CIRCULATION

BASIC THEORIES OF CIRCULATORY FUNCTION

1. The rate of blood flow to each tissue of the body

is almost always precisely controlled in relation to
the tissue need.

When tissues are active, they need

greatly increased supply of nutrients and
therefore much more blood flow than when at
restoccasionally as much as 20 to 30 times
the resting level.

2. The cardiac output is controlled mainly by the

sum of all the local tissue flows.

heart responds automatically
of blood by
pumping it immediately into
it
had originally come.
3. In general the arterial
independently of either
or cardiac output control.
(a) increase the force of heart to this increased inflow
pumping,
(b) cause contraction of the large the arteries from whence
venous reservoirs to provide more
blood to the heart,
(c) cause generalized constriction
of most of the arterioles throughout pressure is controlled
the body local blood flow control
The circulatory system is provided with an extensive system for
controlling the arterial blood pressure. For instance, if at
any time the pressure falls
significantly below the normal level of about 100 mm Hg,
within seconds a barrage of nervous
reflexes elicits a series of circulatory changes to
raise the pressure back toward normal.

INTERRELATIONSHIP AMONG PRESSURE, FLOW AND RESISTANCE

Blood flow through a blood vessel is determined by
two factors:
(1) pressure difference of the blood between
the two ends of the vessel, also sometimes called
pressure gradient along the vessel, which is the force
that pushes the blood through the vessel,

(2) the impediment to blood flow through the vessel, which is

called vascular resistance
F blood flow R-resistance
F=P
P(P1-P2)-pressure diff btwn the 2 ends of a
R
vessel
What is 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 total circulation of an
adult person at rest is about 5000 ml/min.This is called
the cardiac output because it is the amount of blood
pumped into the aorta by the heart each minute.

1)laminar flow of blood in vessels (highly ordered,smooth streamlines)

When blood flows at a steady rate through a long, smooth blood vessel, it flows
in streamlines, with each layer of blood remaining the same distance from the vessel wall. Also,
the central most portion of the blood stays in the center of the vessel.This type of flow is called
laminar flow or streamline flow, and it is the opposite of turbulent flow, which is blood flowing
in all directions in the vessel and continually mixing within the vessel,

2)turbulent flow of the blood under some conditions(highly disordered, velocity fluctuation)

Turbulent flow means that the blood flows crosswise in the vessel as well as along the vessel,
usually forming whorls in the blood called eddy currents.
Turbulence does not begin to occur until the velocity of flow becomes high enough that the flow
lamina break apart. Therefore, as blood flow velocity increases in a blood vessel or across a heart
valve, there is not a gradual increase in turbulence. Instead, turbulence occurs when a critical
Reynolds number (Re) is exceeded. Reynolds number is a way to predict under ideal conditions
when turbulence will occur. The equation for Reynolds number is:

Where v = mean velocity, D = vessel diameter, = blood density, and = blood viscosity

BLOOD PRESSURE
Force exerted by the blood against any unit area of the vessel wall.
Measured in millimeters of mercury (mm Hg)
When one says that the pressure in a vessel is 50 mm Hg, one means that the force
exerted is sufficient to push a column of mercury against gravity up to a level 50 mm
high.
Increase in arterial pressure not only increases the force that pushes blood through the
vessels but also distends the vessels at the same time, which decreases vascular resistance

EXAMINATION OF BP
Usually, indirect measurements of the systolic and diastolic pressures are obtained with
a sphygmomanometer (from the Greek sphygmos pulsing, manos thin).

The systolic blood pressure is the peak pressure that occurs in the artery following
ventricular systole, and the diastolic blood pressure is the level to which the arterial blood
pressure falls during ventricular diastole.

MEASURING THE BLOOD PRESSURE WITH THE SPHYGMOMANOMETER

 The usual blood pressure cuff width is 12.5 centimetres.
This is suitable for a normal-sized adult
forearm.
However, in obese patients with large arms (up to 30% of the adult population) the
normal sized
cuff will overestimate the blood pressure and therefore a large cuff must be used.
A range of smaller sizes are available for children.
Use of a cuff that is too large results in only a small underestimate of blood pressure.

