Mohammad Shariful Alam (Shohan)

CVS (Item no. 4)

Circulation: (Definition+Types+Importance+Factors+Classification of blood vessels fromReflex) Hemodynamics: This is the study of the factors that determine the blood flow and blood pressure. Components: 1. Interrelationship between the diameter of blood vessels and velocity of flowing fluid. 2. Interrelationship between the velocity of the total pressure & lateral pressure of the flowing fluid / Velocity pressure relationship. 3. Relationship between the pressures of the flowing blood with the volume of flow per unit of time. 4. Interrelationship among pressure, flow, and resistance 5. Viscosity of the blood. 1. Interrelationship between the diameter of blood vessels and velocity of flowing fluid: If the diameter of the tube through which blood is flowing is narrow, provided the rate of flow remains constant, the velocity of flow increases. 2. Interrelationship between the velocity of the total pressure & lateral pressure of the flowing fluid / Velocity pressure relationship: When the magnitude of lateral pressure and total pressure are almost same, the velocity of flow is low. But the velocity of flow becomes high if the lateral pressure exerted by the flowing fluid is much less than the total pressure exerted by the flowing fluid. 3. Relationship between the pressures of the flowing blood with the volume of flow per unit of time: Let the blood flow through a narrow rigid tube where L is the length of the tube, P1 and P2 are the pressure of the two ends and is the viscosity of fluid and r is the radius of the tube. The volume of flow per unit of time Q can be mathematically explained by the Poiseuilles law which states ( )

So the volume of blood flow depends on the following factorsi. The pressure gradient ii. The radius of the tube iii. The viscosity of blood iv. The length of the tube 4. Interrelationship among pressure, flow, and resistance: Flow through a blood vessel is determined by two factors: (I) Pressure difference of the blood between the two ends of the vessel (II) The impediment of flow through the vessel, which is called vascular resistance P1 represents the pressure at the origin of the vessel; at the other end the pressure is P2. Resistance to the flow (R) occurs as a result of friction all along the inside of the vessel. The flow through the vessel can be calculated by the following formula, which is called Ohms law: 1

Mohammad Shariful Alam (Shohan)

F In which F is blood flow and P is the pressure difference between the two ends of the vessel. 5. Viscosity of blood: The viscosity of normal blood is about three times as great as the viscosity of water. It is mainly due to the presence of large numbers of suspended red cells in the blood, each of which exerts frictional drag against adjacent cells and against the wall of the blood vessel. Hematocrit: The percentage of blood that is cell is called the hematocrit. Thus, if a person has a hematocrit of 40, this means that 40 per cent of the blood volume is cells and the remainder is plasma. The hematocrit of men average about 42, whereas that of women average about 38. Blood flow: Blood flow means simply the quantity of blood that passes a given point in the circulation in a given period of time. Ordinarily, blood flow is expressed in milliliters per minute or liters per minute. The overall blood flow in the circulation of an adult is about 5000 ml/min. Blood flow is usually laminar or but sometimes also can be turbulent. Laminar flow of blood in vessels: When blood flows at a steady rate through a long, smooth vessel, it flows in streamlines, with each layer of blood remaining the same distance from the wall. Also, the central portion of the blood stays in the center of the vessel. These types of flow are called laminar flow or streamline flow. Turbulent flow: It is opposite to laminar flow, in which blood is flowing in all directions in the vessel and continually mixing within the vessel. Peripheral resistance: The resistance which blood has to overcome while passing through the periphery is called peripheral resistance. We know, Blood pressure = Cardiac output Peripheral resistance So, Factors affecting peripheral resistance: a) Velocity of blood b) Viscosity of blood c) Elasticity of arterial wall d) Lumen of blood vessels. 1 PRU: If the pressure difference between two points is 1 mm of Hg and the flow is 1 ml/sec, the resistance is said to be 1 peripheral resistance unit, usually abbreviated PRU. Cardiac output: The amount of blood that is ejected by each ventricle per minute is called cardiac output. Cardiac output = Stroke volume Heart rate

Mohammad Shariful Alam (Shohan)

