∆ P forces SL valves to close
• Producing the S2 (diastolic), a louder dub
• (protodiastolic) - high-pitched, voiced and short

• SL valves just got closed

• AV valves still closed
• 2nd phase of all valves closed
 Ventricular diastole
Period of ventricular filling = 0.25 s
1)Phase of maximal filling = 0.08 s
2)Phase of reduced filling = 0.17 s
•Pressure in the ventricles rapidly decreases
below atrial pressure → opening of AV valves
→blood that accumulated in atria (since AV
valves closed) flows rapidly into ventricles
(passive VF)
•Heart sound S3 (rapid VF) – normal in
children but not in adults
The most ventricular filling is completed during
early diastole (great importance)
•That’s why in case of tachycardia (duration
11
of
diastole and VF decreases) the filling is not
seriously impaired
•But with HR 200 bpm and more the inadequate
filling (insufficient) will occur
 B C+D E F
G
A
A
Events of the Cardiac Cycle
 Parameters of heart work
• The function of the ventricles is described by the
following three parameters:
1. Stroke volume is the volume of blood ejected by
the ventricle on each beat;
2. Ejection fraction is the fraction of the end-
diastolic volume ejected in each stroke volume,
which is a measure of ventricular efficiency; and
3. Cardiac output is the total volume ejected by
the ventricle per unit time.
 Stoke Volume
• The volume of blood ejected on one ventricular contraction
is the stroke volume.
• Stroke volume is the difference between the volume of blood
in the ventricle before ejection (end-diastolic volume) and
the volume remaining in the ventricle after ejection (end-
systolic volume).
𝑺𝑽 = 𝑬𝑫𝑽 − 𝑬𝑺𝑽
• where
• SV = Stroke volume = Volume ejected on one beat (mL)
• EDV = End-diastolic volume = Volume in the ventricle before
ejection (mL)
• ESV = End-systolic volume = Volume in the ventricle after
ejection (mL)
• Typically, stroke volume is about 70 mL.
 Ejection Fraction
• The ejection fraction is the fraction of the end-
diastolic volume that is ejected in one stroke volume.
𝑺𝑽
𝑬𝑭 = × 𝟏𝟎𝟎%
𝑬𝑫𝑽
• EF characterizes the effectiveness of ventricular
systole
• Normally, ejection fraction approximates 55% (0.55)
• The ejection fraction is an indicator of contractility
o ↑EF reflecting an increase in contractility
o ↓EF reflecting a decrease in contractility.
 Cardiac Output
• The cardiac output is the total volume of blood ejected
per unit time
• Cardiac output depends on the volume ejected on a
single beat (stroke volume) and the number of beats
per minute (heart rate).
𝑪𝑶 = 𝑺𝑽 × 𝑯𝑹
• where
• CO = Cardiac output = Volume ejected per minute
(mL/min)
• SV = Stroke volume = Volume ejected in one beat (mL)
• HR = Heart rate = Beats per minute (beats/min)
 Cardiac Output
• At typical resting values
𝑪𝑶 = 𝟕𝟓 𝒃𝒑𝒎 × 𝟕𝟎 𝒎𝒍 = 𝟓𝟐𝟓𝟎𝒎𝑳/𝒎𝒊𝒏
= 𝟓. 𝟐𝟓 𝑳/𝒎𝒊𝒏

• Thus, the body’s total volume of blood (4–6 L) passes

through the heart every minute
• Vigorous exercise increases Cardiac Output
 to as much as 21 L/min in a person in good condition
 up to 35 L/min in world-class athletes

• The difference between the maximum and resting

cardiac output is called cardiac reserve – an important
parameter of heart adaptation to the load

