30th batch SGD
CVS regulation and coronary circulation
10 6 2021
Q1.
a. Name the components of baroreceptor reflex arc
b. Describe the effects pf baroreceptor stimulation in the body
c. Outline the neural network in brainstem that bring about the effects
describe in question “b”
Q2. Blood pressure in a healthy person is not significantly reduced when stand
up from lying down
Give the physiological basis for the above observation
Q3. Explain the physiological basis of the following tests in assessing integrity
of cardiac autonomic functions
a) Sinus arrhythmia
b) Valsalva maneuver
Q4. Certain organs maintain constant blood flow despite variation in arterial
blood pressure .
Explain the physiological basis for the above statement
Q5. Sub-endocardial portion of the left ventricle is relatively more prone to
ischemia compared to the rest of the myocardium in a person with tachycardia.
Q6. Fillin the blanks recalling your knowledge on coronary circulation and
ECG.
Arterial supply Region supplied in ECG leads which show
heart changes
Left anterior descending
Left lateral
II, III, AVF
Q1.
a. Name the components of baroreceptor reflex arc
Reflex is an automatic (involuntary) stereotyped quick response elicited
to a defined stimulus.
b. Reflex is mediated via a reflex arc’
i. Sensory receptor
ii. Sensory (afferent) neuron
iii. CNS integration (mono/poly synaptic)
iv. Efferent (motor) neuron
v. Effector organ (target tissue)
Baroreceptor reflex arch consists of
[Link] receptors
Baroreceptors in the carotid sinus.
Baroreceptors located in the aortic arch
2. Sensory (afferent) nerves
Baroreceptors in the carotid sinus innervated by a branch of the
glossopharyngeal nerve, the carotid sinus nerve.
Baroreceptors located in the aortic arch are innervated by a branch of the
vagus nerve, the aortic depressor nerve.
[Link] integration Centre
These nerve connect to the blood pressure control centers in the medulla
oblongata
There are two such areas in the medulla oblongata
1. RVLM (also called Vasomotor area, is a group of neurons located near
the pial surface of the medulla in the rostral ventrolateral medulla)
This stimulate the sympathetic to heart and blood vessels
2. Cardio-inhibitory area (Vagus motor nuclei which stimulate the
parasympathetic to heart)
[Link] pathway
1. From RVLM via thoracic sympathetic preganglionic and post
ganglionic fibers to heart and blood vessels
2. From Cardio-inhibitory area via vagus parasympathetic to heart
[Link] tissue
Sympathetic outflow will terminate on
Β1 adrenergic receptors in SA node , myocardium and AV node and purkinje
fibers in the heart
α1 adrenergic receptors in arteries and veins
Parasympathetic outflow will terminate on
Muscarinic receptors in SA node and myocardium
b. Describe the effects pf baroreceptor stimulation in the body
Inhibition of sympathetic and stimulation of parasympathetic to heart
Effects will be lowering of blood pressure, bradycardia, and reduction in cardiac
output ( this is due to negative inotropic and chronotropic effect on the heart by
parasympathetic and vasodilatation resulting reduction in the total peripheral
resistance and increase in the stores of blood in the venous reservoirs due to
venodilatation leading to decrease in venous return)
c. Outline the neural network in brainstem that bring about the
effects describe in question “c”
When baroreceptors are stimulated by stretching/ distension of the arterial
wall , they will be stimulated
The nerve impulses conducted via afferents to the medulla oblongata
These nerve fibers release glutamate neurotransmitter and stimulate neurons
in the nucleus of the tractus solitarius (NTS)
The NTS neurons then send stimulatory signals to caudal ventrolateral
medulla (CVLM).
Then these CVLM neurons release inhibitory neurotransmitter γ-
aminobutyric acid (GABA) and inhibit the discharge of the RVLM
RVLM is also known as vaso motor area usually stimulate the sympathetic
outflow to the heart and blood vessels
So baroreceptor stimulation will lead to inhibition of sympathetic outflow to
the heart/blood vessels
In addition NTS neurons send excitatory signals to vagal motor neurons in
the nucleus ambiguous resulting parasympathetic stimulation to heart
Q2. Blood pressure in a healthy person is not significantly reduced when
stand up from lying down
Give the physiological basis for the above observation
standing
• In sudden upright posture from a supine , venous pooling in legs and
abdomen
• ↓ right heart venous return
• ↓ right and left heart output
• ↓ BP (also hydrostatic effect due to carotid sinus being above heart)
• ↓ baroreceptor firing
• ↑ sympathetic tone
• ↓ parasympathetic tone to heart
• peripheral arteriolar and venous constriction
• ↑ HR, contractility
• All these increases CO and TPR resulting maintaining the blood pressure
So as long as the baroreceptor reflex is normally working, an individual is
capable of maintaining blood pressure despite change in posture.
If baroreceptor reflex is not functioning normally blood pressure will drop
during standing and patient will feel faintish. This is known as postural
hypotension. (drop in Systolic BP >20 mmHg or drop in diastolic BP >10
mmHg after 3 minutes of standing)
Q3. Explain the physiological basis of the following tests in assessing
integrity of cardiac autonomic functions
a) Sinus arrhythmia
• Acceleration of HR during inspiration and decelerates during
expiration
• This is a normal phenomenon
• Due to fluctuations in vagal output to the heart.
