Cardiac

Output
and
Blood
Pressure

Cardiac Output
Cardiac output is the volume of
blood pumped by the heart per
minute (mL blood/min). Cardiac
output is a function of heart
rate and stroke volume.
Theheart rate is simply the
number of heart beats per
minute. The stroke volume is
the volume of blood, in
milliliters (mL), pumped out of
the heart with each beat.
Increasing either heart rate or
stroke volume increases cardiac
output.

Cardiac Output in mL/min =

heart rate (beats/min) X stroke
volume (mL/beat)

An average person has a resting

heart rate of 70 beats/minute
and a resting stroke volume of
70 mL/beat. The cardiac output
for this person at rest is:

Cardiac Output = 70 (beats/min)

X 70 (mL/beat) = 4900
mL/minute.

The total volume of blood in the

circulatory system of an average
 person is about 5 liters (5000
mL). According to our
calculations, the entire volume
of blood within the circulatory
sytem is pumped by the heart
each minute (at rest). During
vigorous exercise, the cardiac
output can increase up to 7 fold
(35 liters/minute)

Control
of Heart
Rate
The SA node of
the heart is
enervated by
both
sympathetic and
parasympathetic
nerve fibers.
Under
conditions of
rest the
parasympathetic
fibers release
acetylcholine,
which acts to
slow the
pacemaker
potential of the
SA node and
thus reduce
heart rate.
Under
conditions of
physical or
emotional
activity
sympathetic
nerve fibers
release
norepinephrine,
which acts to
speed up the
pacemaker
potential of the
SA node thus
increasing heart
rate.
Sympathetic
nervous system
activity also
causes the
release of
epinephrine
from the
adrenal
medulla.
Epinephrine
enters the blood
stream, and is
delivered to the
heart where it
binds with SA
node receptors.
Binding of
epinephrine
leads to further
increase in heart
rate.

Control of Stroke
Volume
Under conditions of rest, the heart
does not fill to its maximum
capacity. If the heart were to fill
more per beat then it could pump
out more blood per beat, thus
increasing stroke volume. Also, the
ventricles of the heart empty only
about 50% of their volume during
systole. If the heart were to contract
more strongly then the heart could
pump out more blood per beat. In
other words, a stronger contraction
would lead to a larger stroke
volume. During periods of exercise,
the stroke volume increases because
of both these mechanisms; the heart
fills up with more blood and the
 heart contracts more strongly.

Stroke volume is increased by 2

mechanisms:

1. increase in end-diastolic
volume
2. increase in sympathetic
system activity

End-diastolic Volume
An increase in venous return of
blood to the heart will result in
greater filling of the ventricles
during diastole. Consequently the
volume of blood in the ventricles at
the end of diastole, called end-
diastolic volume, will be increased.
A larger end-diastolic volume will
stretch the heart. Stretching the
muscles of the heart optimizes the
length-strength relationship of the
cardiac muscle fibers, resulting in
stronger contractility and greater
stroke volume.
Starling's
Law

Starling's
Law
describes
the
relationship
between
end-
diastolic
volume and
stroke
volume. It
states that
the heart
will pump
out
whatever
volume is
delivered
to it. If the
end-
diastolic
volume
doubles
then stroke
volume
will
double.

