CARDIOVASCULAR SYSTEM

BLOOD VESSELS & HEMODYNAMICS

Dr. Nidup Dorji

Faculty of Nursing and Public Health

September 2017
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Vasa vasorum: Because blood vessels require oxygen & nutrients
just like other tissues of the body. Larger blood vessels are served
by their own blood vessels. This vessels are known as vasa vasorum
[meaning vasculature of vessels] located within their walls
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 ar-=air; ter-= to carry. They were found empty at dead, and in
the ancient times, they were through to contain only air
Carries blood away from heart to other organs

Walls of artery has three coats or tunics

1)Tunica interna (intima):
Contains lining of simple squamous epithelium called
endothelium;
Basement membrane (guides cell movement during tissue repair of
blood vessel walls), &
Layer of elastic tissue called internal elastic lamina (facilitates
diffusion of materials to tunica media) 5
 The continuous endothelium covers the entire endocardial
lining of the heart, blood is said to make contact only with this
tissue
It is also the layer closest to the lumen

2) Tunica media (middle layer):

Thickest layer. It consists of elastic fibers & smooth muscle
fibers (cells) that extend circularly around the lumen (regulate the
diameter of the lumen)

3) Tunica externa (outer coat)

It is composed mainly of elastic & collagen (protein) fibers.
(Functionally it helps anchor vessels to surrounding tissues)
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 Sympathetic neurons of the autonomic nervous system are
distributed to the smooth muscle of the tunica media. Therefore
an increase in sympathetic stimulation typically stimulates the
smooth muscle to contract, squeezing the vessel wall and
narrows the lumen
Vasoconstriction: Decrease in the diameter of the lumen of the
blood vessel

In contrast, smooth muscle fibers relaxes when sympathetic

stimulation decreases or when certain chemicals such as nitric
oxide, H+, and lactic acid are present

Vasodilatation: Increase in the lumen diameter of the blood

vessel
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Elastic arteries (largest arteries in the body)
The largest-diameter arteries (greater than 1cm) are called elastic
arteries as their tunica media contains high proportion of elastic
fibers
E.g. Aorta & Pulmonary trunk (2 major trunks); brachiocephalic, common carotid,
subclavian, vertebral, pulmonary, and common illiac arteries

Since they conduct blood from heart to medium sized, more-

muscular arteries, they are also called conducting arteries

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Muscular arteries
Medium-sized arteries ranging in diameter from 0.1 to 10mm, as
their tunica media contains more smooth muscle and fewer
elastic fibers

Muscular arteries are therefore capable of greater

vasoconstriction and vasodilatation (to adjust the rate of blood flow)

 They are also called as distributing arteries, as they distribute

blood to all parts of the body (e.g. brachial, and radial artery in the arm and
forearm respectively)

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Diameter of the arterioles? Small – greater friction ---- more resistance

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(2) Capillaries (capillus=little hair)
It is a microscopic vessels that connect arterioles to venules,
ranging diameter from 4-10 μm

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Vessel Type Diameter Function
(mm)
Aorta 25 Pulse dampening &
distribution
Large Arteries 1-4 Distribution of arterial
blood
Small Arteries 0.2 -1 Distribution and
resistance
Arterioles 0.01-0.20 Resistance (pressure &
flow regulation)
Capillaries 0.006- Exchange
0.010
Venules 0.01-0.20 Exchange, collection,
and capacitance
Veins 0.2-5.0 Capacitance function
(blood volume)
Vena Cava 35 Collection of venous
blood
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 Capillaries are known as exchange vessels, as their main function
is to exchange nutrients & waste between blood and tissue cells
through the intestinal fluid

Three types of capillaries are:

1. Continuous capillaries (found in CNS, lungs, skin, skeletal and

smooth muscle, connective tissues)
2. Fenestrated capillaries: Found in kidneys, villi of the small
intestine, choroid plexus of the ventricles in the brain, and
some endocrine glands.
3. Sinusoids (sinus=curve) found in the liver, red bone marrow,
spleen and some endocrine glands.