If the stroke volume = 70 ml And heart rate = 72 beats/min Then the CO = 70 72 = 5042 ml/min = 5.04 liter/min In a resting supine adult man CO is 5-6 liter/min Cardiac index: The cardiac output per minute per square meters of body surface area is called cardiac index. The average value is = 3.5 liter/min/sq. m of body surface area. Factors affecting cardiac output: 1) Physiological factors 2) Pathological factors and Physiological factors: 1. Age: CO increases with age 2. Sex: CO is 10% to 20% less in female than male due to less body wt. and surface area etc. 3. Surface area: The more surface area and the more will be cardiac output. 4. Posture: Cardiac output is greater in sitting and lying than erect posture due to less venous return in erect posture. 5. Exercise: CO markedly increases in severe exercise and small amount in moderate exercise due to excess muscular activity and venous return. 6. Emotion & excitement: Increases cardiac output. 7. Temperature: Temp. Increases heart rate, so the cardiac output increases. 8. Pregnancy: Increases cardiac output. 9. Epinephrine, histamine: Increases cardiac output. Pathological factors: CO 1. Hyper thyroidism : body metabolism & heart rate CO 2. Anaemia: Hemoglobin delivery of O2 to the tissue local vasodilatation CO 3. Fever: metabolism temperature & CO. 4. Beriberi: ability of tissues to use cellular nutrients peripheral vasodilatation peripheral resistance CO. 5. Any large arteriovenous fistula: venous return cardiac output. CO 1. Hypothyroidism 2. Hemorrhage 3. Congestive cardiac failure 4. Shock 5. Arrhythmia

Mohammad Shariful Alam (Shohan)

*Nice to know: Some factors affecting cardiac output irrespective of age and sex: No change 1) 2) 1) 2) 3) 4) 5) 6) 7) 1) 2) 3) Sleep Moderate changes in environmental temperature Anxiety and excitement (50% - 100%) Eating (30%) Exercise (up to 700%) High environmental temperature Pregnancy Epinephrine Histamine Sitting or standing from lying position (2030%) Rapid arrhythmic Heart disease
[Ref. Ganong]

Increase

Decrease

Factors regulating cardiac output: Cardiac output Stroke volume Heart rate

End systolic volume

End diastolic volume

Pressure load

Myocardial contractility
Initial length of muscle fiber Nutrition and oxygen supply Sympathetic stimulation Diastolic period Homometric and heterometric autoregulation Circulating hormones Calcium level in blood

Filling time Effective filling pressure Atrial contraction Venous return depends on Total peripheral resistance Ejection fraction Ventricular distensibilty

Respiration Barroreceptor reflex Bainbridge reflex Exercise Temperature Hormones Age, sex & surface area

Methods of measurement of cardiac output: Cardiac output is measured by1) Direct method (in animal) 2) Indirect method (in human being): It is done by the help of following methodsa) Fick principle method by using O2 or CO2 b) Stewart and Hamiltons dye dilution method c) Ballisto-cardiography d) Heart lungs preparation. 4

Mohammad Shariful Alam (Shohan)

Fick principle method: Fick principle: Ficks principle states that the amount of a substance taken up by an organ (or by the whole body) per unit of time is equal to the arterial level of the substance minus the venous level (AV differences) times the blood flow. Measurement of cardiac output: ( (
( )

) )

Here, O2 consumption in lungs = 250 ml/min Arterial blood O2 level = 190 ml/L Venous blood O2 level = 140 ml/L Distribution of cardiac output in various organs: Brain 750 ml/minute Heart 200 ml/minute (coronary circulation) Liver 1500 ml/minute Kidney 1300 ml/minute Muscle 750 ml/minute Venous return: It is the amount of blood that comes from periphery to right atrium of heart in each minute. It is equal to cardiac output. The amount of venous return is about 5 liters/min. Factors controlling/regulating venous return: 1. Mean systemic filling pressure: 7 mm of Hg. Mean systemic filling pressure Venous compliance & venous capacity Venous return. 2. Right atrial pressure: (Central venous pressure): Right atrial pressure venous return. 3. The resistance to flow 4. Thoraco-abdominal pump: During inspiration: Intrathoracic pressure Intra abdominal pressure During expiration: Opposite effect occur. Venous return

5. Skeletal muscle pump: Contraction of skeletal muscle Compress the underlying veins Venous return. 6. Tissue vasomotor tone: Vasomotor tone capacitance of venous reservoir venous return 7. Respiratory pump 8. Gravity: Gravity venous return.