An Increase in Sympathetic
Activity Increases Stroke
Volume

The cardiac muscle cells of the

ventricular myocardium are richly
enervated by sympathetic nerve
fibers. Release of norepinephrine by
these fibers causes an increase in the
strength of myocardiall contraction,
thus increasing stroke volume.
Norepinephrine is thought to
increase the intracellular
concentration of calcium in
myocardial cells, thus facilitating
faster actin/myosin cross bridging.
Also, a general sympathetic
response by the body will induce the
release of epinephrine from the
adrenal medulla. Epinephrine, like
norepinephrine will stimulate an
increase in the strength of
myocardial contraction and thus
increase stroke volume.
 Blood Volume
Fluid Exchange Betweem
Capillaries and Tissues
Capillaries
are
composed
of a single
layer of
squamos
epithelium
surrounded
by a thin
basement
membrane.
Most
capillaries
(except
those
servicing
the
nervous
system)
have pores
(spaces)
between
the
individual
cells that
make up
the
capillary
wall.
Plasma
fluid and
small
nutrient
molecules
leave the
capillary
and enter
the
interstitial
fluid
through
these
pores, in a
process
called bulk
flow. Bulk
flow
facilitates
the
efficient
transfer of
nutrient
out of the
blood and
into the
tissues.
However,
blood cells
and plasma
proteins,
which are
too large to
fit through
the pores,
do not
filter out of
the
capillaries
by bulk
flow.
Together, blood plasma and
interstitial fluid make up the
extracellular fluid (ECF). Plasma
constitutes 20%, while interstitial
fluid constitutes 80% of the ECF.
The distribution of extracellular
fluid between these two
compartments is determined by the
balance between two opposing
forces: hydrostatic pressure and
osmotic pressure.
The beating
of the heart
generates
hydrostatic
pressure,
which, in
turn, causes
bulk flow of
fluid from
plasma to
interstitial
fluid through
walls of the
capillaries. In
other words,
the pressure
in the system
forces plasma
to filter out
into the
interstitial
compartment.
The
composition
of the
interstitial
fluid and the
plasma is
essentially the
same except
that plasma
also contains
plasma
proteins not
found in the
interstitial
fluid. Because
of the
presence of
plasma
proteins, the
plasma has a
 higher solute
concentration
than does the
interstitial
fluid.
Consequently,
osmotic
pressure
causes
interstitial
fluid to be
absorbed into
the plasma
compartment.
In other
words, the
plasma
proteins drive
the
reabsorption
of water back
into the
capillaries via
osmosis.
The magnitudes
of filtration andabsorption are
not equal. The net filtration of
fluid out of the capillaries into
the interstitial compartment is
greater than the net absorption
of fluid back into the
capillaries. The excess filtered
fluid is returned to the blood
stream via the lymphatic
system. In addition to its roles
in digestion and immunity, the
lymphatic system functions to
return filtered plasma back to
the circulatory system. The
smallest vessels of the
lymphatic system are the
lymphatic capillaries (shown in
yellow). These porous, blind-
ended ducts form a large
network of vessels that
infiltrate the capillary beds of
most organs. Excess interstitial
fluid enters the lymphatic
capillaries to become lymph
fluid.
 Lymphatic
capillaries
converge to
form lymph
vessels that
ultimately
return lymph
fluid back to
the
circulatory
system via
the
subclavian
vein. The
presence of
one-way
valves in the
lymph
vessels
ensures
unidirectional
flow of
lymph fluid
toward the
subclavian
vein.

If excess
fluid cannot
be returned to
the blood
stream then
interstitial
fluid builds
up, leading to
swelling of
the tissues
with fluid,
this is
callededema.

Causes of Edema
1. Reduced concentration of
plasma proteins. When the
concentration of plasma proteins
drops, the osmotic potential of
plasma drops, thus less interstitial
fluid is absorbed into the capillaries.
The rate of filtration, however,
remain unchanged. Therefore, the
ratio of filtration to absorption
increases, leading to a build up of
interstitial fluid. Any condition that
would lead to a reduction in plasma
proteins could potentially cause
edema. Examples of conditions that
reduce plasma proteins include:

Kidney disease can result in

the loss of plasma proteins in
the urine.
Liver disease can decrease
the synthesis of plasma
proteins.
A protein-deficient diet will
decrease plasma proteins.
Severe burns result in a loss
of plasma proteins (albumin)
at the burn site

2. Increased capillary
permeability. During an
inflammatory response, tissue
damage leads to the release of
histamine from immune cells.
Histamine causes an increase in the
size of capillary pores. As
capillaries become more permeable,
the rate of filtration increases.

3. Increase in venous pressure. If

venous pressure is increased then
blood dams up in the upstream
capillary bed, resulting in excess
filtration. Examples of this condition
include:

Left heart failure. The left

half of the heart drains blood
from the lungs. When the
left ventricle fails to
adequately pump blood,
venous pressure in the lungs
increases. This increase in
hydrostatic pressure causes
an increase in the rate of
 filtration of fluid out of the
capillaries and into the
interstitial compartment. As
a result, the lungs fill with
fluid, a condition called,
pulmonary edema.
Standing still. If one stands
still for long period of time,
then blood will pool in the
veins of the legs. This will
increase venous pressure and
lead to weeping of fluid into
the tissues. You can actually
feel your feet swell if you
stand motionless for a long
time.