19
 SAMPLE PROBLEM
A man has an end-diastolic volume of 140 mL,
an end-systolic volume of 70 mL, and a heart
rate of 75 beats/min.
What is his stroke volume, his cardiac output,
and his ejection fraction?
 SOLUTION
• These calculations are basic and important.
• The stroke volume is the volume ejected from the ventricle
on a single beat; therefore, it is the difference between the
volume in the ventricle before and after it contracts.
𝑺𝑽 = 𝑬𝑫𝑽 − 𝑬𝑺𝑽 = 𝟏𝟒𝟎 − 𝟕𝟎 = 𝟕𝟎 𝒎𝒍
• Cardiac output is stroke volume multiplied by heart rate.
𝒎𝒍
𝑪𝑶 = 𝑺𝑽 × 𝑯𝑹 = 𝟕𝟎 × 𝟕𝟓 = 𝟓𝟐𝟓𝟎 = 𝟓, 𝟐𝟓 𝑳/𝒎𝒊𝒏
𝒎𝒊𝒏
• The ejection fraction is the efficiency of the ventricle in
ejecting blood, and it is the stroke volume divided by the
end-diastolic volume.
𝒔𝒗 𝟕𝟎
𝑬𝑭 = = = 𝟎. 𝟓 = 𝟓𝟎%
𝑬𝑫𝑽 𝟏𝟒𝟎
 Balance of Ventricular Output 𝑺𝑽𝑹𝑽 = 𝑺𝑽𝑳𝑽

To maintain homeostasis, the two ventricles must have equal output

a) If SVRV >SVLV, blood would accumulate in the lungs and cause

pulmonary hypertension and edema → risk of suffocation as fluid
filled the lungs and interfered with gas exchange
b) If SVLV > SVRV, blood would accumulate in the systemic circuit and cause
systemic hypertension and edema → could lead to aneurysms 22
(weakened, bulging arteries), stroke, kidney failure, or heart failure
 Phenomena accompanying heart work

1) electrical 3) mechanical
2) sound vibrations
phenomena phenomenon

𝑺𝑽 = 𝑬𝑫𝑽 − 𝑬𝑺𝑽
Changes of heart Sounds occur during Apical thrust appear at
voltage caused by heart contraction and the moment of
depolarization and movement of blood in ventricles contraction
repolarization of its chambers and great and heart motion in the
myocardium vessels chest

Electrocardiography Phonocardiography Apex-cardiography

23
 Ventricular Pressure-Volume Loop
• The function of the left ventricle can be observed over an entire
cardiac cycle (diastole plus systole) with the help of ventricular
pressure-volume loop
• The dashed line shows the maximum possible pressure that can
be developed for a given ventricular volume during systole
 Ventricular filling (4 → 1)
• At point 4, ventricular pressure has fallen to a level
that now is less than left atrial pressure, causing the
mitral (AV) valve to open.
• The left ventricle fills with blood from the left atrium
passively and also actively, as a result of atrial
contraction in the next cycle.
• Left ventricular volume increases back to the end-
diastolic
• volume of 140 mL.
• During this phase, the ventricular muscle is relaxed,
and pressure increases only slightly as the compliant
ventricle fills with blood.
 Isovolumetric contraction (1 → 2)
• Point 1 marks the end of diastole.
• The left ventricle has filled with blood from the left atrium,
and its volume is the end-diastolic volume, 140 mL.
• The corresponding pressure is quite low because the
ventricular muscle is relaxed.
• At point 1 mitral valve is getting closed, the ventricle is
activated, it contracts, and ventricular pressure increases
dramatically.
• Because all valves are closed, no blood can be ejected from
the left ventricle, and ventricular volume is constant,
although ventricular pressure becomes quite high (point 2).
• Thus, this phase of the cycle is called isovolumetric
contraction.
 Ventricular ejection (2 → 3)
• At point 2, left ventricular pressure becomes higher than aortic
pressure, causing the aortic valve to open.
• You may wonder why the pressure at point 2 does not reach the
systolic pressure-volume curve shown by the dashed gold line. The
simple reason is that it does not have to.
• The pressure at point 2 is determined by aortic pressure. Once
ventricular pressure reaches the value of aortic pressure, the aortic
valve opens and the rest of the contraction is used for ejection of
the stroke volume through the open aortic valve.)
• Once the valve is open, blood is rapidly ejected, driven by the
pressure gradient between the left ventricle and the aorta. During
this phase, left ventricular pressure remains high because the
ventricle is still contracting. Ventricular volume decreases
dramatically, however, as blood is ejected into the aorta.
• The volume remaining in the ventricle at point 3 is the end-systolic
volume, 70 mL.
• The width of the pressure-volume loop is the volume of blood
ejected, or the stroke volume. The stroke volume in this ventricular
cycle is 70 mL (140 mL − 70 mL).
 Isovolumetric relaxation (3 → 4)