Methods of measuring BP: (from CPG)

Patients should be adequately rested and seated with their arms supported.
The cuff and the mercury reservoir should be at the level of the heart.
They should not have smoked or ingested caffeine within 30 minutes of measurement.
The SBP should be estimated initially by palpation. While palpating the
brachial/radial artery, the cuff is inflated until the pulse disappears. The cuff should then
be inflated to a further 20 mmHg. The cuff is then slowly deflated and the pressure at
which the pulse is palpable is the estimated SBP.
The bladder is again inflated to 20 mmHg above the previously estimated SBP and
the pressure reduced at 1-2 mmHg per second whilst auscultating with the bell of the
stethoscope. The bell should not be placed under the cuff. The point at which repetitive,
clear tapping sounds first appears (Korotkoff Phase I) gives the SBP.
Phase I sounds sometimes disappear as pressure is reduced and reappears again at a lower
reading (the auscultatory gap), resulting in under estimation of the SBP.
The complete disappearance of sound (Korotkoff Phase V) should be taken as the
diastolic reading.
Check BP in both arms in the first consultation. Use the higher reading for making
diagnosis.
(In some groups, (e.g. anaemic or elderly patients) the sounds may continue until the zero
point. In such instances the muffling of the repetitive sounds (Korotkoff Phase IV) is
 taken as the diastolic pressure. The point of muffling is usually higher than the true
arterial diastolic pressure. If Korotkoff Phase IV is used,
this should be clearly REMINDER recorded.)
-The patients brachial
5 different sounds will be heard due artery should be at about to the pressure
-Korotkoff sounds the level of the heart

K1=systolic bp -If the arm is too

K2=sound increases in intensity highfor example, at
K3=sound decreases in intensity the level of the
supraclavicular K4=muffled
diastolic bp notchthe blood K5=disappears
pressure reading will be
about 5 mmHg lower;

-if the arm is too low,

the reading
will be higher than is
accurate.

HYPERTENSION
Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or
diastolic BP of 90 mmHg or greater

TYPES OF HYPERTENSION:
1) Isolated systemic hpt- defined as SBP of 140 mmHg and DBP 90
2) Isolated office(white coat) hpt- elevation in clinic blood pressure but normal home or
ambulatory blood-pressure values.
3) Masked hpt- Patients with masked hypertension have normal clinic blood pressure but
elevated 24- hour ambulatory or home blood-pressure load (135/85 mmHg).
Prognosis of masked hypertension is worse than isolated office hypertension

BRITISH HYPERTENSION SOCIETY CLASSIFICATION OF BP

BP SYSTOLIC BP(mmHg) DIASTOLIC BP(mmHg)

Optimal 120 80
Normal 130 85
High normal 130-139 85-89
HPT
Grade 1(mild) 140-159 90-99
Grade 2(moderate) 160-179 100-109
Grade 3(severe) 180 110
ISOLATED SYSTOLIC HPT
Grade 1 140-159 90
Grade 2 160 90

Causes of secondary hypertension

R-Renal diseases
E-Endocrine disease
D-Drugs(NSAIDs.OCP)
C-Cushings syndrome,Conns
A-Acromegaly
P-Pheochromocytoma
T-Takayatsu
S-Sleep apnoea

Investigations
1)serum urea and electrolytes may show evidence of renal impairment (hypokalemia occurs in
Conns syndrome)
2)Urine stix testing is performed to look for hematuria and proteinuria
3)Blood glucose
4)Serum lipids
5)ECG may show evidence of left ventricular hypertrophy or MI

Managements
Non-pharrmacological measures
-weight reduction (aim for BMI 25kg/m2)
-low fat and low saturated fat diet
-low-salt diet(6g sodium chloride per day)
-limited alcohol consumption
-dynamic exercise (at least 30 min brisk walk per day)
-increased fruit and vegetable consumption
-reduce cardiovascular risk

Pharmacological measures:
-treatment begun immeadiately in patients with severe hpt(BP 220/120 mmHg)
-other patients treatment is started if repeated measurements show that sustained hpt is present
ABCDE

DRUGS EXAMPLES MOA S/E C/I

Angiotensin Captopril,enapril -blocks the conversion of -cough, -renal
converting enzyme ,lisinopril, angiotensin I to II which is a proteinuria, artery
inhibitors ramipril potent vasoconstrictor and rashes, stenosis as
blocks degradation of leucopenia it causes
 bradykinin(vasodilator) infarction
of kidney
Angiotensin 2 receptor Losartan, -blocks receptor for - -pregnancy
blocker valsartan, angiotensin II headache -renovas-
irbesartan, - cular
candesartan fainting diseases
-
dizziness
-
nasal
congestion
-
diarrhea
-
back pain

-leg
pain

-blocker Propranolol - block the receptor sites for -nausea -asthma

Labetalol the endogenous catecholamines e -diarrhea
pinephrine (adrenaline)
Nadolol -broncho
and norepinephrine(noradrenaline)
Timolol on adrenergic beta receptors, of spasm
the sympathetic nervous system -dyspnea
-raynauds
syndrome
-bradyca
rdia
-HF

Calcium channel Verapamil

blocker Diltiazem
Amlodipine
Nifedipine