4. Blocked Lymphatics. If lymph

vessels become blocked, then lymph
fluid will not be drained from the
effected area and the area will swell.
Any condition that causes blockage
or removal of lymph vessels can
lead to edema. Examples of this
condition include:

Filaria round worms are

transmitted to humans by
some species of mosquitos.
The worms migrate to the
lymph vessels and block
them. This causes dramatic
swelling of the effected area,
a condition
called elaphantiasis.
Treatment for breast cancer
may include removal of
lymph vessels from breast
and arms. This is done to
limit the metastasis (spread)
of cancerous cells to other
parts of the body through the
lymph. Removal of lymph
vessels results in swelling of
the effected area.
Regulation of Blood
Volume by the
Kidneys
The kidneys filter the blood and
eliminate excess water and
metabolic wastes by producing and
excreting urine. The daily volume of
urine produced by the kidneys
affects the amount of ECF in the
body and thus has a direct influence
on blood volume. If the kidneys
retain water then blood volume
rises. However, if the kidneys
excrete large amounts of water then
the blood volume will decrease.

The regulation of water excretion by

the kidneys is controlled, in large
part, by antidiuretic hormone
(ADH). In the presence of ADH, the
kidneys retain water. In the absence
of ADH the kidneys excrete more
water. ADH is produced by the
hypothalamus and secreted by the
posterior pituitary gland. The
hypothalamus contains
osmoreceptors that directly monitor
the osmolality of plasma. Plasma
osmolality is high when plasma
volume is low. Osmoreceptors
detect this condition and signal for
the secretion of ADH. Retention of
water by the kidney restores blood
volume to normal. ADH has the
added effect of stimulating thirst.
Thus when your body needs water
you are driven to seek water.

Regulation of
Blood Flow
Blood Flow through Vessels is effected by
Pressure and Resistance
The flow of blood through the vessels of the circulatory system is a
function of the pressure in the system and the resistance to flow
caused by the blood vessels. Blood flow is directly proportional to
pressure and inversely proportional to resistance.

If the pressure in a vessel increases then the blood flow will increase.
However, if the resistance in a vessel increases then the blood flow
will decrease.

Resistance in the blood vessels is effected by three parameters:

1. Length of the vessel. The longer the vessel the greater the
resistance.
2. Viscosity of the blood. The greater the viscosity the greater
the resistance.
3. Radius of the vessel. The smaller the radius the greater the
resistance.

The relationships between factors that effect blood flow are described
by Poiseuille's Law, which states:

Of all of the
factors that effect
blood flow, the
radius of the
blood vessel is
the most potent.
Blood flow is
proportional to
the 4th power of
vessel radius.
This means that
if the radius of a
blood vessel
doubles (by
vasodilation)
then the flow will
increase 16 fold
(2 to the 4th
power is 16). On
the other hand, if
the radius of a
vessel is reduce
in half (by
vasoconstriction),
then the blood
flow will be
reduced 16 fold.
Because small
changes in vessel
radius make very
large changes in
blood flow, it is
no surprise that
the body controls
blood flow to
specific areas of
the body by
controlling the
radius of
arterioles
servicing those
areas.

Extrinsic Regulation
of Blood Flow
Extrinsic regulation refers to a form
of control that comes from an
outside source. The extrinsic
regulation of blood flow refers to
the control of arteriolar radius by
both the autonomic nervous system
and the endocrine system.
Sympathetic Control of
Arteriolar Radius
Arterioles are
enervated by the
sympathetic
nervous system
only.
(Parasympathetic
enervation of
arterioles only
occurs in the
male penis,
where it results
in erection.)
Sympathetic
nerve fibers
secrete
norepinephrine.
Binding of
norepinephrine
to receptors on
the smooth
muscles of
arterioles causes
contraction and
thus leads to
vasoconstriction.
Arterioles
servicing tissues
at rest receive a
baseline amount
of sympathetic
stimulation and
thus are slightly
constricted
(vessel b in the
figure). This
baseline level of
constriction is
called Vascular
Tone.
Vasodilation is
accomplished by
decreasing
sympathetic
stimulation
below baseline
(vessel a).
Vasoconstriction
is accomplished
by increasing
sympathetic
 stimulation
above baseline
(vessel c).

Endocrine Control of
Arteriolar Radius.

