Chapter 1

INTRODUCTION TO THE CARDIOVASCULAR

SYSTEM

Learning Objectives

After reading this chapter you should be able to:

1. List the major functions of the cardiovascular system.

2. Describe its organization.
3. Explain why the output from the left heart must be more or less the same as the output
from the right heart.
4. Define systole and diastole.
5. State the features that distinguish the pulmonary and systemic circulations.
6. Define a portal circulation and state its significance.
7. Define cardiac output and stroke volume. Explain how SV is calculated. Know normal values.
8. Write down the basic law of flow.
9. Apply the law of flow to explain the pressure changes seen across the circulation.
10. Explain why velocity of flow is slowest in capillaries.
11. Describe the different classes of blood vessels and how their morphology is suited to their
various functions.

This chapter is an introduction to the cardiovascular system (CVS). Some important terms are
defined, and some principal concepts are introduced.

Introduction

The CVS consists of the heart and the vascular system, and has evolved to deliver O2 and
nutrients rapidly to all cells of the body and to remove CO2 and waste products. O2 is used by
all cells to generate ATP the metabolic energy source of the body. However, oxidative
metabolism generates acidic products, particularly CO2, and continual removal of these
sources of H+ is essential since increases in intracellular [H+] alters protein conformation -
with disastrous consequences - such as, changes in ion channel protein conformation which
would affect membrane permeability and excitability. Imagine how this would affect the
brain and the heart! Therefore, should O2 delivery or H+ removal be impaired, the result is
tissue damage and morbidity (illness). However, should either or both fail, death would occur
within minutes!

Organization of the Cardiovascular System

We breathe in air containing O2 which needs to get from the alveoli in the lungs to all cells of
the body; similarly CO2 needs to be removed from all cells of the body and exhaled by the
lungs. Since diffusion is only effective over very short distances, a CVS has evolved which
consists of two pumps in series (the heart) joined by blood vessels.

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The two pumps are the right ventricle (RV) and left the ventricle (LV). Each pump is filled
from the right atrium (RA) and left atrium (LA), respectively.

The RV contracts and pumps deoxygenated blood through the pulmonary artery, which
divides and supplies the lungs. Inhaled O2 diffuses into the blood and CO2 diffuses out and is
exhaled. The oxygenated blood returns to the LA through the pulmonary veins, thus
completing the short pulmonary circulation.

The LV pumps out an equal volume of

oxygenated blood to all tissues of the body Organization of the CVS
(except the lungs). The blood flows through
Systemic Circulation
the aorta, which gives off several major
arteries. Repeated branching gives rise to Right Right
millions of capillaries where the ultimate Atrium Ventricle
function of the CVS is fulfilled the delivery
of O2 and nutrients to the tissues and the
removal of waste products. The deoxygenated
Left Left
blood returns to the RA via a convergent
system of veins that drain into the superior and Ventricle Atrium
inferior vena cavae, which join and enter the Pulmonary Circulation
RA, thus completing the systemic circulation.

Blood flows only in the direction described because of the presence of one-way valves
between the atria and ventricles (atrio-ventricular valves) and between the ventricles and the
pulmonary artery and aorta (the semilunar valves).

Note again that the left heart and the right heart function in series so that blood is pumped
sequentially from the left heart to the systemic circulation, to the right heart, to the pulmonary
circulation, and then back to the left heart.

Systole and Diastole

Although the heart consists of two separate pumps, both the LV and the RV contract at the
same time and eject approximately the same volume of blood. Contraction of the heart is
called systole, and diastole is when the heart is relaxing.

Cardiac Output and Venous Return

Cardiac Output (CO) = Volume of blood ejected from one ventricle per minute
= ~ 5 L/min at rest

Note:
Normal physiological values refer to the standard textbook person who is a 70 kg,
Caucasian male, aged ~ 20!

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Both the LV and the RV are each pumping out ~ 5 L of blood every minute, and they
are doing it at the same time.

Venous Return (VR) = Volume of blood returning to the RA from the vena
cava or to the LA from the pulmonary vein per minute.

Because the right and left heart operate in series, the VR to the RA must equal the VR to
the LA.

Finally, in steady state conditions, the venous return to the heart must equal the cardiac
output from the heart.
(We include the words in steady state conditions because as you will see later, minor
differences in CO between the LV and the RV do occur, but compensatory mechanisms come
into play to ensure that the overall output over a few beats is more or less the same).

