Niruja Srilinganathan PBL ASSIGNMENT

PBL 1: Control of Cardiac Output

A well-trained, 20-year-old athlete is in excellent health and has often run a mile in under 4
minutes. As part of a large group study of young athletes engaged in endurance sports, he
enters the exercise laboratory for evaluation of his physical condition during treadmill
exercise. He runs hard for 10 minutes. At this point he is exhausted and has to stop.
Dramatic changes in cardiorespiratory parameters are noted during the exercise.

Learning Objectives

• How does exercise affect cardiac output & how does body change and
implement to these change
• How is Cardiac output measured
• Treadmill Test
• For what reason does the body become exhausted during exercise

The following issues will be discussed in the essay: cardiac output in particular the
changes that occur during exercise, ways of measuring cardiac output, the purpose of
the treadmill test and the causes of exhaustion in exercise.

How does exercise affect cardiac output & how does body change and
implement to these change

Cardiac output is the volume of blood pumped by the heart every minute. It is calculated
by multiplying the stroke volume, the amount of blood expelled by the heart, with the
heart rate, the number of times the heart contracts every minute. The stroke volume at
rest for an average male is approximately 70 ml and the heart rate is around 75 beats
per minute. However this varies greatly with every individual and could be different in
the athlete since factors such as age, gender and fitness can affect these values. If we
take these numbers then we get:

Cardiac Output = Stroke volume (ml/beat) x heart rate (beats/minute)

= 70 x 75
= 5250 ml/minute

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As a result, it is often said that the average cardiac output of a person at rest is
approximately 5 l/min. In times of greater demand for oxygen by metabolising cells,
such as in the scenario during periods of exercise, cardiac output is increased to match
demand. During intense exercise cardiac output can be increased to about 20 l/min and
as high as 35 l/min in trained people. This change is primarily achieved by increasing the
stroke volume and heart rate with the contribution of other physiological factors. (1)

Controlling Stroke Volume

An increase in stroke volume would mean that more blood is ejected per heart beat. An
increase in the end-diastolic volume and in the force of contraction but a decrease in the
afterload, which is the pressure against which the ventricles have to contract, would
result in a greater stroke volume. End diastolic volume refers to the amount of blood
left in the ventricles during diastole (the relaxed phase) of the cardiac cycle. This is
proportional to the preload, the force of stretch of the ventricles before contraction
occurs, and increasing preload causes a greater stretch of the ventricles which
consequently produces a greater contraction. This is referred to as Starling’s Law and is
llustrated in the graph below (Fig 1). (2)

Figure 1: Relationship between stroke volume and ventricular end diastolic volume (3)

Increase in venous return to the heart, in order to increase stroke volume, can be
achieved by the following ways:

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• Muscle pump mechanism in which skeletal muscle contract and relax veins

• Activation of sympathetic nervous system which causes venoconstriction

• Respiratory pump mechanism in which inspiration causes reduced pressure in the
chest (4)
During exercise, one of the other physiological changes taking place is vasodilation of
vessels in the skeletal muscles which consequently increases venous return and thereby
increases preload. (1)

The strength of contractility of the muscles is also enhanced by the sympathetic nervous
system via stimulation of beta -1 adrenorecepters. This is called a positive ionotropic
effect. (5)

Controlling Heart Rate

In the normal electrical conduction pathway of the heart, the electrical signal generated
in the sino-atrial node (SAN) is passed along the cells of the atria to the atrio-ventricular
node (AVN). There is a delay at the AVN to allow the atria to fully contract before the
impulse is passed down the Bundle of His which splits into the left and right bundle
branch supplying each ventricle and eventually to the purkinje fibres. The following
diagram illustrates this pathway (Fig 2). (1)

Figure 2: Electrical conduction system of the heart (6)

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In order to increase the heart rate, the impulses generated at the SAN needs to be faster
and the delay at the AVN needs to be reduced. This effect is achieved by the activation
of the sympathetic nervous system again as described above producing a positive
ionotropic effect. (1) (5)

It should be noted that although both heart rate and stroke volume needs to be raised to
increase cardiac output, the diastolic filling time decreases with increasing heart rate and
this is one of the factors limiting cardiac output. (7)

How is cardiac output measured?