Microcirculation: The flow of blood from arterioles to venules through capillaries

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Many veins features valves, projecting into the lumen, and
pointing towards the heart

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Why does vein appear blue in color?
Venous blood is a deep dark red in color, however, their thin wall
and the tissues of the skin absorb the red-light wavelength,
allowing the blue light to pass through the surface of our eyes
seeing them as blue.

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Varicose Veins
Leaky venous valves can cause vein to become dilated &
twisted in appearance. This condition is known as Varicose
veins (varic-=a swollen vein). The condition can become in all
parts of the body, but the most commonly found are in the
esophagus and the superficial veins of the lower limbs

Caused by:
Main: Defective/damaged valves;
Others: Pregnancy, long standing, obesity, straining,
trauma to the leg, ageing

Hemorrhoids, esophageal varices are some form of varicose vein

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 Varicose veins

Prolapsed Internal Hemorrhoids

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Esophageal varices
Treatment
1. Put elastic stocking
2. Elevate legs as much as possible
3. Control overweight (A healthy diet high in fiber and low in fat and
salt can help)
4. Avoid alcohol (cause veins in the legs to dilate)
5. Straining due to chronic constipation, urinary retention
or chronic cough? See healthcare provider(s)
6. Exercise (walking)
7. Schlerotherapy, radiofrequency endovenous occlusion,
laser occlusion called stripping
8. Operative hemorrhoidectomy (surgical removal of hemorrhoids)

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 Difference between Arteries and Veins
Arteries Veins
Take blood away from the Take blood to the heart
heart
Walls are thick and elastic Walls are thin
Transports oxygenated blood Transport de-oxygenated
blood
Has small lumen Has large lumen
Has a pulse and blood travels Has no pulse and blood
in spurts travels smoothly
Has no valves Has valves

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Difference between Arteries and Veins

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 Distribution of blood in the cardiovascular system (%)

CVS parts Percent

Systemic veins and venules (blood reservoir) 64
Systemic arteries &arterioles 13
Systemic capillaries 7
Heart 7
Pulmonary vessels 9
Total 100%

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 Most tissues of the body receives blood from more than one
artery. The union of the branches of two or more arteries
supplying the same body region is called Anastomosis. Or it is
also define as end-to-end union or joining of the blood
vessels

Collateral circulation

The alternate route of blood flow to a body part through

an anastomosis is known as collateral circulation

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Capillary Exchange

The mission of the entire CVS is to keep the blood

flowing through the capillaries to allow capillary
exchange, and movement of substances between the
blood plasma & interstitial fluid

Substance enter & leave capillaries by three basic

mechanisms
(a) Diffusion
(b) Transcytosis
(c) Bulk flow
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(a) Diffusion: Most important method of capillary exchange

A passive process in which there is a net or greater

movement of molecules or ions from the region of higher
concentration to the region of low concentration until
equilibrium is reached

Many substances such as O2, CO2, glucose, amino acids,

& hormones, enters & leaves capillaries by simple diffusion
(O2 and nutrients in higher concentration in blood flows down to the interstitial
fluid & then into body cells, while CO2 & other waste products released by the
body cells diffuses into the blood through the interstitial fluid)

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 Water soluble substances such as glucose & amino acids
pass across capillary walls through intercellular clefts or
fenestrations

Lipid soluble materials such as O2, CO2, and steroid

hormones may pass across capillary walls directly through the
lipid bilayer of endothelial cell plasma membranes

Plasma proteins and red blood cells cannot pass through

capillary walls of the continuous or fenestrated capillaries as
they are too large to fit it through. So it can be diffused
through sinusoids
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(b) Transcytosis (Trans= across; cyt=cell; - osis= process )
Large, lipid insoluble molecules are transported by means
of transcytosis
e.g Hormone Insulin enters the bloodstream by transcytosis, & certain
antibodies also pass from the maternal circulation to the fetal circulation by
transcytosis

(c) Bulk flow

Passive process, where large number of ions. Molecules,
particles in a fluid move together in the same direction.

