Cardiovascular System: The Integrated System for Blood Pressure Regulation

Mary Christenson, PT, PhD DPT 732 Management Applications of Physiology II Spring 2009
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Kidney Facts

~50 gallons of blood pass through the 2 kidneys every day ~1.3 quarts of urine produced from the 50 gallons Kidneys about the size of a computer mouse Several important functions including role in maintaining BP
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Objectives

Compare and contrast the integrated system of both short-term and longterm (including kidney involvement) regulation of arterial blood pressure Compare and contrast the effects of various physiologic stressors on the integrated regulation of the cardiovascular system
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Objectives (cont.)

Describe components in measuring cardiac output Describe factors that contribute to the homeostatic disruption of normal circulatory function

What We Already Know

Rapidly Acting Arterial Pressure Control Mechanisms

SNS: effect on total peripheral vascular resistance and capacitance and cardiac pump

Shift of fluid through the capillary walls

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Long-term control mechanisms for arterial blood pressure

What We Are Missing

Long-term mechanisms for BP Regulation

Related to maintaining homeostasis of body fluid volume Based on maintaining a balance between intake and output of body fluid

Variables account for variation in blood volume

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Overall regulation of kidney excretion of H2O and Na+

Simple Concept

Increase in extracellular fluid results in increased blood volume and arterial pressure Normal body response: kidneys excrete excess extracellular fluid and returns the pressure to normal Mechanism reverses if reduced blood volume
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Terminology/General Concepts

Pressure diuresis Pressure natriuresis blood volume blood pressure blood volume blood pressure Excess salt intake: increase H2O retention increase MAP

Volume X Pressure
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{Guyton & Hall, 2006}

Urinary Volume Output (x normal)

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Arterial Pressure mmHg

200
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Renal Output Curve and Net Water/Salt Intake

Over long-term, water and salt intake must equal output Demonstrated at equilibrium point of curve Two determinants of long-term arterial pressure

Location of renal output curve (shift?) Level of intake line

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TPR, Arterial Pressure and Kidney Function

Arterial Pressure = CO X TPR If increase TPR:

Get acute rise in arterial pressure However, normal kidney function will respond by returning arterial pressure to the pressure level of the equilibrium point Why?

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Effect of Fluid Volume on Arterial Pressure

Increased extracellular fluid volume Increases blood volume Increased mean circulatory filling pressure Increased venous return Increased CO Increased arterial pressure
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CO: Two Mechanisms to Increase Arterial Pressure

Direct effect

Increased CO increases pressure Autoregulation

Indirect effect

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Salt Intake

Effect of Na+ greater than effect of H2O Why? Amount of salt accumulation in body is main determinant of extracellular fluid volume

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Chronic Hypertension

MAP > 110 mmHg Results of pathology With dialysis, what happens if patients body fluid level is not kept at a normal level?
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Renal Mechanisms for Control of BP

Review: 1st mechanism of kidney control of arterial pressure 2nd system: Renin-Angiotensin

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Renin-Angiotensin System

Renin hormone that acts as an enzyme; released when arterial pressure drops i.e., when renal perfusion is inadequate Helps raise arterial pressure Can be life-saving system in circulatory shock
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Renin-Angiotensin Pathway
Decreased Arterial Pressure Renin (kidney) Angiotensin I Angiotensin II

Renin substrate
(angiotensinogen)

Retention
(salt/H2O)

Vasoconstriction

Inactivation

Increased Arterial Pressure

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Angiotensin and Salt/Water Retention

Direct effect: on kidneys to retain salt and water Indirect effect: causes adrenal glands to secrete aldosterone which increases salt/water reabsorption by kidneys

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Renin-Angiotensin and Salt Regulation

Allows body to deal with widely varying Na+ intake and maintain normal BP
extracellular volume renin and angiotensin

salt intake arterial pressure

renal retention of Na+ and H2O Return of extracellular volume almost to normal Return of arterial pressure almost to normal
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Primary Hypertension = Silent Killer

Unknown Cause i.e., not secondary to a known cause Influence of weight gain and sedentary lifestyle

PT role?

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Weight Gain and Obesity Role in HTN

Cardiac output increased SNS activity increased Angiotensin II/Aldosterone levels increased

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Treatment Options in HTN

Lifestyle modifications Pharmacological

Vasodilator drugs Natriuretic or diuretic drugs

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Summary of Mechanisms to Control Arterial Pressure

Rapid (seconds) Semi-rapid (minutes/hours) Long-term (hours/days/months/years)

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Additional Circulatory Factors

Cardiac Output

Venous Return

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Cardiac Output and Venous Return

Cardiac output controlled by venous return under most normal unstressful conditions

Factors in the peripheral circulation affecting venous return to the heart (not heart itself) Sum of local blood flows contribute to venous return

CO inversely related to TPR

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Heart Influence on CO

Frank-Starling Law Receptors Heart is limiting factor if receives more venous return than it can handle

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Cardiac Output

Normal: ~5L/min Normal CO plateaus at ~13 L/min without any special stimulation Hypereffective heart Hypoeffective heart

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How Can We Measure CO?

Fick Principle

CO (L/min) = O2 absorbed per minute by the lungs (ml/min)/A-VO2 difference (ml/L of blood)

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