The endocrine system is composed

of a variety of glands that produce
and secrete hormones. Hormones
are signalling molecules that enter
the blood stream and travel
throughout the body. Although all
body cells are exposed to the
hormone, the only cells that respond
to it are the cells that have specific
receptors that bind the hormone.
Epinephrine is a hormone that has a
significant effect on the radius of
blood vessels. Epinephrine is
secreted by the adrenal medulla (an
endocrine gland atop the kidneys) in
response to sympathetic stimulation.
Epinephrine enters the blood stream
and travels to all part the body
interacting with those cells having
epinephrine receptors on their cell
surface.

There are two types of

epinephrine receptors found
in blood vessels, alpha
receptors () and beta-2
receptors ().
Epinephrine can cause
either vasoconstiction or
vasodilation of blood
vessels depending on the
type of receptor found in the
smooth muscle of a
particular vessel. The
binding of epinephrine
to receptors leads to
vasoconstriction. receptors
are found in all arterioles.
Conversely, the binding of
epinephrine
to receptors leads to
vasodilation. receptors
are found predominantly in
arterioles servicing skeletal
muscle and heart muscle.
During a full-blown
sympathetic response (fight
or flight), blood is directed
to the skeletal muscle and
heart, and away from the
internal organs. This is
possible
because receptors
mediate vasodilation in the
skeletal muscle and heart,
while the rest of the
circulatory system (which
has receptors) experiences
vasoconstriction.

Intrinsic Regulation of
Blood Flow
Intrinsic regulation refers to local
control of arteriolar radius. Intrinsic
regulation allows some organs to
regulate their own blood flow
regardless of what may be
happening elsewhere in the body.
Intrinsic regulation take the form of
metabolic control or myogenic
control.
Metabolic
Control
As a result of
metabolic
activity, cells
produce by-
products called
metabolites.
When a tissue
increases its
activity the
production of
metabolites will
also increase. If
blood flow to
the area
remains
constant in the
face of this
change, then
the metabolites
will build up in
the tissues. The
major
metabolites that
build up
include CO2,
ADP,
extracellular
K+ and organic
acids. These
metabolites
directly
stimulate the
vasodilation of
local arterioles,
thus increasing
blood flow.
This
mechanism, in
which an
increase in the
activity of a
tissue induces
an increase in
blood flow to
the area, is
called active
hyperemia.
This increase in
blood flow
eventually
lowers the
levels of
metabolites
thus removing
the original
stimulus for
vasodilation. In
the absence of
excess
metabolites the
arteriole returns
to its original
diameter.

Myogenic Control
The smooth muscles in blood
vessels are directly affected by
pressure. If blood pressure and flow
of blood to an organ are low then
the smooth muscles of adjacent
arterioles relax. The resulting
vasodilation restores adequate blood
flow. Conversely, if blood flow to
an organ is excessive then smooth
muscles of the arterioles will
vasoconstrict, thus reducing flow to
appropriate levels. Through
myogenic control, arterioles are
somewhat self-regulating.

Exercise and Blood

Flow
The changes in blood flow that
occur during exercise provide an
excellent illustration of intrinsic and
extrinsic control of arteriolar radius.
The vascular tone of arterioles found
in skeletal muscle is relatively high,
consequently blood flow to resting
muscles is low (20-25% of total
blood flow). However, during heavy
exercise, blood flow to the skeletal
muscles increases significantly (up
to 80-85% of total blood flow). The
increase in blood flow to skeletal
muscles during exercise is mediated
by three factors: (1) an increase in
cardiac output, (2) vasodilation of
skeletal muscle arterioles, (3)
vasoconstriction of arterioles in the
viscera and skin.

1. An increase in cardiac
output. Exercise activates
the sympathetic nervous
system. Increased
sympathetic output to the
heart causes an increase in
heart rate and stroke volume.
Heavy exercise increases
venous return of blood to the
heart via the skeletal muscle
pump and the respiratory
pump. An increase in venous
return leads to an increase in
end-diastolic volume (EDV),
which in turn, causes an
increase in stroke volume.
2. Vasodilation of skeletal
muscle arterioles. The most
important factor governing
flow of blood to exercising
muscles is local metabolic
control (active hyperemia).
As muscular activity
increases, metabolites build
up and directly induce the
vasodilation of local
arterioles. Additionally,
beta-adrenergic stimulation
by epinephrine causes
vasodilation of arterioles in
skeletal muscle.
3. Vasoconstriction of
arterioles in the viscera
and skin. As a result of
alpha-adrenergic
sympathetic stimulation,
 arterioles in the viscera and
skin vasoconstrict during
exercise. However, as
exercise progresses and body
temperature rises, cutaneous
arterioles dilate in order to
radiate heat and reduce body
temperature.

