X.

Blood Pressure
A. INTRODUCTION
When the ventricles contract (systole), the pressure inside the ventricles increases and this closes the atrioventricular (mitral and tricuspid) valves. Further contraction increases the ventricular pressure until it exceeds the aortic pressure. At this point, the arterial pressure is at its lowest point during the cardiac cycle (diastolic pressure), the semilunar (pulmonary and aortic) valves are forced open, and blood flows into the arteries. Blood entering the arterial system, slightly inflates the aorta and increases blood pressure to a maximum (systolic pressure). These pressure and volume changes are illustrated in Figure X-1.

Figure X-1. Wiggers diagram showing the relationship between pressure and volume c hanges in the left heart and aorta. Adapted from Silverthorn Fig. 14-27.

Although the variation in arterial blood pressure during the cardiac cycle is smoothed by the elasticity of the major arteries, blood still exhibits pulsatile flow through the arteries. This pulsatile arterial blood flow is measured using a stethoscope and a sphygmomanometer (blood pressure cuff). Blood is delivered to all tissues of the body by the maintenance of an adequate arte rial blood pressure, which is directly dependent on cardiac output (volume of blood pumped by the heart per minute) and peripheral resistance (which is increased by constriction and decreased by dilation of the arterioles). A As explained above, this procedure involves stopping blood flow to the arm, which is potentially dangerous. Subjects should be healthy individuals who do not have a personal or family history of cardiovascular problems. If possible, use more than one subject during the course of the lab session. Please take the following precautions: 1. Know what you are doing ahead of time. 2. Do not leave the cuff inflated for a prolonged period of time (>30 seconds). 3. Flex and extend fingers between experiments to maintain blood flow.

B. MEASURING BLOOD PRESSURE

1. Measuring Blood Pressure using a Sphygmomanometer and Stethoscope The routine clinical procedure for measuring arterial blood pressure is to use a device known as a sphygmomanometer (Figure X-2). This instrument consists of an inflatable rubber cuff connected by rubber hoses to a hand pump and to a pressure gauge (manometer) graduated in millimeters of mercury. The cuff is wrapped around the upper arm and inflated to a pressure greater than the systolic pressure, which occludes blood flow in the brachial artery. The examiner listens to the brachial artery with a stethoscope while the pressure in the cuff is decreased. When the pressure in the cuff is lower than systolic pressure but higher than diastolic pressure, blood flow in the artery is partially occluded; this causes a turbulence, which can be heard using a stethoscope. These are called the Korotkoff sounds (or K-sounds), after the man who first described them. The sounds of Korotkoff are divided into the following five phases based on the loudness and quality of the sounds (see Figure X-3). The first appearance of the Korotkoff sounds indicates the systolic pressure. These sounds continue to get quieter as pressure drops and diastolic pressure is marked by their disappearance.
Figure X-2. Setup of sphygmomanometer

(a) Sounds of Korotkoff Phase 1: A loud, clear tapping (or snapping) sound is evident, which increases in intensity as the cuff is deflated. Phase 2: A succession of murmurs can be heard. Sometimes the sounds seem to disappear during this time, which may be a result of inflating or deflating the cuff too slowly. Phase 3: A loud, thumping sound, similar to phase 1 but less clear, replaces Cuff the murmurs. pressure Phase 4: A mm Hg muffled sound abruptly replaces the thumping sounds of phase 3. Relative Phase 5: All intensity of sounds sounds disappear. This phase is absent in some people.
Figure X-3. Sounds of Korotkoff

The cuff pressure at which the first sound is heard (that is, the beginning of phase 1) is taken as the systolic pressure. The cuff pressure at which the sound disappears (the beginning of phase 5) is taken as measurement of the diastolic pressure. In the example shown in Figure X-3, the pressure would be indicated as 120/76. (b) Procedure 1. Ask the subject to relax with their left hand resting on the table as before. 2. Place the blood pressure cuff around the upper portion of the left arm, between the elbow and shoulder, about 2-3 cm above the elbow. 3. Position the manometer so it is easy to read. 4. Palpate the brachial artery just above the elbow, and place the head of the stethoscope where the pulse is felt, and hold it firmly in place. 5. Clean the ear pieces of the stethoscope with alcohol wipes before using them. 6. Watch the manometer as you pump up the pressure in the cuff to about 180 mmHg. 7. While listening for the Korotkoff sounds, open the valve and allow the pressure in the cuff to decrease slowly. 8. Record the systolic pressure (beginning of phase 1, when the first sounds can be heard). 9. Record the diastolic pressure (beginning of phases 4 and 5, when the sounds disappear). 10. Repeat these steps a few times until you become comfortable with the procedure and you obtain consistent readings.

