11/20/21, 1:30 PM CV Physiology | Hypotension - Introduction

Cardiovascular Physiology Concepts

Richard E. Klabunde, PhD

 
Introduction
Acknowledgements

Topics:

Arrhythmias
Cardiac Valve Disease
Coronary Artery Disease
Edema
Heart Failure
Hypertension
Hypotension
Peripheral Artery Disease

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Click here for information on Cardiovascular Physiology Concepts, 3rd edition, a textbook published by Wolters Kluwer (2021)

Click here for information on Normal and Abnormal Blood Pressure, a textbook published by Richard E. Klabunde (2013)

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11/20/21, 1:30 PM CV Physiology | Hypotension - Introduction

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Hypotension - Introduction

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Definition of Hypotension and its Causes

Hypotension is a physiologic state in which the arterial blood pressure is abnormally low. For an adult, hypotension
exists when the systolic pressure is less than 90 mmHg and the diastolic pressure is less than 60 mmHg. Hypotension
reduces blood flow and therefore oxygen delivery to organs and tissues, which may cause cellular damage and
dysfunction. When oxygen delivery is insufficient to support tissue metabolic requirements, a person is said to be in
circulatory shock. Because arterial pressure is determined by cardiac output, venous pressure and systemic vascular
resistance (Click here for more details), a reduction in any of these variables can lead to hypotension. Hypotension
may result from:

1. Reduced cardiac output

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11/20/21, 1:30 PM CV Physiology | Hypotension - Introduction

2. Hypovolemia (low blood volume)

3. Blood volume redistribution
4. Reduced systemic vascular resistance (systemic vasodilation)
5. Vascular obstruction (e.g., pulmonary embolism)

The following diagram shows diseases or conditions that may result in reduced cardiac output, or those related to
abnormal vascular function.

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11/20/21, 1:30 PM CV Physiology | Hypotension - Introduction

 
 
Hypotension of Cardiac Origin
Reduced cardiac output that cannot be compensated by neurohumoral reflexes can cause hypotension, which can lead
to shock. If impaired cardiac output is caused by a problem with the pumping ability of the heart (e.g., arrhythmias or
heart disease), then the term cardiogenic shock is used to describe the origin of the shock state.

Cardiac arrhythmias

Bradycardia caused by an abnormally slow sinus rate or resulting from an atrioventricular block that reduces
ventricular rate leads to a decrease in cardiac output. Very high heart rates (tachycardia), by reducing ventricular
filling time, can cause a large reduction in stroke volume and therefore cardiac output. Ventricular fibrillation causes
cardiac output to fall to zero, and therefore leads to profound hypotension.

Cardiac structural disease

Cardiomyopathies (diseases of the myocardium) can impair either systolic function (inotropic state) or diastolic
function (ventricular filling) and thereby reduce cardiac output and arterial pressure. Valve disease, pericardial
disease, and congenital defects, can impair ventricular filling or net forward flow, thereby reducing cardiac output.
Ischemic heart disease caused by atherosclerosis or thromboembolism impairs ventricular function. Primary
pulmonary hypertension can lead to right ventricular failure and impaired left ventricular filling and output.

Hypotension of Vascular Origin

Hypovolemia

Hypovolemia caused by blood loss (hemorrhage) or orthostatic volume shifts decreases central venous pressure and

ventricular filling (preload), which reduces cardiac output through the Frank-Starling mechanism. However, reduced
cardiac output under these circumstances is due to inadequate cardiac filling from the systemic vasculature, not to
impaired intrinsic function. Hypovolemia can also result from excessive water loss (dehydration) caused by profuse
sweating, restricted water intake, or use of diuretic drugs. Although hypovolemia reduces cardiac output, the heart
itself is not the origin (non-cardiogenic), and therefore the term hypovolemic shock is used to describe the shock
state that results from hypovolemic hypotension.

Systemic vasodilation

Hypotension can also be caused by excessive systemic vasodilation (decreased systemic vascular resistance). This
may result from sepsis (blood infections) leading to septic shock, anaphylaxis (immunological reactions) that can
lead to anaphylactic shock, autonomic dysfunction (e.g., diabetic neuropathy; spinal cord injury) leading
to neurogenic shock, or drugs (e.g., antihypertensive vasodilators). These specific causes of vasodilation-
induced shock are grouped together as distributive shock.

Vascular obstruction

Another vascular origin of hypotension is vascular obstruction such as pulmonary embolism. Vascular obstruction
most frequently is caused by blood clots forming in systemic veins (e.g., deep vein thrombosis in legs) that travel to
the right side of the heart and embolize in pulmonary arteries. When this occurs, venous return to the left ventricle is
dimished, thereby decreasing its output and arterial pressure, which can lead to state of obstructive shock.

To understand more fully the physiology and pathophysiology of hypotension, see the Blood Pressure Regulation
Tutorial.
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11/20/21, 1:30 PM CV Physiology | Hypotension - Introduction

You can view an 18 minute YouTube introductory lecture on Hypotension and Shock.

Revised 2/02/21

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DISCLAIMER: These materials are for educational purposes only, and are not a source of medical decision-making
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