Mohammad Shariful Alam (Shohan)

Stroke volume: The volume of blood pumped out by each ventricle in each beat called stroke volume. It is about 70 80 ml. Stroke volume = End diastolic volume End systolic volume = (120 50) ml = 70 ml Stroke volume per square meter of body surface area is called stroke volume index. Factors affecting stroke volume: 1. Venous return: Stroke volume Venous return 2. Heart rate: 3. Force of contraction: SV Force of contraction 4. Total peripheral resistance: End diastolic volume (EDV): The volume of blood which remain in each ventricle at the end of ventricular diastole. Amount: 110 to 120 ml Factors affecting end diastolic volume: a. Filling time: The ventricular filling is affected by decreased filling time. b. Effective filling pressure: This is the gradient between inside and outside of the ventricle. It depends uponi. Degree of positivity of intra abdominal pressure ii. Degree of negativity of intrathoracic pressure c. Distensibility of ventricle: Hear muscle is distended during diastole to receive blood from periphery. It depends on i. Condition of pericardium ii. Condition of myocardium d. Atrial contraction: It contributes 30% of blood, when atria contract, and pushed the blood into the ventricle. It is important during increased heart rate. e. Venous return: Increased venous return increases the ventricular filling that increases EDV. f. Ejection fraction: The fraction of the EDV that is ejected is called the ejection fraction.
*Nice to know: EDV 1) Stronger arterial contraction 2) Increased total blood volume 3) Increased venous return 4) Increased pumping action of skeletal muscle 5) Increased negative intrathoracic pressure EDV 1) Increased intrapericardial pressure 2) Decreased ventricular compliance

End systolic volume: The volume of blood which remains in each ventricle at the end of the ventricle at the end of the ventricular systole. Amount: 40 to 50 ml. Factors affecting ESV: See factors regulating cardiac output.

Mohammad Shariful Alam (Shohan)

Pre-load: This is defined as the tension of the myocardial fibers at the end of diastole, just before the onset of ventricular contraction. Preload is therefore related to the degree of stretch of the myocardial fibers. Factors affecting preload: Total blood volume Venous tone Body position Intrathoracic & intraopericardial pressure Atrial contraction. After load: This is the load or resistance against which the ventricle contracts (or this is defined as the myocardial wall tension developed during systolic ejection). Factors affecting afterload: Left ventricular volume Elasticity of vessels Presence of outflow obstruction.
Afterload Contractility Preload

Myocardial fiber shortening

Left ventricular size

Heart rate
Cardiac output

Stroke volume Peripheral resistance Arterial pressure

Fig. Interactions between the components that regulate cardiac output and arterial pressure. (Solid line indicates increases and the dashed line indicates a decrease)

Stokes-Adams syndrome: When the cardiac impulse fails to pass from atria into the ventricles through the A-V nodal and bundle system the atria continue to beat at the normal rate of rhythm of the sinus node, while a new pacemaker develops in the Purkinje system of the ventricles and drives the ventricular muscle at a new rate somwhere between 15 and 40 beats per minute. After sudden A-V bundle block, the Purkinje system does not begin to emit its intrinsic rhythmical impulse until 5 to 20 seconds later because, before the blockage, the Purkinje fibers had been over-driven by the rapid sinus impulses and, consiquently, are in a suppressed state. During these 5 to 20 seconds, the ventricle fail to pump blood, and the person faints after the first 4 to 5 seconds because the lack of blood flow to the brain. This delayed pickup of the heartbeat is called Stokes-Adams syndrome. If the delay period is too long, it can lead to death. 7