Stroke Volume (SV)

CO is the volume of blood ejected from one ventricle per minute.
Can you work out how much blood is ejected per beat, if the heart is beating at a rate of
72 /minute?

SV = Volume of blood ejected (from either ventricle) per heart beat

Since CO = Stroke Volume (SV) x Heart Rate (HR)

Then, SV = CO
HR
Therefore, SV = 5000 ml = ~ 70 ml
72
Resting HR varies between 50 90 beats/min. (Our male model has a HR of 72/min!).
Olympic athletes can have resting HR as low as 35/min. Their CO at rest is normal. Why?

The CO is not fixed, when the bodys demand for O2 increases the CO increases accordingly.
During vigorous exercise it can increase to 20 L/min (even to 30 L/min in trained athletes).

How much blood is in your circulation?

Blood Volume = 5 5.5 L (~ 7 8% of body weight)

You are the male model, lying in bed resting, your blood volume is 5 L - how long would it take for
one of your red blood cells to go once round the whole circulation?

The distribution of the CO amongst the various organs

Blood, ejected from the LV into the aorta, is then distributed to the various organs via
arteries. Generally the arterial supply to each organ arises more or less directly from the
aorta such that each organ is supplied directly with arterial blood. For this arrangement to
work the blood vessels to each organ are arranged in parallel which means that each organ

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receives its blood simultaneously. Each organ receives a fraction of the cardiac output but the
total blood flow through all these organs must equal the cardiac output.

Organs do not receive the same fraction of the CO - some receive much more than others.
Generally, the amount of blood they receive is related to their metabolic needs which is
reflected by their O2 consumption. There are some glaring exceptions: the O2 consumption of
the kidney is only 6% but it receives ~20% of CO. This is to fulfill its function to excrete
water and urea.

CO distribution (at rest) O2 consumption (at rest) Figure 1

Other
10% Other
14%
Skin Liver and gut Skin Liver and gut
8% 25% 2% 30%

Muscle
Muscle
20%
20%
Kidneys
Kidneys
6%
20%
Heart Heart
Brain
4% Brain 10%
18%
13%

Comparison of O2 usage and CO distribution at rest.

What % of the CO do the lungs receive?

The lungs, of course, receive 100% of the cardiac output (but from the RV).

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The Parallel Arrangement of Blood Vessels

Figure 2 The parallel arrangement of blood vessels within the circulation.

(From Rhoades and Bell: Medical Physiology: Lippincott, Williams and
Wilkins)

The above figure shows that the blood vessels to most systemic organs are arranged in
parallel, but the liver and renal tubules also have an in series supply.

The Portal System

There are some exceptions to the parallel arrangements of blood flow. Some organs (listed
below) are connected in series with another organ such that they receive the venous outflow
of another organ. Such a system is called a portal system.

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Liver: Has a direct arterial supply via the hepatic artery, but ~70% of its blood
supply comes from the hepatic portal vein, which is venous blood drained
from the gut and spleen. The advantage is that digestive products can be
transported directly from the gut to the liver, for further processing.

Kidney: Afferent arterioles supply the glomeruli and efferent arterioles carry venous
blood from the glomeruli. These efferent arterioles then supply oxygen and
nutrients to the kidney tubules.

Brain: A portal system exists between the hypothalamus and the pituitary gland
which functions to transport hypothalamic hormones to the pituitary.

Each portal system described above fulfills a particular role (see above). However, a
disadvantage of portal systems is that the downstream organ receives partially deoxygenated
blood under a reduced pressure head. This makes the receiving tissues more vulnerable than
other tissues during episodes of hypotension (e.g. renal tubules can easily become damaged).

The Vascular System

The entire circulation consists of blood vessels lined with endothelial cells and surrounded by
varying amounts of smooth muscle, elastin and connective tissue (mainly collagen).

Figure 3 Arrangement of blood vessels in the cardiovascular system.

(From Rhoades and Bell: Medical Physiology))

The aorta divides into a set of named arteries which branch repeatedly to form tiny arteries
called arterioles. Arterioles branch to form capillaries. Capillaries converge to form venules,
which drain into veins. The peripheral veins drain into the central veins which empty into the
atria.

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Structure of Blood Vessels Revise your histology!

Figure 4 Structure of a Wall of a Muscular Artery

All blood vessel (except capillaries!) have 3 layers:

Tunica Intima: Endothelial cells

(inner layer) Barrier between blood and rest of blood vessel wall.
Secretes vasoactive agents e.g. NO
Disruption of this barrier implicated in the development of atheroma

Tunica Media 2 layers of elastic laminae - either side of smooth muscle

(middle layer) Supplies mechanical strength and contractile power
Endothelial cells may project through the lamina to directly contact
smooth muscle cells.