Pressure driven: flows from area of higher pressure to an area of

lower pressure continuing as long as pressure differences exists.
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Filtration: Pressure driven movement of fluid and solutes
from blood capillaries into interstitial fluid, while pressure
driven movement from interstitial fluid into blood
capillaries is called reabsorption

Getting familiar with pressures that promotes filtration and

reabsorption:
1. Blood Hydrostatic Pressure (BHP)
2. Interstitial Fluid Hydrostatic Pressure(IFHP)
3. Blood colloid osmotic pressure (BCOP)
4. Interstitial Fluid Osmotic Pressure (IFOP)

The balance of these pressures is called Net Filtration Pressure(NFP)

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Dynamics of capillary exchange

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 EDEMA
If the filtration exceeds reabsorption, the end result is edema
(swelling), an abnormal increase in interstitial fluid volume

Edema is resulted either from excess filtration or from

poor resabsorption
Excess filtration is caused either through
1. Increased capillary blood pressure: Causing more fluid to
be filtered out from the capillaries
2. Increased permeability of the capillaries:

Poor reabsorption: Due to decreased concentration of plasma

protiens (what will happen?) 36
 Factors affecting blood flow

Hemodynamics?

It is defined as the study of factors that governs the flow

of blood through the blood vessels

Blood flow: It is the volume of blood that flows

through any tissue in a given period of time (mL/min)

This total blood flow is the cardiac output (CO)

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Cardiac output getting distributed to various body tissues
through the circulatory routes depends on two more factors

(1)The pressure difference that drives the blood flow through a tissue

(2) The resistance to blood flow in specific blood vessels

Blood flows from higher to lower pressure region ]

Greater the pressure difference, the greater the blood flow
Higher the resistance, by contrast, smaller the blood flow

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Blood Pressure
Blood Pressure is the force or pressure by which the
blood exerts on the walls of the blood vessels.
Blood pressure is generated through the contraction of
the ventricles

Systolic Pressure: When the Lt. ventricle contracts &

pushes the blood into the aorta, the pressure built within
the arterial system is called systolic pressure OR It is the
highest pressure attained in the arteries during systole. In
normal adults it is about 120mmHg

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Blood Pressure
Diastolic pressure : It is the lowest pressure attained in the
arteries during diastole. In an adult it is 80mmHg

Pressure is said to be highest in the area nearer to the Lt.

Ventricle, & decreases as the blood passes farther away from
the Lt. ventricle. E.g. BP decreases to about 35mmHg as
blood passes from systemic arteries through systemic
arterioles into capillaries. At the venous end of capillaries, BP
has dropped to 16mmHg. BP continues to drop, as blood
moves from systemic venules to veins, as these vessels are
farthest from the left ventricle. By the time blood reaches to
right ventricle it is almost 0mmHg.

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Blood Pressure

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The difference between the systolic & the diastolic pressure is
called Pulse Pressure. Normally it is about 40mmHg. It
provides an information about the condition of the CVS. E.g.
Patient with atherosclerosis & patent ductus arteriosus,
thyrotoxicosis, shows great increase in pulse pressure.
However the ratio of systolic to diastolic to pulse pressure is
about 3:2:1(120:80:40mmHg)

Blood pressure is also known to be the products of CO & Total

Peripheral Resistance (TPR)

i.e. BP = CO X TPR & CO = SV X HR

Check point: Do you think BP also depends on total blood
volume???
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What is mean arterial pressure(MAP)?
The average pressure within an artery over a complete cycle of one
heartbeat. On an average blood pressure in arteries is roughly 1/3rd
of the way between diastolic and systolic pressure, which can be
estimated as:
MAP=Diastolic BP+1/3(Systolic BP-Diastolic BP)