Summary of Factors that Effect Blood

Flow during Exercise

Regulation of
Blood Pressure
Constant and adequate pressure in
the arterial system is required to
drive blood into all of the organs.
Abnormally low blood pressure
results in inadequate perfusion of
organs, while abnormally high blood
pressure can cause heart disease,
vascular disease and stroke.
Therefore, it is essential that blood
pressure be maintained within a
narrow range of values that is
consistent with the needs of the
tissues.

Pressure in the arterial system

fluctuates with the cardiac cycle.
Blood pressure reaches a peak in
systole and is lowest in diastole.
Rather than focusing on these
extremes of blood pressure we will
discuss blood pressure in terms of
the mean arterial pressure (MAP).
Mean arterial pressure represents the
average pressure in the arterial
system. This value is important
because it is the difference between
MAP and the venous pressure that
drives blood through the capillaries
of the organs. Because more time is
spent in diastole than in systole,
MAP is not simply the average of
the systolic and diastolic pressures.

A simple formula for calculation of

MAP is:

MAP = diastolic pressure + 1/3

pulse pressure

Pulse pressure = systolic pressure -

diastolic pressure

Major Factors that

Effect Mean Arterial
Pressure
The three most important variables
effecting MAP are:

1. total peripheral resistance

(TPA)
2. cardiac output
3. blood volume.

MAP = Cardiac Output X

Total Peripheral Resistance

Total Peripheral Resistance (TPA)

Blood vessels provide resistance to
the flow of blood because of friction
between moving blood and the wall
of the vessel. The TPA refers to the
sum total of vascular resistance to
the flow of blood in the systemic
circulation. Because of their small
radii, arterioles provide the greatest
resistance to blood flow in the
arterial system. Adjustments in the
radii of arterioles has a significant
effect on TPA, which in turn has a
significant effect on MAP.
Resistance and pressure are directly
proportional to each other. If
resistance increases, then pressure
increases. When the radii of
arterioles decrease with
vasoconstriction, TPA increases,
which causes MAP to increase.

Cardiac Output

Cardiac output refers to the volume

of blood pumped by the heart each
minute. Put another way, the cardiac
output is a measure of blood flow
into the arterial system. Blood flow
is directly proportional to pressure
(Flow = pressure/resistance),
therefore an increase in flow
(cardiac output) will cause an
increase in pressure (MAP).

Blood Volume

Blood volume is directly related to

blood pressure. If the blood volume
is increased, then venous return of
blood to the heart will increase. An
increase in venous return will, by
Starling's Law, cause stroke volume
to increase. As stroke volume goes
up the cardiac output goes up and
the blood pressure rises. Thus one
way to control blood pressure over
 the long term is to control blood
volume.

Baroreceptor Reflexes
in Short-term
Regulation of MAP
Blood pressure is contolled on a
minute-to-minute basis by
baroreceptor reflexes. Baroreceptors
are specialized stretch receptors that
detect changes in blood pressure.
Baroreceptors are located in the
walls of arteries, veins and the heart.
The most important baroreceptors
being those found in the carotid
sinus and the aorta. Baroreceptors,
which constantly monitor blood
pressure, communicate with the
Cardiovascular Control Center
(CCC) found in the brain stem.
Changes in blood pressure effect the
frequency of action potentials sent
to the CCC from the baroreceptors.
The CCC responds to changes in
baroreceptor input by initiating
compensatory mechanisms that
restore blood pressure back to
normal.
The diagram
to the right
illustrates the
efffect of
blood
pressure on
the
production of
action
potentials by
the
baroreceptors.
80 mmHg is a
baseline
MAP for a
typical person
(given a
 measured
blood
pressure of
120/60). At a
baseline of 80
mmHg a
baroreceptor
will produce
a constant
baseline
frequency of
action
potentials
(seen as
small,
vertical, blue
lines in the
diagram). If
blood
pressure rises
above
baseline, the
baroreceptor
increases its
frequency of
action
potential
output. On
the other
hand, if blood
pressure
drops below
baseline, then
the
baroreceptor
decreases its
frequency of
action
potential
output.