Tunica Adventitia Connective tissue (mainly collagen) holds blood vessels in place.
(outer layer) Vasa vasorum run through this layer.
Adventitia of veins contain nociceptive fibres.

Note: Capillaries are a single layer of endothelial cells.

How does blood flow through the circulation?

The Concepts of Flow, Pressure and Resistance

Below is a brief introduction to Hemodynamics it will be dealt with in more detail later.

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Why Blood Flows round the Circulation

Blood flows through the systemic circulation from the LV to the RA because the LV
contracts and ejects the blood forcefully at a high pressure into the aorta. The aortic blood
pressure is typically ~ 120 mm Hg (i.e. 120 mm Hg above atmospheric pressure). After
passage of the blood through the systemic circulation, the blood returns to the RA where the
pressure is only ~ 3 mm Hg. The contraction of the LV then creates a pressure gradient
between the aorta and the RA which enables blood to flow down this gradient and through
the circulation.
Similarly the contraction of the RV forcefully ejects blood into the pulmonary artery.
However the pressure generated by the RV is much less (~ 25 mm Hg) than that generated by
the LV. The pressure in the pulmonary vein and LA is ~ 8 mm Hg. The pressures generated
by the RV do not have to be as high as those generated by the LV since the resistance to the
flow of blood in the pulmonary circulation is much less compared with the systemic
circulation. The systemic circulation is a high pressure circuit and the pulmonary circulation
is a low pressure circuit.

Because the heart is a pump it ejects blood intermittently and so the aortic (arterial)
pressure is pulsatile. When the LV contracts (systole) the pressure in the aorta is 120 mm Hg,
when the heart relaxes (diastole) the pressure in the aorta does not fall to zero but falls only to
80 mm Hg. In the pulmonary circulation the systolic blood pressure in the pulmonary artery
is 25 mm Hg and the diastolic blood pressure is ~8 mm Hg. Conventionally these are written
as 120/80 mmHg and 25/10 mmHg respectively. When blood pressure is measured
routinely, it is the systemic BP that is measured.

Although arterial pressure is pulsatile with a peak and a trough, most aspects of
hemodynamics can be understood by considering the mean arterial pressure which is ~ 93
mm Hg. For reasons given later, the mean arterial pressure is not simply the arithmetic
mean between systolic (120) and diastolic (80).

Flow and Resistance

Flow = Volume of fluid transferred per unit time. (It is, by definition, a rate).

Flow (F) Pressure gradient (P1 P2) or (P)

Flow P

When we insert a proportionality constant K we get:

Flow = K . P

K is called the hydraulic conductance. But since it is easier conceptually to think of difficulty
of flow rather than ease of flow the term resistance (R) is used (K = 1/R).

Flow = P Bulk Flow Law (Darcys Law)

R

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The above is Darcys (or Bulk) Law of Flow. Note its similarity to Ohms Law (where I =
V/R).

In the CVS: the larger the pressure gradient, the bigger the flow of blood (when resistance is
constant) and the greater the resistance the smaller the flow.

Both the systemic and the pulmonary blood vessels offer resistance to blood flow. Most of
the resistance is due to the friction between the blood components and the walls of the
vessels. The diameter of the blood vessel is very important in determining the resistance to
flow: the smaller the diameter the higher the resistance, and vice versa. The total resistance
of the systemic circulation is ~ 0.02 mmHg/ml/min; the pulmonary circulation is much lower
0.003mmHg/ml/min and as mentioned earlier, a low pulmonary artery pressure is usually
sufficient to drive the cardiac output through the lungs whereas the LV has to generate a
much higher pressure in the aorta to drive blood through the high resistant systemic
circulation.

How changes in vessel diameter (radius) affects flow.