• At point 3, systole ends and the ventricle relaxes.

• Ventricular pressure decreases below aortic
pressure and the aortic valve closes.
• Although ventricular pressure decreases rapidly
during this phase, ventricular volume remains
constant (isovolumetric) at the end-systolic value
of 70 mL because all valves are closed again.
• At point 4 mitral valve opens and 4→1 is the
ventricular filling
• New cycle of the left ventricle starts at point 1
9.On the graph showing left ventricular volume and pressure,
isovolumetric contraction occurs from point
(A) 4 → 1
(B) 1 → 2
(C) 2 → 3
(D) 3 → 4
• 12. If the heart rate is 70 beats/min, then the
cardiac output of this ventricle is closest to
• (A) 3.45 L/min
• (B) 4.55 L/min
• (C) 5.25 L/min
• (D) 8.00 L/min
• (E) 9.85 L/min
11. The first heart sound corresponds to point
(A) 1
(B) 2
(C) 3
(D) 4
• 10. The aortic valve closes at point
• (A) 1
• (B) 2
• (C) 3
• (D) 4
•
 USMLE task
A patient undergoes cardiac catheterization to assess his left
ventricular function prior to thoracic surgery. What is his ejection
fraction percentage, as determined from the left ventricular pressure–
volume curve illustrated below?
A. 34%
B. 46%
C. 54%
D. 60%
E. 75%
 Solution & Explanation
• The answer is c. (Barrett, p 540. Le, pp 254, 582.)
• The ejection fraction (EF) is equal to the stroke
volume (SV) divided by the end-diastolic volume
(EDV), and the SV is equal to the EDV minus the
end-systolic volume (ESV).
• In this case, the end-diastolic volume is 130 mL
and the end-systolic volume is 60 mL. Therefore,
the ejection fraction is 70 mL/130 mL or 0.54
(54%).
• 36. During which phase of the cardiac cycle is aortic pressure
highest?
• (A) Atrial systole
• (B) Isovolumetric ventricular contraction
• (C) Rapid ventricular ejection
• (D) Reduced ventricular ejection
• (E) Isovolumetric ventricular relaxation
• (F) Rapid ventricular filling
• (G) Reduced ventricular filling (diastasis
• 41. The physiologic function of the relatively slow conduction
through the atrioventricular (AV) node is to allow sufficient
time for
• (A) runoff of blood from the aorta to the arteries
• (B) venous return to the atria
• (C) filling of the ventricles
• (D) contraction of the ventricles
• (E) repolarization of the ventricles
• 45. During which phase of the cardiac cycle is
ventricular volume lowest?
• (A) Atrial systole
• (B) Isovolumetric ventricular contraction
• (C) Rapid ventricular ejection
• (D) Reduced ventricular ejection
• (E) Isovolumetric ventricular relaxation
• (F) Rapid ventricular filling
• (G) Reduced ventricular filling (diastasis)
• 58. During which phase of the cardiac cycle does the mitral
valve open?
• (A) Atrial systole
• (B) Isovolumetric ventricular contraction
• (C) Rapid ventricular ejection
• (D) Reduced ventricular ejection
• (E) Isovolumetric ventricular relaxation
• (F) Rapid ventricular filling
• (G) Reduced ventricular filling (diastasis)
• 59. A hospitalized patient has an ejection fraction of 0.4, a
heart rate of 95 beats/min, and a cardiac output of 3.5 L/min.
What is the patient’s end-diastolic volume?
• (A) 14 mL
• (B) 37 mL
• (C) 55 mL
• (D) 92 mL
• (E) 140 mL
• Examination of a person revealed that minute
volume of heart is 3500 mL, systolic volume is 50
mL. What is the frequency of cardiac contraction?
• 90 bpm
• 50 bpm
• 80 bpm
• 60 bpm
• 70 bpm
 Solution & Explanation
• Correct answer is E. (Stuart Ira Fox Human