Baroreceptor Response to Increased Blood Pressure

An increase in blood pressure causes an increase in action potentials sent to the

cardiovascular control center. The CCC responds by decreasing sympathetic input and
increasing parasympathetic input to the heart. This causes a drop in heart rate and stroke
volume, which lowers cardiac output, which in turn lowers MAP. The CCC also
decreases sympathetic input to the blood vessels. This causes vasodilation, which lowers
resistance (TPA) which causes blood pressure to drop. Overall, the compensatory
mechanisms of the baroreceptor reflex act to restore blood pressure back to normal.

Conversely, a decrease in blood pressure causes a decrease in action potentials sent to the
cardiovascular control center, which causes an increase in sympathetic input, which
causes vasoconstriction and increased cardiac output, which causes a rise in blood
pressure, thus restoring blood pressure back to normal.

Blood Volume in Long Term Regulation of MAP

Blood volume is directly related to blood pressure. If the blood volume is increased then
venous return of blood to the heart will increase, thus stroke volume will increase, thus
cardiac output will increase and the blood pressure will rise. Therefore, blood pressure
can be controlled by controlling blood volume.

Plasma, the liquid portion of blood, is part of the extracellular fluid (ECF). If the kidneys
retain water, then the volume of the ECF rises and blood volume rises. If the kidneys
retain salt (NaCl), then the ECF becomes saltier and thus capable of retaining more water
(water follows solute). Higher ECF volume leads to higher blood volume and thus higher
blood pressure.
 Summary of Factors that Effect Mean
Arterial Pressure

Table of
Quiz
(Revised September 17 1999) Contents
The art on this page is reproduced by
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Inc.

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25.7.2016

Bibliographic information
Title Exercise Physiology for Health Fitness and Performance
M - Medicine Series

Authors Sharon A. Plowman, Denise L. Smith

Edition illustrated

Publisher Lippincott Williams & Wilkins, 2013

ISBN 1451176112, 9781451176117

Length 744 pages

Subjects Medical

Allied Health Services

General

Medical / Allied Health Services / General

Medical / Physiology
Medical / Sports Medicine

==================================================================================

(lengkapkan yg atas)Under normal physiological conditions, the human heart

functions as two separate pumps: (1) the right heart pumps
blood through the pulmonary circulation, and (2) the left heart pumps blood through the systemic
circulation. Each contraction of the heart and subsequent ejection of blood creates pressures
that are commonly monitored clinically to assess the function of the heart and its work against
resistance. In general,the mechanical function of the heart is described by the changes in pressures,
volumes, and flows that occur within a given cardiac cycle. A single cardiac cycle is one complete
sequence of myocardial contraction and relaxation.

2. CARDIAC CYCLE
The normal electrical and mechanical events of a single cardiac
cycle of the left heart are correlated in Fig. 1. The mechanical
events of the left ventricular pressurevolume curve are
displayed in Fig. 2. During a single cardiac cycle, the atria and
ventricles do not beat simultaneously; the atrial contraction

1.1. Physiology of Blood Pressure

Blood pressure is the force applied on the arterial walls as the heart pumps blood through the
circulatory system. The rhythmic contractions of the left ventricle result in cyclic changes in
the blood pressure. During ventricular systole, the heart pumps blood into the circulatory system, and
the pressure within the arteries reaches its highest level; this is called systolic blood pressure. During
diastole, the pressure within the arterial system falls and is called diastolic blood pressure.
The mean of the systolic and diastolic blood pressures during the cardiac cycle represents the time-
weighted average arterial pressure; this is called mean arterial blood pressure. Alternating systolic
and diastolic pressures create outward and inward movements of the arterial walls, perceived as
arterial pulsation or arterial pulse. Pulse pressure is the difference between systolic
and diastolic blood pressures.