• During inspiration, impulses in the vagi from the stretch receptors in
the lungs inhibit the cardio-inhibitory area (vagus motor neuclus) in the
medulla oblongata.
• Tonic vagal discharge that keeps the heart rate become inhibited ,
and the heart rate rises.
So if the sinus arrhythmia is absent it indicated that the cardiac
autonomic functions are impaired
b) Valsalva maneuver
• This is a maneuver of forceful expiration against close glottis which is
maintained for a period of time and suddenly released
• The persons blood pressure and heart rate is monitored throughout the
procedure
In VALSALVA MANEUVER , the following changes will be
observed in a patient with normal cardiac autonomic functions
Stage 1
Brief rise in BP initially -(pressure transmitted directly on blood in aorta)
Stage 2
BP falls- due to reduced venous return resulting low CO
Stage 3
Increase in HR due to inhibition of baroreceptor reflex due to reduced
blood pressure
Stage 4-Release pressure in the maneuver
overshoot of BP due to sustain vasoconstriction mediated via
baroreceptor inhibition
Stage 5
Bradycardia due to baroreceptor stimulation
Stage [Link] normal
• Changes in BP and pulse rate is not seen if ANS is affected eg. diabetic
neuropathy
Q4. Certain organs maintain constant blood flow despite variation in
arterial blood pressure. Explain the physiological basis for the above
statement
• The ability of an organ to maintain normal or near normal blood flow
despite variation in the arterial blood pressure is autoregulation
• Autoregulation is a local responses of the arterial smooth muscle to local
stimuli.
• It occurs independently of any nerve activity on the organ vasculature
• Autoregulation is well developed in the kidney, brain, heart, skeletal
muscle and mesentery & liver.
• Two theories to explain the phenomenon of autoregulation.
– Myogenic theory of autoregulation
– Metabolic theory of autoregulation
– Myogenic theory of autoregulation
This is due to the intrinsic contractile response of vascular smooth muscle to
stretch.
As the pressure rises, blood flow will increase.
Then blood vessels are distended
Vascular smooth muscle fibers contract in response to stretch resulting
elasric recoli and vasoconstriction. With this resistance increases , so blood
flow back to normal
When blood pressure reduced and blood flow reduces to organ, the tension
on the blood vessle wall is reduced. This will lead to reduction in elastic
recoil and vasodilation. So resistance is reduced and blood flow will increse.
This is smooth muscle response to tension in the vessel wall to maintain
constant blood flow despite variation in the blood pressure
Futhermore this explain the greater degree of contraction of vessel wall at
higher pressures
As wall tension is proportional to the distending pressure times the radius of
the vessel (law of Laplace) capillaries which has small radius will need to
develop low wall tension to counter balance even high distended pressure
Otherwise vessel wall WILL rupture
Capillaries that have very thinned wall can withstand high pressure because
of this
– Metabolic theory of autoregulation
• Vasodilator substances accumulate in active tissues when blood flow is
reduced
• These include “metabolites”such as CO2, H+, nitric oxide, adenosine,
prostaglandins, K+, PO4- and hypoxia)
• These have direct vasodilator effect on the blood vesseles
• When blood flow decreases, they accumulate and the vessels dilate
• The resulted increased in blood flow washes out the vasodilator
substances in the area.
• As a result, the arterioles constrict, the vascular resistance increases and
the blood flow returns to normal
Increases in CO2 tension
-The direct dilator action of CO2 is most pronounced in the skin
and brain
A rise in temperature
Increased K +
-secondary to the hyperpolarization of vascular smooth muscle
cells.
Adenosine
-vasodilator in cardiac muscle not in skeletal [Link] also
inhibits the release of norepinephrine
Q5. Sub-endocardial portion of the left ventricle is relatively more prone
to ischemia compared to the rest of the myocardium in a person with
tachycardia.
• During systole the cardiac muscle contracts and compresses the coronary
arteries.
• During systole the pressure inside the left ventricle is slightly higher than
the aorta
• Blood flow does not occur during systole to the subendocardial portions
of LV
• During diastole the pressure in the left ventricle drops and the cardiac
muscle relaxes.
• The gradient between the aorta and left ventricle increases
• Therefore blood flow in the coronaries supplying the left ventricle only
occurs during diastole.
As no flow occurs in the subendocardial portions of the LV during systole this
region is more prone to ischemic damage.
When heart rate is increased (tachycardia) diastoly is shortened and therefore
coronary blood flow is affected to a greater extent.
Q6. Fillin the blanks recalling your knowledge on coronary circulation and
ECG.
Arterial supply Region supplied in ECG leads which show
heart changes
Left anterior descending Anterior V1, V2, V3, V4
Circumflex artery Left lateral I, AVL, V5,V6
Right coronary Inferior II, III, AVF
(Not required for answer but to recapitulate)
Right coronary supplies – Right ventricle
Right atrium
Posterior part of left ventricle
Posterior part of interventricular septum
SA node
AV node
Left coronary - Left ventricle
Left atrium
Anterior part of left ventricle