One way of measuring CO=MAP/R

MAP=CO X R

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 How to measure blood pressure?
Place the sphygmomanometer on the client’s arm & a stethoscope
over the brachial artery. Instruct the client to breath normally.
Inflate the cuff to 20 mmHg above the normal systolic pressure, &
then deflate it slowly( 1-2 mmHg/sec), and listen to Korotkoff’s
sound to appear only during expiration

As you deflate the cuff, the onset of the first tapping sound heard
corresponds to the systolic blood pressure. As you keep on
deflating the cuff, the sounds suddenly becomes faint, & this
sound corresponds to diastolic pressure

Korotkoff’s sounds:

Various sounds heard while measuring blood pressure 44

Vascular Resistance
Vascular resistance is the opposition to the blood flow due to
friction between the blood & the walls of the blood vessels

Vascular Resistance depends on

1. Size of the blood vessel’s lumen: Smaller the blood vessel’s

lumen, greater its resistance to blood flow
2. Blood viscosity: Higher the blood viscosity, higher the
resistance. Conditions such as dehydration, polycythemia,
increases the blood pressure, while depletion of plasma
proteins and RBC, due to anemia or hemorrhage decreases the
viscosity and thus decreases the blood pressure
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3. Total blood vessel length: Longer the blood vessel, greater
the resistance

Systemic Vascular resistance (SVR)

It is also known as Total Peripheral Resistance (TPR)

Refers to total vascular resistance offered by all the

systemic blood vessels

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Velocity of blood flow
The speed or the velocity of blood flow measured in cm/sec is
inversely proportional to the cross-sectional area

Larger the cross sectional area, slower the blood flow it will
be and vice versa.

As the larger artery gets branch out into arterioles and capillaries
as it goes away from the heart, the cross-sectional area becomes
larger than the parent artery. So the blood flow slows. In contrast,
as the venules and veins collects blood from the capillary bed, its
cross-sectional area decreases, and the velocity of blood flow
increases
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CONTROL OF BLOOD PRESSURE & BLOOD FLOW

1. Role of cardiovascular Center: Situated in the medulla

oblongata helps regulate heart rate and stroke volume

2. Neural regulation of Blood pressure

2.1 Baroreceptor reflexes: Pressure-sensitive sensory receptors,

located in the aorta, internal carotid arteries, and other large
arteries in the neck and the chest
2.2 Chemoreceptor reflexes: These are sensory receptors that
monitor the chemical composition of the blood, and are located
close to the baroreceptors of the carotid sinus and arch of aorta
in small structures called carotid bodies and aortic bodies
respectively
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CONTROL OF BLOOD PRESSURE & BLOOD FLOW
3. Hormonal regulation of blood pressure
3.1 Renin-angiotensin-aldosterone (RAA) system
When blood volume decreases, the Juxtaglomerular cells in the
kidnesy secretes renin into the blood stream. In sequence, renin
and angiotensin converting enzyme acts on their substrate to
produce the active hormone angiotensin II, which raises the
blood pressure in two ways:-
Increasing the systemic vascular resistance
Stimulates the secretion of aldosterone, which increases
the reabsorption of the sodium ions and water by the
kidneys. Water reabsorption increases the total blood
volume, which increases the blood pressure
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3.2 Epinephrine and norepinephrine: The release of these
hormones increases the cardiac output by increasing the heart rate
and force of heart contractions

3.3 Antidiuretic hormone(ADH): released from the posterior

pituitary gland in response to dehydration and decreased blood
volume. It causes vasoconstriction, increasing the BP. It is therefore
called as Vasopressin

3.4 Atrial natriuretic peptide(ANP): Released by cells in the atria,

it lowers the blood pressure by causing vasodilation, and also
promotes the loss of salt and water in the urine, which then
reduces the blood volume

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4. Auto-regulation of blood pressure
The special ability of a tissue to automatically adjust its
blood flow to match its metabolic demands

General types of stimuli to cause autoregulation

1. Physical changes: warming promotes vasodilation, and
cooling causes vasoconstriction

2.Vasodilating and vasoconstricting chemicals:

Vasodilators: K+, H+, Kinins, histamine, lactate, ATP, NO

Vasoconstrictors: Thromboxane A2, serotonin ( from platelets), &
endothelins 51
Checking circulation

Pulse

An alternate expansion and recoil of elastic arteries after each

systole of the let ventricle creates a travelling pressure wave

OR
It is the wave of distention and elongation felt in an arterial
wall due to contraction of the left ventricle forcing about 60-
80mL of blood
The number of pulse beats/minute normally represents the
heart rate & varies considerably in different people or in a
same person at different times. 52
 Pulse is strongest in the arteries closest to heart, becomes
weaker in the arterioles, & disappears in the arterioles

Pulse rate is normally as same as the heart rate and is about

70-80 beats / minute at rest

Tachycardia (heart hurry): When the heart beat is greater than

100 bpm. It may result from elevated body temperature, stress,
certain drugs, or heart disease. Since tachycardia occasionally
promotes fibrillation, persistent tachycardia is considered
pathological

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 Bradycardia (brady = slow): When the heart beat is slower than
60 beats per minute. It may result from low body temperature,
certain drugs, or parasympathetic nervous activation. It is also a
desirable known consequences of endurance training.

As physical and cardiovascular conditioning increases, the heart

hypertropies and the stroke volume increases. Thus, resting heart
rate can be lower and it still provide the same cardiac output;

However, persistent bradycardia in a poorly conditioned people

may result in grossly inadequate blood circulation to body tissues,
and therefore bradycardia is a frequent warning of brain edema
after head trauma.

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Places where Pulse rates are felt

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Shock and Homeostasis
Shock??
It is the failure of the cardiovascular system to deliver enough O2
& nutrients to meet the cellular metabolic demands

Types of Shock
Types of shock Reasons
Hypovolemic Due to decreased blood volume
Cardiogenic Due to poor heart function
Vascular Due to inappropriate vasodilation
Obstructive Due to obstruction of blood flow
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Signs & Symptoms of shock
Systolic BP <90mmHg
Resting heart rate is rapid
Weak pulse and rapid
Cool skin, pale and clammy
Altered mental status
Reduced urine formation
Person is thirsty
Acidosis due to built up lactic acid
Nausea

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 Hypovolemic shock
Common causes:

Acute hemorrhage: Trauma (external), rupture of an aortic

aneurysm (internal)
Loss of body fluids (excessive sweating, diarrhea, vomiting)
Others: Diabetes mellitus – polyuria
Inadequate intake of fluids

Vol. body fluids Venous return to heart Filling of heart

BP Cardiac output Stroke Vol.

Intervention??? FLUID replacement 59

Cardiogenic shock
Common causes:

Myocardial infarction (heart attack)

Others: poor perfusion of the heart (ischemia); heart valve
disorders, excess preload, afterload, impaired contractility &
arrythmias

Vascular shock
Normal blood volume and cardiac output!!!
Decrease in the systemic vascular resistance

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Vascular shock (con…)
Anaphylactic shock: severe allergic reaction (e.g. bee sting –
releases histamine & other mediators causing vasodilation)

Neurogenic shock: vasodilation following trauma to the head

causing malfunction of the cardiovascular centre in the medulla
Septic shock: Bacterial toxins causing vasodilation >100,000
deaths / year in the USA

Obstructed shock
Blood flow through the portion of circulation is blocked
Causes: Pulmonary embolism (a blood clot lodged into the blood vessels
of the lungs)
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Homeostatic response to shock

Major mechanisms: Negative feedback systems

1. Activation of renin-angiotensin-aldosterone system

2. Secretion of antidiuretic hormone (ADH)

3. Activation of the sympathetic division of the ANS

4. Release of local vasodilators

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Circulatory routes
Aorta and its branches
The principal divisions are:

1. Ascending aorta: gives off TWO coronary arteries

2. Arch of the aorta:
a. Brachiocephalic trunk – Rt. Common carotid artery
(right side of head & neck); Rt. Subclavian artery (rt. upper limb)
b. Left common carotid artery (Left side of head & neck)
c. Left subclavian artery (Lt. upper limb)
3. Thoracic aorta
4. Abdominal aorta