Blood pressure is measured in units called millimeters of mercury (mmHg). A normal systolic blood
pressure is less than 140 mmHg; a normal diastolic blood pressure is less than 90 mmHg. Blood
pressure higher than normal is called hypertension,and one lower than normal is called hypotension.
Hence, normal mean arterial pressure is between 60 and 90mmHg. Mean arterial pressure is
normally considered a good indicator of tissue perfusion and can be measured directly using
automated blood pressure cuffs or calculated using the following formulas:
MAP = DBP + PP/3 or MAP = [SBP + (2 DBP)]/3
where PP = SBP DBP; MAP is mean arterial pressure, DBP is diastolic blood pressure, PP is pulse
pressure, and SBP is systolic blood pressure.

Blood flow throughout the circulatory system is directed by pressure gradients. By the time blood
reaches the right atrium,which represents the end point of the venous system, pressure has
decreased to approx 0 mmHg. The two major determinants of blood pressure are: (1) cardiac output,
which is the volume of blood pumped by the heart per minute; and (2) systemic vascular resistance,
which is the impediment offered by the vascular bed to flow. Systemic vascular resistance is
controlled by many factors, including vasomotor tone in arterioles, terminal arterioles, or precapillary
sphincters. Blood pressure can be calculated using the formula

BP = CO SVR
where BP is blood pressure, CO is cardiac output, and SVR is systemic vascular resistance.

Blood pressure decreases by 35 mmHg in arteries that are 3 mm in diameter. It is approx 85 mmHg
in arterioles, which accounts for approx 50% of the resistance of the entire systemic circulation. Blood
pressure is further reduced to around 30 mmHg at the point of entry into capillaries and then becomes
approx 10 mmHg at the venous end of the capillaries.
The speed of the advancing pressure wave during each cardiac cycle far exceeds the actual blood
flow velocity. In the aorta, the pressure wave speed may be 15 times faster than the flow of blood. In
an end artery, the pressure wave velocity may be as much as 100 times the speed of the forward
blood flow.

As the pressure wave moves peripherally through the arterial system, wave reflection
distorts(menggalakkan) the pressure waveform, causing an exaggeration of systolic and pulse
pressures. This enhancement of the pulse pressure in the periphery causes the systolic blood
pressure in the radial artery to be 2030% higher than the aortic systolic blood pressure and the
diastolic blood pressure to be approx 1015% lower than the aortic diastolic blood pressure.
Nevertheless, the mean blood pressure in the
radial artery will closely correspond to the aortic mean blood pressure.

1.2. Methods of Measuring Blood Pressure

Arterial blood pressure can be measured both noninvasively and invasively; these methods are
described next.

1.2.1. Noninvasive Methods

1.2.1.1. Palpation
Palpation is a relatively simple and easy way to assess systolic blood pressure. A blood pressure cuff
containing an inflatable inflatable bladder is applied to the arm and inflated until the arterial pulse felt
distal to the cuff placement disappears. Then, the pressure in the cuff is released at a speed of
approx 3 mmHg perheartbeat until the arterial pulse is felt again. The pressure at which the arterial
pulsations start is the systolic blood pressure.
Diastolic blood pressure and mean arterial pressure cannot be readily estimated using this method.
Furthermore, the measured systolic blood pressure using the palpation method is often an
underestimation of the true arterial systolic blood pressure because of the insensitivity of the sense of
touch and the delay between blood flow below the cuff and the appearance of arterial pulsations distal
to the cuff.

Noninvasive Arterial
Blood Pressure Monitoring
Noninvasive blood pressure assessment is the most utilized and simplest technique to monitor arterial
blood pressure. This technique utilizes a blood pressure cuff and the principle of pulsatile flow. A
blood pressure cuff is applied to a limb such
as forearm or leg and is inflated to a pressure greater than
systolic blood pressure, which stops blood flow distal to the
inflated cuff. As the pressure in the cuff is gradually decreased,

7. BLOOD PRESSURE MONITORING

The cardiovascular system is most commonly assessed by monitoring arterial blood pressure. Blood
pressure is proportional to the product of cardiac output and systemic vascular
resistance:

BP = CO SVR
CO = HR SV
MAP = 1/3 SBP + 2/3 DBP

where BP is blood pressure, CO is cardiac output, SVR is systemic vascular resistance, HR is heart
rate, SV is stroke volume,MAP is mean arterial pressure, SBP is systolic blood pressure, and DBP is
diastolic blood pressure. Stroke volume is dependent on preload, afterload, and contractility (Fig. 8).