Cardiac output is a valuable indicator of how well the heart is pumping blood around the
body and hence it is an important measurement taken for the diagnosis of many
cardiovascular diseases. (8)

There are now several methods of measuring the cardiac output of a person, both
invasive, such as pulmonary artery thermodilution and the Fick principle, and non-
invasive as for example Doppler ultrasound. Since there are numerous methods
currently being employed, each method will not be discussed; instead the focus will be
on some of the more commonly used ones. The following will be explained: The Fick
principle, Doppler Ultrasound and Velocity encoded MRI. (8)

The Fick principle

In this method, the oxygen consumption per minute of the person is measured using a
spirometer which is a device that provides the values of a person’s volume of air
involved in expiration and inhalation. The oxygen content of a peripheral artery and of a
pulmonary artery is taken as values of arterial and venous oxygen content respectively.
The cardiac output can then be simply worked out by dividing the oxygen consumption
per minute by the difference in arterial and venous oxygen content as shown in this
equation:

Cardiac Output = oxygen consumption per minute__________

(arterial oxygen content) – (venous oxygen content)

This invasive technique is known for its high accuracy yet is not the most straightforward
one since the values required are difficult to obtain and also rather time consuming.
(8)(9)

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Niruja Srilinganathan PBL ASSIGNMENT

Doppler Ultrasound
In this method, a transducer, which transmits high frequency sound waves, is passed
along the skin over a blood vessel. The sound waves are reflected off red blood cells that
are moving through the vessel. The change in frequency of the reflected sound waves is
called the Doppler shift which allows you to measure how fast blood is flowing through
the vessel. The following equation is then used with the data obtained from the test to
calculate the cardiac output:

Cardiac Output = velocity time integral x cross sectional area of tract x heart rate

This is one of the preferred methods for measuring cardiac output since it is cheap,
accurate and easy to carry out. (8)(10)(11)

Velocity encoded MRI

In velocity encoded MRI, cardiac output is measured by measuring the change in
direction of rotating protons present in the blood. This method is the most accurate way
of measuring the cardiac output of a person yet at the same time the most expensive
one as well and thus explains the seldom practice of this method. It is currently a very
significant research tool. (8)

Treadmill Exercise

The treadmill exercise that the athlete carries out is also called the exercise or treadmill
stress test. This test allows the physician to detect any problems in the heart’s blood
pumping action during an increased demand. It is used in particular for diagnosing
coronary artery disease in which there is reduced blood flow to the heart caused by
plaque build up in the coronary arteries. The heart rate, blood pressure and any
symptoms that the patient reveals are noted down before any exercise and thereafter
during varying intensities of exercise. The patient will also be connected to an
electrocardiograph machine via electrodes attached to the skin. This machine reads the
electrical activity produced by the heart and generates the results in the form of an
electrocardiogram as shown below (Fig 3). (12)

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Figure 3: Example of a standard 12 lead ECG (13)

The electrocardiogram is important and extremely useful in diagnosing conditions such

as angina, chest pain caused by coronary artery disease, and myocardial infarctions. (1)

For what reason does the body become exhausted during exercise

After ten minutes, the athlete becomes too tired to carry on and stops. The main reason
that leads to his exhaustion is the depletion of substrates available for production of
adenosine triphosphate (ATP), which is the energy source. Two pathways of producing
ATP are the aerobic pathway, which requires oxygen, and the anaerobic, which does not
require oxygen. Aerobic mechanism is the most efficient since more ATP is made
however as exercise continues oxygen is not delivered fast enough to produce sufficient
ATP and as a result the athlete’s body switches to anaerobic respiration. Before this
takes place, however, energy stored in creatine phosphate is used up to convert
adenosine diphosphate (ADP) into ATP. Once those stores are depleted anaerobic
mechanism occurs. Eventually this is also limited since the substrates that are used up
needs to be replenished for this mechanism to continue. As a result, there is an eventual
lack of energy available for the contraction of the exercising muscles. (1)(7)

