Myocardial perfusion
Pathway of coronary blood flow
Supply of coronary blood flow
- Right coronary artery is dominant in 50% of individual
- Left coronary artery is dominant in 20%
- Equal in 30%
Drainage of coronary blood flow
- Most (90%) coronary venous blood returns to right atrium via coronary sinus.
- Some reach right atrium via anterior coronary veins
- Some reach cardiac chambers directly via:
* Arteriosinusoidal vessels
* Arterioluminal vessels
* Thebesian vessels
Left coronary artery vs right coronary artery
Coronary perfusion pressure
= Aortic blood pressure - (intraventricular pressure or right atrial pressure, whichever is higher)
Left ventricle
Because the pressure is much higher in left ventricle in systole
- Perfusion of LV is mainly in diastole
- Reversal of blood flow can happen in systole
Also,
Transmural pressure is greatest in the endocardium
- Impairment of blood flow during systole is more severe in the endocardial region
e.g.
- In systole, LV perfusion pressure
= 120-120 (transmural pressure)
= 0 mmHg
- In diastole, LV perfusion pressure
= 80 - 5 (RA pressure)
= 75 mmHg
Right ventricle
Difference in perfusion during systole and diastole less marked in the RV
* Intra-ventricular pressure is much lower (SBP=25)
* Perfusion pressure is same as LV
RV wall is thinner too
Regulation of coronary perfusion
Metabolic autoregulation overrides the neural factors.
--> Metabolic demands of the heart regulate coronary blood flow
Metabolites involved include:
[BL8:p233-234]
- NO
- ATP-sensitive K+ channels
- Adenosine
NB:
- Direct noradrenergic stimulation actually causes vasoconstriction via alpha-adrenergic receptors
Other notes
Coronary steal
... when administration of vasodilator can fully dilate normal vessel branches parallel to the narrowed segment and divert blood away from it.