Blood pressure can be defined to consist of three components:

systolic blood pressure, mean arterial pressure (MAP), and diastolic blood pressure. Systolic blood
pressure is the peak pressure during ventricular systole, MAP is used clinically as a crucial
determinant for adequate perfusion of the major organs, and diastolic blood pressure is the main
determinant for myocardial perfusion. Recall that the majority of coronary blood
flow occurs during diastole.

In general, arterial blood pressure monitoring involves two techniques: noninvasive (indirect) and
invasive (direct) methods. The decision to utilize either blood pressure monitoring method depends on
multiple factors such as cardiovascular stability or instability, need for frequent arterial blood samples,
frequency of blood pressure recordings, or major surgery and trauma. One of the advantages of an
invasive blood pressure monitor is that it provides continuous, beat-to-beat blood pressures (see
JPEG 1 on the Companion CD). Direct arterial blood pressure monitoring is considered a requirement
during cardiopulmonary bypass surgery. Because there is no pulsatile flow during such surgery, the
noninvasive methods to monitor blood pressure cannot be employed.

7.1. Noninvasive Arterial

Blood Pressure Monitoring
Noninvasive blood pressure assessment is the most utilized and simplest technique to monitor arterial
blood pressure. This technique utilizes a blood pressure cuff and the principle of pulsatile flow. A
blood pressure cuff is applied to a limb such as forearm or leg and is inflated to a pressure greater
than systolic blood pressure, which stops blood flow distal to the inflated cuff. As the pressure in the
cuff is gradually decreased, blood flow through the artery is restored. The change in arterial pressure
and flow creates oscillations that can be detected by auscultation of Korotkoff sounds and scillometric
methods.
For accurate blood pressure measurement, the width of the cuff should be approximately one-third
the circumference of the limb. A small, improper size cuff will overestimate systolic blood pressure; a
large cuff will underestimate the pressure. The rate of cuff deflation should be slow enough to hear
Korotkoff sounds or detect oscillations. Noninvasive blood pressure monitors do not work if there is no
pulsatile flow.
The automated method of noninvasive blood pressure monitoring is the oscillometric technique.
Oscillometric blood pressure monitors are basically composed of oscillotonometers and a
microprocessor. The blood pressure cuff is inflated until no oscillation is detected. As the cuff
pressure is decreased, flow in the distal blood vessel is restored, and the amplitude of oscillations
increases. A large increase in arterial wave oscillation amplitude is recorded as systolic blood
pressure, the peak oscillation as MAP, and the sudden decrease in amplitude as diastolic blood
pressure (Fig. 9). Because of the relative sensitivity of such a monitoring system, the MAP is usually
the most accurate and reproducible measurement. For more details on such monitoring,
refer to Chapter 14.

Typical clinical sites for intraarterial cannulation for arterial pressure monitoring are the radial,
brachial, axillary, or femoral arteries. Although the ascending aorta is the ideal place to monitor
arterial pressure waveforms, this is not practical in most clinical settings. However, it should be noted
that pressure measurements in the more peripheral arteries become distorted when compared to
central aortic pressure waveform (Fig. 10) Fig. 10. Arterial blood pressure wave. A typical optimally
damped arterial blood pressure waveform. The peak portion of the waveform corresponds to the systolic blood
pressure and the trough corresponds with the diastolic blood pressure. The dicrotic notch is associated with
closing of the aortic valve. Information about cardiovascular function can be estimated from the waveform. The
upstroke correlates with myocardial contractility. The downstroke and position of the dicrotic
notch give information about systemic vascular resistance. The stroke volume is estimated by integrating the
area under the curve..

Peripherally, the systolic blood pressure may be higher and diastolic blood pressure lower, and the
MAP is usually similar to central aortic pressure. The pressure waveform becomes more distorted as
pressure is measured farther away from the aorta. This distortion is caused by a decrease in arterial
compliance and reflection and oscillation of the blood pressure waves. For example, an arterial
pressure wave monitored from the dorsalis pedis will be significantly different from a central aortic
wave when it is graphically displayed (Fig. 11). There is also a loss in amplitude or absence of the
dicrotic notch, an increase in systolic blood pressure, and a decrease in diastolic blood pressure. One
should also be aware of the possible appearance of a reflection wave as the blood pressure is
monitored from a peripheral site. Importantly, risks associated with an indwelling intraarterial
pressure catheter include thrombosis, emboli, infection, nerve injury, and hematoma.