Another cause of fatigue is by the increased levels of potassium ions, which is a

metabolite of muscle contraction, in the muscle. Potassium depolarises the muscle fibres

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making it harder for action potentials to be generated and thereby limits muscle
contractility. (14)

Pain can also result in fatigue caused by the increased levels of lactic acid which is
produced by the anaerobic pathway of producing ATP. Pain receptors in the heart pick up
this information and transmit this information to the central nervous system. (15)

In conclusion, this essay highlights the ways in which the athlete’s cardiac output was
increased during exercise. However, it is important to note that even with an increased
cardiac output exhaustion will eventually lead to the athlete discontinuing the exercise
for the reasons just mentioned above. It is also important to appreciate that tests and
measurement carried out while exercising are significant for detecting many problems
especially of the heart.

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References

1. Marieb NM, Hoehn K. Human Anatomy & Physiology. 7th ed. United States of
America : Pearson Benjamin Cummings, 2007.

2. Mohrman DE, Heller LJ. Cardiovascular Physiology. 5th ed. United States of
America : McGraw-Hill Companies, 2003.

3. World Federation of Societies of Anaesthesiologist. Cardiovascular Physiology

[online] 1999. Available from:
http://www.nda.ox.ac.uk/wfsa/html/u10/u10a_p03.htm [accessed 24/10/2008].

4. Klabunde RE. Cardiovascular Physiology Concepts [online] 2007. Available from:

http://www.cvphysiology.com/Cardiac Function/CF016.htm [accessed 24/10/2008].

5. Wikipedia. Ionotropic effect [online] 2007. Available from:

http://en.wikipedia.org/wiki/Ionotropic_effect [accessed 26/10/2008].

6. Centra Health. Conduction system of the heart [online] 2007. Available from:
http://myhealth.centrahealth.com/library/healthguide/en-us/support/topic.asp?
hwid=tp12556 [accessed 26/10/2008].

7. Kumar P, Clark M, ed.. Clinical Medicine. 6th ed. London, GB : Elsevier Saunders,
2005.

8. Wikipedia. Cardiac Output [online] 2008. Available from:

http://en.wikipedia.org/wiki/Cardiac_output [accessed 24/10/2008].

9. LiDCO. Cardiac Output [online] 2008. Available from: http://lidco-

ir.co.uk/html/clinical/cardiacoutput.asp [accessed 24/10/2008].

10. WebMD. Doppler Ultrasound [online] 2007. Available from:

http://www.webmd.com/a-to-z-guides/doppler-ultrasound [accessed 24/10/2008].

11. Usher SM, Walker DA, Mythen MG. Doppler cardiac output monitoring: a tool for
all physicians. British Journal of Hospital Medicine. 2007;68(11):126-130.

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12. WebMD. Exercise Electrocardiogram [online] 2008. Available from:

http://www.webmd.com/heart-disease/exercise-electrocardiogram [accessed
25/10/2008].

13. MacLeod R, Birchler B. ECG Measurement and Analysis [online] 2002. Available
from: http://www.cvrti.utah.edu/~macleod/bioen/be6000/labnotes/ecg/descrip.html
[accessed 26/10/2008].

14. Wikipedia. Muscle Weakness [online] 2008. Available from:

http://en.wikipedia.org/wiki/Muscle_weakness [accessed 26/10/2008].

15. The a Word. Central Pain [online] 2005. Available from:

http://www.theaword.org/index.php?option=com_content [accessed 26/10/2008].