2. Measuring Blood Pressure using iWorx (a) Equipment Required Plethysmograph Event marker Sphygmanometer/Blood pressure cuff Stethoscope

(b) Equipment Setup 1. Connect the plethysmograph to Channel 3, and the subjects volar surface of the distal segment of a middle finger or thumb. 2. Connect the event marker to Channel 4. 3. Place the blood pressure cuff around the upper portion of the left arm, in the same manner as in the previous exercise. 4. The subject should sit quietly. 5. Start LabScribe and select the "Heart #4" settings file. (c) Procedure 1. Ask the subject to sit quietly and relax with their left hand resting on the table at the level of the heart. 2. Make sure to label your data trace appropriately and start recording. 3. Inflate the cuff until the pressure is just above 200 mm Hg, notice that the finger pulse disappears as in Figure IX-4 below.

Figure X-4. Finger pulse during cuff inflation and deflation

4. Slowly release the cuff pressure. When the pressure reaches 200, quickly press and release the event marker to produce a signal on channel four (event). Repeat the signal every time the pressure drops by an increment of 20 mmHg. 5. When the cuff reaches 40 mmHg stop recording and remove the cuff. The subject should flex and extend their fingers to enhance blood circulation. 6. Save the file. 7. Repeat this whole procedure (including the data analysis) two more times. (d) Data Analysis - Measuring Blood Pressure Systolic Pressure 1. Find when the finger pulse reappears and the pair of event markers closest to this point (see Figure X-5). Move all this data to the Analysis window.

Figure X-5. Finger pulse reappears between 120 and 100 mm Hg

2. Place one cursor on the peak of the smallest signal and the second cursor on the event marker signal entered prior to the peak. Measure the time interval (T2-T1) and call this time value#1 (shown above). 3. Repeat with the second cursor on the Event marker signal entered after the peak-call this time value#2 (shown above). 4. Calculate:

value#2 pressure increment(20) value#1 + value#2

5. Add this number to the lowest value in the bracket (100 in the above example) to give you the systolic pressure.

Diastolic Pressure Look at your recording and find where the amplitude of the finger pulse increases until it reaches (and stays at) its largest amplitude. Repeat the above for the largest peak to give you the diastolic pressure. 3. Clinical Significance Normal blood pressure for a given individual depends on the persons age, sex, heredity, and environment. The traditionally accepted values for arterial blood pressure are given in Table X-1. Chronic high blood pressure is called hypertension. Hypertension is a major contributing factor in heart disease and stroke. Hypertension may be divided into two general cate gories. Primary hypertension, which comprises 95% of all cases, refers to hypertension of unknown causes. This category is, in turn, divided into benign hypertension (also known as essential hypertension) and malignant hypertension. When the pathology that produces the hypertension is known, it is referred to as secondary hypertension.
Table X-1 . Normal arterial blood pressure at different ages.

Recently, the conclusions of a major national study1 (JNC 7 report) of hypertension were published in the Journal of the American Medical Association. This study recommended a significant lowering of the b lood pressure values used to define hypertension. The following excerpts were taken from an accompanying summary of the article 2.
The World Health Organization has estimated that high blood pressure causes 1 in every 8 deaths worldwide, making hypertension the third leading killer in the world. The JNC 7 reportsummarizes how the burden of hypertension can be decreased. Among the

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report JAMA Vol. 289, No. 19, pp. 2560-2571. May 21, 2003.
2

JNC 7 - It's More Than High Blood Pressure. JAMA Vol. 289, No. 19, pp. 2573-2575. May 21, 2003.

messages emphasized is that systolic blood pressure control should be the focus of treatment. Cardiovascular risk from systolic hypertension begins at 115 mm Hg and risk from diastolic hypertension begins at 75 mm Hglowering blood pressure toward the new goal level of 120/80 mm Hg will decrease heart attacks, heart failure, stroke, kidney disease, and will save lives. For many, high blood pressure is just one manifestation of what may be termed the lifestyle syndrome, which is a cluster of conditions and diseases that result from consuming too many calories; ingesting too much saturated fat, sodium, and alcohol; not expending enough calories; and using tobacco or being exposed to tobacco smoke. In addition to hypertension, manifestations of the lifestyle syndrome include the metabolic syndrome, obesity, dyslipidemia, cardiovascular disease, cancer, osteoarthritis, depression, sexual dysfunction, and type 2 diabetes mellitus. To the extent that the stakeholders in hypertension controlclinicians, patients, health services organizations, and the purchasers of health care servicesact and are organized toprevent hypertension, the burden from the diseases and conditions of the lifestyle syndrome also will be decreased.