In the CVS, homeostatic mechanisms try and ensure that the pressure head generated by the
heart is fairly constant in a resting individual. This is to ensure that each organ will be
adequately perfused with blood and oxygen. We know from Darcys Law that the flow of
blood round the circulation is dependent on this pressure head. But does this mean that the
blood flow through each individual organ is fixed and cannot be altered? What if youre in a
very cold room and you need to preserve your body heat. One way of doing this is to reduce
your skin blood flow. Or if you are exercising, your skeletal muscles need a greater blood
flow since they require more O2 and nutrients. Can such changes in flow be achieved if the
pressure head is relatively constant? Yes, because the resistance to blood flow through
individual organs can be altered. Go back to Darcys Law: blood flow is inversely
proportional to resistance, and resistance is related to the diameter of the blood vessel. So
should the diameter of skin blood vessels decrease the blood flow through the skin would be
reduced, thus conserving body heat. Conversely, if the diameter of skeletal muscle blood
vessels increases muscle blood flow would increase. Changes in diameter of blood vessels
are brought about by altering the degree of tone in vessel smooth muscles. These smooth
muscles are always partially contracted: an increase in contraction results in vasoconstriction
and a reduced blood flow; whereas a decrease in contraction (relaxation) results in
vasodilation and a larger blood flow.

Velocity of Blood Flow and Cross Sectional Area of the Circulation

The vascular system is made up of arteries, arterioles, capillaries, venules and veins. Let us
now consider the total cross sectional area of each component which is the cross sectional
area of one vessel times the number of vessels. Which component do you think has the
largest cross sectional area? Yes, the capillaries. Although the diameter of each is very tiny,
we have millions of them. The aorta has a very large diameter but we only have one! As
blood spreads out along the arterial tree the increase in number of vessels due to branching
more than outweighs the reduction in vessel diameter. As a result, the total cross sectional

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area of the circulation increases from the aorta to the capillaries and then decreases as venules
converge into veins.

Cross Sectional Area (cm2) 2500

300

200

100

Aorta Arteries Arterioles Capillaries Veins/ Vena Cava

Venules
Number 1 105 107 1010 1012 1

Figure 5 The cross sectional area of the various types of blood vessels

Effect of cross sectional area on velocity of blood flow.

Velocity of Blood Flow (cm/s) = Flow (mL/s)

Cross sectional area (cm2)

Velocity = Flow (= Cardiac Output)

Area

From the above equation, provided that flow is constant, the velocity is inversely related to
the cross sectional area. Which vessels have the largest cross sectional area? Yes, the
capillaries. Where in the vascular system is the velocity of blood the slowest? Yes, the
capillaries. In fact, the blood travels 200 times more slowly through the capillaries than
through the arteries. Is there an advantage to this? Yes, the slow velocity through the
capillaries allows time for the diffusion of gases and nutrients. The same scenario is found in
the pulmonary circulation, where the slow transit time in pulmonary capillaries allows time
for the blood to equilibrate with alveolar gases.

Dont confuse flow and velocity. Flow is the volume displaced per unit time. In the dimensional terms
mass M, length L and time T: Flow = L3/T ; velocity = L/T but since velocity is flow per unit area =
L3/T x 1/L2 which is = L/T). Therefore the equation is mathematically correct.
Imagine walking by a river with a constant flow, as the river widens the current (velocity of flow) gets
slower, and as it narrows the current is faster.

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Functions of the different types of Blood Vessels
Blood vessels can be divided on functional grounds into the following classes:

Classes of Blood Vessels Examples

Elastic Aorta and large arteries
Conduit Arteries
Resistance Arterioles
Exchange Capillaries
Capacitance Veins

The wall of each type of vessel is adapted to its particular function.

Elastic vessels: Large Arteries: Aorta and iliac artery

Thick wall - much elastin.

Elastin makes them distensible: they inflate with blood during systole and during
diastole the elastin component recoils.
Accommodate blood at high pressures
Collagen which is much stiffer than elastin prevents them being overstretched.
Amount of collagen increases with age, and elasticity is .

Conduit vessels: Smaller (muscular) arteries: cerebral, coronary, radial

Less collagen, less elastin but more smooth muscle than the aorta.
Innervated by sympathetic vasoconstrictor fibres.
The smooth muscle can contract or relax thus altering vessel diameter.
Vasospasm of diseased coronary arteries gives rise to angina.

Resistance Vessels: Arterioles

Smooth muscle (major component)

Sites of highest resistance to blood flow in the circulation.
Richly innervated by sympathetic vasoconstrictor nerves.
Highly susceptible to vasoactive substances in the circulation, or those released
locally.
Sites in the circulation where blood flow to various organs can be altered.

Terminal arterioles adjust the number of capillaries perfused with blood, possibly by
contracting a cuff of smooth muscle which lies at the entrance of each capillary (pre-
capillary sphincters).

In resistance vessels the pulsatile flow is smoothed out to a constant flow.