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Circulatory routes of the heart 66
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Principal veins

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Circle of Willis (Circulus Arteriosus)
Named after Thomas Willis (very influential English Physician), who
discovered it and then published his findings in his 1664 work
It is located at the base of the brain
In Latin: Circulus arteriosus cerebri, is a circle of blood
arteries supplying the brain. It is formed by both internal
carotid arteries and the basilar artery

After the internal carotid arteries enter skull from each side,
they will trifurcate into anterior cerebral artery, middle
cerebral artery, and posterior communicating artery

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Components of Circle of Willis

1. Anterior Cerebral artery (Lt & Rt)

2. Anterior Communicating artery (1)
3. Internal carotid artery (Lt & Rt)
4. Posterior Communicating artery (Lt & Rt)
5. Posterior Cerebral artery (Lt & Rt)
6. Basilar artery (1): Usually not considered part of Circle
although it supplies blood to brain

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Hepatic Portal Circulation
1. Carries venous blood from GIT organ and spleen to liver
2. Veins carrying blood from one capillary networks to
another is called portal vein
3. Hepatic portal vein received blood from capillaries of GI
organs & spleen and delivers it to the sinusoids of liver
4. After meal, hepatic portal blood is rich in nutrients
absorbed from GIT
5. Superior mesenteric & splenic veins (find out where they drains
blood from?) unite to form hepatic portal vein
6. Liver receives nutrients rich, deoxygenated blood from
hepatic portal vein, but do receive nutrients rich &
oxygenated blood from hepatic artery
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Hepatic Portal Circulation

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Fetal Circulation
What is fetal circulation?
It is the circulatory system of the fetus
Lungs, kidneys, & GI organs do not begin to function until
birth
Obtains O2 & nutrients from the maternal blood &
eliminates CO2 & other wastes into it
Exchange of materials between maternal & fetal circulation
occurs through placenta connected to fetus by umbilical cord
Normally there is no direct mixing of maternal and fetal
blood as exchanges of nutrients and gases occurs by diffusion
through the capillary walls
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 Blood passes from fetus to placental via 2 umbilical arteries
(in the umbilical cord)
Umbilical arteries are the branches of the internal iliac
(hypogastric) arteries
At the placenta: fetal blood picks up O2 & nutrients &
eliminates CO2 & wastes
Oxygenated blood returns from the placenta via single
umbilical vein in the umbilical cord
Umbilical vein ascends to the liver of the fetus, dividing
into two branches.
Some blood flow through the branch that joins the hepatic
portal vein and enters the liver
Most of the blood flows into the second branch, ductus
venosus that drains blood directly into the IVC
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 Deoxygenated blood returning from the lower body parts
of the fetus mingles with the oxygenated blood from the
ductus venosus in the IVC

Mixed blood then enters into the Rt. Atrium like

deoxygenated blood returning from upper body parts returns
to the Rt. Atrium

Most of the fetal blood does not pass from Rt. Ventricle to
the lungs as done so in postnatal circulation

Most of the blood passes from Rt. Atrium to Lt. atrium

through the opening called foramen ovale existing in
between the interatrial septum & joins the systemic
circulation 80
 Blood that do pass into the Rt. Ventricle are pumped into
the pulmonary trunk and is sent through the (joining of
pulmonary trunk with aorta)

Little blood reaches to the non functioning fetal lungs

As common iliac arteries branch into internal and external

iliac arteries, part of the blood flows into the internal iliacs,
into the umbilical arteries and back to the placenta for
another exchange of materials

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Scheme of Fetal Circulation 82
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health and Illness. 11th Ed. Churchill Livingstone: United Kingdom.
4. Marieb, EN. (2006). Human Anatomy & Physiology. 6th ed. Dorling Kindersley (India)
Pvt. Ltd. : India

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