C. BLOOD PRESSURE, BODY POSITION, AND GRAVITY

As you know, blood pressure is tightly regulated; however, most of this regulation is concerned with blood reaching the brain and the heart. Blood pressure in the peripheral system is influenced by distance from the heart as well as other factors such as temperature and gravity. This laboratory is meant to explore how some factors influence overall blood pressure, but also to look at how pressure varies in different parts of the body and how it is influenced by body position and gravity. For instance, if you are lying down, by the time blood reaches the capillaries in the foot, the systolic pressure is lower than it was when it left the heart. Now, if you stand up, gravity makes it more difficult for the blood to flow upward to the brain and to return to the heart, because it tends to pull blood to the lower extremities. So when standing, the pressure at the foot is muc h greater than when lying down. This pressure is transmitted to the veins, which need to generate enough pressure to work against gravity and propel the blood back to the heart. Our bodies have several mechanisms to deal with gravity and changes in body position. Baroreceptors quickly sense changes in blood flow to the brain and heart and make adjustments to peripheral resistance and the heart to modulate overall blood pressure. Leg muscles help in the process of venous return by functioning as pumps. During walking or other leg movements, the muscles contract, forcing blood up through the veins back to the heart. Also, blood return is aided by valves in the veins, which do not allow blood to flow backwards. For a demonstration of these valves, keep your hand below heart level, place a finger on a vein to prevent blood from moving into it. Then push the remaining blood in the vein towards the heart. Because valves are preventing backflow, and you are not allowing any blood to enter them, the vein will remain collapsed until you release your finger. 1. Effect of Body Position on Blood Pressure 1. Use one of the two methods above to measure blood pressure and enter these values in Table X-2 under the sitting entry. 2. Compare yo ur pressure with the range of normal values listed in Table 2. 3. Calculate the subjects pulse pressure (systolic minus diastolic pressure) and enter this value in Table X-2. 4. Calculate the subjects mean arterial pressure. This is equal to the diastolic pressure plus 1/3 of the pulse pressure. Enter this value in Table X-2.

5. Repeat these measurements on the same subject after they have been lying down for a few minutes (arms at sides), and again in a standing position for a few minutes (arms down). Enter these values in Table X-2.
Table X-2. Body position blood pressure data

Sitting

Reclining

Standing

Systolic pressure (P s)

Diastolic pressure (P D)

Pulse pressure (P) Mean arterial pressure (P A)

2. Effect of Gravity and Cardiac Return on Blood Pressure 1. Choose a new subject. Measure blood pressure in the left arm in the sitting position and enter the same variables you calculated in Table X-2, in Table X-3. 2. Measure the subjects blood pressure in the left arm while their left hand is placed on their head and repeat step 2. 3. Repeat these measurements while the subject is sitting but holding their right arm on their head, while in a prone position, and from the prone position immediately after lifting both legs perpendicular to the bench.
Table X-3. Gravity and cardiac return blood pressure data

Sitting Ps PD P PA

Left Arm Up

Right Arm Up

Prone

Legs Up

In order to see how blood flow to the extremities is affected by gravity, place the plethsymograph on the left finger and monitor blood flow using Heart #3. Repeat the positions used i n the previous experiment and see how changes in gravity and cardiac return change the blood flow to the left finger. An example of how the trace may change when the left hand is lifted above the head is shown in Figure X-6.
Figure X-6. Plethysmograph data recorded with a change in the subject's hand elevation

3. Blood Pressure and Distance from the Heart The purpose of the experiments on this page is to examine blood pressure in different parts of the body. In this part of the lab we want to concentrate more on the effect of distance from the heart, so to minimize other factors, make sure the subject is lying down for all the measurements. Use the iWorx system for all these measurements. Measure the blood pressure of the left arm using the iWorx system as before. Compare these to measurements from the forearm, and measurements from the left leg (move the plethysmograph to the left big toe and wrap the cuff around the calf).

D. EFFECTS OF EXERCISE ON CARDIOVASCULAR DYNAMICS

During exercise, the distribution of blood to organs of the body may be very different from that seen at rest. For example, the blood flow to the gut decreases during exercise, while blood flow to the skeletal muscles increases dramatically (how does this effect arterial resistance?); furthermore, the cardiac output (Q) may be increased several times. In this laboratory you will record the heart rate and the blood pressure from a subject at rest and immediately after exercise. A NOTE: This experiment involves exercise and an elevation of heart rate. It should not be performed by anyone who is not healthy or has a personal or family history of cardiovascular or respiratory problems. Monitor the subjects blood pressure in their left arm. To obtain the heart rate, you may use the iWorx system to record the ECG of your subject, or you may take the subjects pulse (at least 30 seconds for each reading). If you use the iWorx system, open a new Heart #1 file. If you take the subjects pulse, use their right wrist. Have the subject lie down for 5 minutes and make baseline measurements of HR and BP. Calculate the pulse pressure (P = P s P D) and the mean arterial pressure (PA = P D + 1/3 P). These will be your Time = 5 min readings.