physiology, ninth edition, p. 426)
• Cardiac output can be calculated using
following formula:
• Cardiac output=stroke volume x heart rate,
• if CO and SV are known, so HR = CO/SV
=3500/50=70 ml
• The electrocardiogram demonstrated that the
duration of man's heart cycle is 1 sec. What is
the heart rate per minute?
• 50
• 60
• 70
• 80
• 100
• While preparing a patient to the operation the heart
chambers' pressure was measured. In one of them the
pressure changed during one heart cycle from 0 to 120 mm
Hg. What chamber of heart was it?
A. Left atrium
B. Left ventricle
C. Right atrium
D. Right ventricle
E. –
 Solution & Explanation
• Correct answer is B. (Kaplan Medical. USMLE. Step 1. Lecture notes.
Physiology. Section V. Peripheral circulation. P.86)
• The ejection of blood begins when ventricular pressure exceeds
arterial pressure and forces the semilunar valves open. The
pressure peaks at 120 mmHg in the left ventricle and 25 mmHg in
the right. Blood spurts out of each ventricle rapidly at first (rapid
ejection) and then flows out more slowly under less pressure
(reduced ejection).
• During phonocardiogram registration it was ascertained that
the duration of the first heart sound twice exceeds the norm.
It is most likely that patient has the following organ affected:
A. Cardiomyocytes of heart atriums
B. Cardiomyocytes of ventricles
C. Cardiomyocytes of atriums
D. Atrioventricular valves
E. Semilunar valves
• Systemic blood pressure of a person equals
120/65 mm Hg. Blood ejection into the aorta
occurs when left ventricular pressure exceeds:
A. 120 mm Hg
B. 65 mm Hg
C. 90 mm Hg
D. 10 mm Hg
E. 100 mm Hg
• An animal experiment is aimed at studding of cardiac
cycle. All the heat valves are closed. What phase of
cardiac cycle is characterized by this status?
A. Protodiastolic period
B. Asynchronous contraction
C. Isometric contraction
D. Rapid filling
E. Reduced filling
 Solution & Explanation
• Correct answer is C. (Linda. S. Costanzo. – Elsevier,
2014 . Chapter 4: Cardiovascular Physiology, p. 152).
• In ejection period the ventricle continues to contract,
and ventricular pressure reaches its highest value.
• When ventricular pressure becomes greater than aortic
pressure, the aortic valve opens.
• Now blood is rapidly ejected from the left ventricle into
the aorta through the open aortic valve, driven by the
pressure gradient between the left ventricle and the
aorta.
• Ventricular pressure is keeping to increase and the rest
of the contraction is used for ejection of the stroke
volume through the open aortic valve (Pressure-
Volume Loop, points 2→3).
 The Fick principle
• The fundamental assumption of Fick principle is that, in the steady state,
𝐶𝑂𝐿𝑉 = 𝐶𝑂𝑅𝑉
• In the steady state, the rate of O2 consumption by the body must equal the
amount of O2 leaving the lungs in the pulmonary vein minus the amount of O2
returning to the lungs in the pulmonary artery.
𝑶𝟐 𝒄𝒐𝒏𝒔𝒖𝒎𝒑𝒕𝒊𝒐𝒏 = 𝑪𝑶 × 𝑶𝟐 𝒑𝒖𝒍𝒎𝒐𝒏𝒂𝒓𝒚 𝒗𝒆𝒊𝒏𝒔 − 𝑪𝑶 × 𝑶𝟐 𝒑𝒖𝒍𝒎𝒐𝒏𝒂𝒓𝒚 𝒂𝒓𝒕𝒆𝒓𝒚
or, rearranging to solve for cardiac output:
𝑂2 𝑐𝑜𝑛𝑠𝑢𝑚𝑝𝑡𝑖𝑜𝑛
𝐶𝑂 =
𝑂2 𝑝𝑢𝑙𝑚. 𝑣𝑒𝑖𝑛𝑠 − 𝑂2 𝑝𝑢𝑙𝑚. 𝑎𝑟𝑡𝑒𝑟𝑦
• The Fick principle applicable to measurement of cardiac output (essentially
the blood flow to the whole body),
• It also can be applied to the measurement of blood flow to individual
organs.
• For example, renal blood flow can be measured by dividing the O2 consumption of the kidneys by the difference in O2 content
of renal arterial blood and renal venous blood.