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Exchange vessels: Capillaries

Thin-walled with only a single layer of endothelial cells resting on a basement

membrane.
No smooth muscle but contractile elements within the endothelial cells allow them to
change shape in response to chemical mediators.
Site of exchange of nutrients and waste products between circulation and interstitial
fluid aided by the low velocity.
Because they are so profuse and have a large in parallel arrangement they have an
enormous cross sectional area and a relatively low resistance to flow.
Not all capillaries are perfused with blood at all times. Perfusion is dependent on the
metabolic needs of the tissue.

Arteriovenous anastomoses: mainly in skin and nasal mucosa

Shunt vessels that connect arterioles directly to venules - by-passing capillaries. The
thick walls are innervated by sympathetic nerves. In the skin they are involved in the
control of body temperature; and in the nasal mucosa they warm inspired air.

Capacitance Vessels: venules, peripheral and central veins

Venules: Thin walled with some smooth muscle

Some exchange of nutrients and waste products takes place across the walls of
the smaller venules.

Veins: Relatively thin walled. Less elastin, slightly more collagen (compared with
arteries)

Venules and veins are more numerous than the corresponding arterioles and arteries.
Very distensible. Because of their large number and size, veins contain ~ 60% of the
circulating blood at any one instance, and are referred to as capacitance vessels since
they provide a reservoir for blood. (See histogram in Figure 5).
Richly supplied by sympathetic venoconstrictor nerves which can alter the volume of
blood. Constriction of peripheral veins displaces blood into the central veins and into
the heart.
Limb veins possess valves which prevent backflow of blood.

Central veins: Vena Cavae

Less elastin and more collagen compared with the aorta.

Collagen provides strength.

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The Distribution of Blood Volume within the Cardiovascular System

Pulmonary Circulation
10 12%
Heart
8 11%

Systemic veins
and venules Systemic Arteries
60 70% 10 12%

Capillaries
4 5%

Figure 6 Distribution of blood volume in the circulation.

As can be seen from the above pie chart, two thirds of the blood within the circulation resides
in the veins and venules, which is why they are known as the capacitance vessels.

The pressure gradients across the circulation

Blood flows through the systemic circulation because of a pressure gradient between the
aorta and the right atrium, and through the pulmonary circulation because of a pressure
gradient (albeit smaller) between the RV and the LA. The pressure gradient is created by the
heart pumping blood out at a high pressure into the aorta and pulmonary artery. The mean
aortic pressure is ~ 93 mmHg but by the time the blood reaches the right atrium the pressure
has dropped to almost zero. Where does this pressure drop occur?

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Figure 7 Pressure gradients across the systemic circulation.
(Rhoades and Bell: Medical Physiology)

From the diagram above you can see that there is very little pressure drop from the aorta to
the large arteries; in fact from the aorta to the radial artery there is only a drop of ~ 2 mm Hg.
This is because these vessels have a large diameter, and so do not provide much resistance to
flow.
The largest fall in pressure is seen to occur across the smallest, terminal arteries and the
arterioles. According to Darcys law this must be because these vessels must offer the largest
resistance to flow. This is the case, and this is why they are called resistance vessels.
The capillaries, although very narrow, surprisingly offer little resistance to flow and the
pressure drop across them is minimal. This is due to the fact that there are very many of them
and they are arranged mostly in parallel. (Remember your electricity, circuits with parallel
resistances have a smaller total resistance than circuits with series resistances).
Since there are many more venules and small veins compared with arterioles and small
arteries their net resistance is low. The pressure in small veins is ~10 15 mmHg and this is
sufficient to drive the blood (cardiac output) from the veins to the right atrium.

The dashed line illustrates the velocity of blood flow which is least through the capillaries.

Figure 8 The pressure drop across the pulmonary circulation.

The 100

Mm Hg

20

0
Pulmonary Artery

Arterioles

Veins
Capillaries

diagram above shows the pressure drop across the pulmonary circulation. In the pulmonary
arteries the pressure is pulsatile, just like in the aorta, but the pressure level is far less: the
systolic is only ~25 mm Hg and the diastolic ~8 mm Hg with a mean arterial pressure of ~ 16
mm Hg. The mean pulmonary capillary pressure is only ~ 7 mm Hg. Yet, the total blood flow
through the pulmonary circulation is the same as the total blood flow through the systemic
circulation. The low pressures of the pulmonary system are in accord with the needs of the
lungs because all that is required is that the blood is exposed to the alveolar gases, and the
distances the blood has to travel are short.

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