HR =

Ps =

PD =

P =

PA =

Have the subject exercise for 5 minutes, by either jumping-rope or running stairs. Make sure the exercise is rigorous enough to raise their heart rate by a sizeable percentage (preferably i n most subjects it should reach over 140 beats/minute). Have them immediately lay down on the table for the rest of their readings (have them stay in this position for the duration of the experiment). Be prepared to measure the BP and HR as quickly as possible after exercise. This will be your time=0 reading. Try to get 2-3 data points within the first 10 minutes. This may be difficult, but do your best. Just be sure to note the time at which you take your readings. Take another reading at 10 minutes and then another reading every 5 minutes for a total duration of 20 minutes. Your readings should look something like the table below. Again, compute Pa for each reading. The state of the organism has gone through a lot of changes. Q is almost certainly no longer 5L, and many cardiovascular variables have almost certainly changed quite a bit. Make a graph of HR, and Pa as a function of time. An un-normalized graph will look something like the one below.

TIME -5 0 2 4 6 8 10 15 20

HR 71.0 122.2 117.7 113.1 108.6 104.1 95.0 102.0 86.0

BP(s) 120 175 166 157 148 138 120 120 123

BP(d) 80 60 62 63 65 67 70 70 80

140.0 120.0 100.0 80.0 60.0 40.0 20.0 0.0 -5 0 5 10 15 20 25 30

HR (Beats/min)

TIME

In order to see how all the variables change over time in relation to each other, you can normalize all the traces and re-plot them. The way to do this is to take all your data points for a variable and divide them by your baseline value. The purpose of this experiment is to understand how these variables are related to each other. More than likely, most of these results will not be surprising to you. HR and BP should all have increased and come back towards baseline over a fairly short period of time. However, many other variables that were not measured probably changed more even more than the ones we did measure. What most likely happened to stroke volume, total cardiac output, and peripheral resistance?

QUESTIONS
MEASURING BLOOD PRESSURE How similar are the values for blood pressure (systolic and diastolic) from these different methods and trials within each method?

What may cause any variations you see?

Using the iWorx system, you are looking for changes in the volume pulse. How would changing the rate of pressure released from the cuff influence the accuracy of your readings?

The first sound of Korotkoff occurs when the cuff pressure equals the________________ pressure, and the last sound occurs when the cuff pressure equals the ________________ pressure. Suppose a persons blood pressure is 165/110. What is the pulse pressure? What is the mean arterial pressure? What condition does this person have? Why is this dangerous if it is allowed to continue indefinitely?

Why cant you hear the sounds of Korotkoff in the brachial artery before you inflate the cuff?

EFFECT OF BODY POSITION ON BLOOD PRESSURE How does body position affect overall blood pressure?

How does it affect the pulse pressure and mean arterial pressure?

Explain why you find these results.

THE EFFECTS OF GRAVITY AND CARDIAC RETURN ON BLOOD PRESSURE What happens to the pulse pressure in each of these positions?

What happens to the mean arterial pressure in each of these positions?

What accounts for the differences you see?

EFFECT OF GRAVITY AND CARDIAC RETURN ON BLOOD PRESSURE How does lifting the left arm above the head affect blood pressure? Blood flow?

Why does this occur?

Do you think this is a good measure of your bodys overall blood pressure in this position?

What happens to blood pressure when the right arm is lifted above the head compared to the sitting position?

When the legs are lifted up from the prone position?

Why do these changes occur and how do they compare to each other?

BLOOD PRESSURE AND DISTANCE FROM THE HEART How does the blood pressure values compare in these areas?

Explain the reason behind the readings you obtained from these different areas.

EFFECTS OF EXERCISE ON CARDIOVASCULAR DYNAMICS What happened to HR after exercise? Pulse pressure? Mean arterial pressure?

Explain why you may be able to use pulse pressure changes as an indicator of stroke volume changes.

Now, using pulse pressure as an indicator of stroke volume, would you guess that stroke volume or heart rate changes more after this sort of exercise? (hint: look at your normalized charts).

What happens to cardiac output after this type of exercise?

How about total peripheral resistance?

What other changes are occurring in your body?