49
 USMLE task
An 82-year-old woman was admitted to the hospital with ascites,
peripheral edema, and shortness of breath. Cardiac
catheterization was conducted and the following values were
obtained:
Pulmonary vein O2 content = 20 mL O2/100 mL blood
Pulmonary artery O2 content = 12 mL O2/100 mL blood
Oxygen consumption (VO2) = 280 mL/min
Stroke volume = 40 mL
What is the woman’s cardiac output?
A. 2.86 L/min
B. 3.5 L/min
C. 7.0 L/min
D. 8.0 L/min
E. 9.24 L/min
50
 Explanation

• The answer is b - 3.5 L/min

• .

51
• 235. The spouse of a 58-year-old man calls 911 because her
husband complains of chest pain radiating down his left arm. He is
transported to the emergency department, where an ECG and
cardiac enzymes indicate a recent myocardial infarction. The man
undergoes cardiac catheterization, including coronary angiography
and hemodynamic recordings throughout the cardiac cycle. No
valvular defects were present. During ventricular ejection, the
pressure difference smallest in magnitude is between which of the
following?
• a. Aorta and capillaries
• b. Left atrium and left ventricle
• c. Left ventricle and aorta
• d. Pulmonary artery and left atrium
• e. Right atrium and right ventricle
• The answer is c. (Barrett, pp 539-544, 577. Le, p 256. Widmaier, pp
367-371.)
• The pressure gradient between regions of the cardiovascular
system is directly proportional to the resistance of the intervening
structures.
• During ventricular ejection, the aortic valves are open and do not
offer any significant resistance to blood flow. Therefore, there is
very little, if any, pressure difference between the left ventricle and
the aorta (choice c).
• Because most of the resistance in the systemic vasculature occurs
at the level of the arterioles, there is a large pressure gradient
between the aorta and the capillaries (choice a).
• Because the mitral valve is closed during ventricular ejection, there
is a pressure difference between the left ventricle and left atrium
(choice b).
• Similarly, because the tricuspid valve is closed during ventricular
ejection, there is an appreciable pressure difference between the
right ventricle and the right atrium (choice e).
• There is no anatomical connect between Pulmonary artery and left
atrium (choice d).
• 237. In the hemodynamic pressure tracings
below, rapid ventricular filling begins at which
point?
• a. A
• b. B
• c. C
• d. D
• e. E
• The answer is d. (Barrett, pp 539-544. Le, p 256. Widmaier, pp 367-
371.)
• The graph illustrates the development of pressure in the aorta, the
left atrium, and the left ventricle during a single cardiac cycle.
• At point time D, the pressure within the left ventricle is less than
the pressure in the left atrium, and therefore the mitral valve
opens and ventricular filling begins.
• Although the volume in the left ventricle is increasing, the pressure
is falling. During this time period, the recoil of the ventricle causes
its pressure to decrease as it is filling. Later in diastole, the pressure
of the blood returning from the lungs causes both volume and
pressure in the ventricle to increase (time A).
• At time B, the atrial and ventricular pressure curves separate as the
mitral valve closes and isovolumetric contraction occurs.
• At time E, ventricular filling begins to slow.