Arthur Guyton presented a paradigm shift in understanding how the circulation works. He argued that cardiac output is determined by the interaction of two functions: cardiac function and venous return function. Venous return depends on factors like stressed blood volume, venous compliance, venous resistance, and right atrial pressure. Guyton provided a graphical tool to analyze how changes in one function can impact cardiac output depending on where the two functions intersect. At the bedside, understanding Guyton's concepts can help interpret changes in cardiac output and blood pressure in response to therapy or disease.
LabVIEW Based Measurement of Blood Pressure using Pulse Transit TimeRSIS International
Blood Pressure is the pressure exerted by blood on the
walls of arteries. Normal blood pressure is considered to be a
systolic blood pressure of 120 millimetres of mercury and
diastolic pressure of 80 millimetres of mercury (stated as "120
over 80"). If an individual were to have a consistent blood
pressure reading of 140 over 90, he would be evaluated for
having high blood pressure. If left untreated, high blood pressure
can damage important organs, such as the brain and kidneys, as
well as lead to a stroke. Thus it becomes important to measure
blood pressure as it can lead to early diagnosis of diseases that
may be linked to high or low blood pressure. PTT is the time
taken by the arterial pulse propagating from the heart to a
peripheral site. This can be calculated from ECG signals and
PlethysmoGram signals. Since, PTT has been found to be
correlated to Blood Pressure, it is imperative to calculate PTT
accurately. In this paper, a relation has been developed between
PTT and Blood Pressure using regresssion analysis. Another
indicator, known as the Photoplethysmogram Intensity Ratio,
henceforth known as the PIR has also been used in estimation of
the Blood Pressure. The coding has been done in LabVIEW
which is has a graphical programming syntax that makes it
simple to visualize, create, and code engineering systems.
Cardiology
From Wikipedia, the free encyclopedia
Jump to navigationJump to search
This article is about the medical specialty. For the album, see Cardiology (album). For the medical journal, see Cardiology (journal).
Cardiology
Heart diagram blood flow en.svg
Blood flow diagram of the human heart. Blue components indicate de-oxygenated blood pathways and red components indicate oxygenated blood pathways.
System Cardiovascular
Subdivisions Interventional, Nuclear
Significant diseases Heart disease, Cardiovascular disease, Atherosclerosis,
earning websites that make the most money
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
LabVIEW Based Measurement of Blood Pressure using Pulse Transit TimeRSIS International
Blood Pressure is the pressure exerted by blood on the
walls of arteries. Normal blood pressure is considered to be a
systolic blood pressure of 120 millimetres of mercury and
diastolic pressure of 80 millimetres of mercury (stated as "120
over 80"). If an individual were to have a consistent blood
pressure reading of 140 over 90, he would be evaluated for
having high blood pressure. If left untreated, high blood pressure
can damage important organs, such as the brain and kidneys, as
well as lead to a stroke. Thus it becomes important to measure
blood pressure as it can lead to early diagnosis of diseases that
may be linked to high or low blood pressure. PTT is the time
taken by the arterial pulse propagating from the heart to a
peripheral site. This can be calculated from ECG signals and
PlethysmoGram signals. Since, PTT has been found to be
correlated to Blood Pressure, it is imperative to calculate PTT
accurately. In this paper, a relation has been developed between
PTT and Blood Pressure using regresssion analysis. Another
indicator, known as the Photoplethysmogram Intensity Ratio,
henceforth known as the PIR has also been used in estimation of
the Blood Pressure. The coding has been done in LabVIEW
which is has a graphical programming syntax that makes it
simple to visualize, create, and code engineering systems.
Cardiology
From Wikipedia, the free encyclopedia
Jump to navigationJump to search
This article is about the medical specialty. For the album, see Cardiology (album). For the medical journal, see Cardiology (journal).
Cardiology
Heart diagram blood flow en.svg
Blood flow diagram of the human heart. Blue components indicate de-oxygenated blood pathways and red components indicate oxygenated blood pathways.
System Cardiovascular
Subdivisions Interventional, Nuclear
Significant diseases Heart disease, Cardiovascular disease, Atherosclerosis,
earning websites that make the most money
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
Dr Vivek Baliga - Diastolic heart failure - A complete overviewDr Vivek Baliga
In this presentation, Dr Vivek Baliga, Consultant Internal Medicine, discusses a common problem in medical practice that often confuses many - diastolic heart failure. Now a misnomer, it is referred to as heart failure with preserved ejection fraction. For patient articles - http://heartsense.in/author/dr-vivek-baliga-b/ . LinkedIn - https://www.linkedin.com/in/dr-vivek-baliga-7b59b0125
Methods: Central Venous Pressure and Physician administration of Intravenous ...Todd Belok
Our study is using the independent variables of low CVP coupled with hypotension and dependent variable of physician administered fluids to test how the Venus 1000 can alter physician actions in the emergency department setting.
Exploring Applied Physiology of the Cardiovascular System
The cardiovascular system is a cornerstone of human health, regulating the circulation of vital nutrients, oxygen, and waste products throughout the body.
Understanding the applied physiology of this system is essential for healthcare professionals to provide effective medical care and interventions.
Importance of Applied Cardiovascular Physiology
Effective healthcare requires a deep comprehension of how the cardiovascular system functions under various conditions.
Applied physiology knowledge empowers healthcare practitioners to make informed decisions, diagnose disorders, and formulate targeted treatment plans.
Focus on Practical Applications in Healthcare
This presentation delves into the practical aspects of cardiovascular physiology that directly impact clinical practice.
We will explore how physiological concepts are translated into real-world medical scenarios and interventions.
By grasping the applied physiology of the cardiovascular system, healthcare providers can optimize patient care, enhance diagnostics, and improve treatment outcomes.
Throughout this presentation, we'll bridge the gap between theoretical understanding and its practical implications in the field of healthcare.
Understanding the Components
The cardiovascular system comprises three crucial components: the heart, blood vessels, and blood.
Heart: A muscular organ that pumps blood, ensuring a continuous flow throughout the body.
Blood Vessels: A network of tubes that transport blood to and from various tissues.
Blood: A specialized fluid that carries nutrients, oxygen, hormones, and removes waste products.
Role in Oxygen and Nutrient Delivery
Oxygen from the lungs and nutrients from the digestive system are transported to body tissues through the bloodstream.
These essential components are required for cellular metabolism and energy production.
Dr Vivek Baliga - Diastolic heart failure - A complete overviewDr Vivek Baliga
In this presentation, Dr Vivek Baliga, Consultant Internal Medicine, discusses a common problem in medical practice that often confuses many - diastolic heart failure. Now a misnomer, it is referred to as heart failure with preserved ejection fraction. For patient articles - http://heartsense.in/author/dr-vivek-baliga-b/ . LinkedIn - https://www.linkedin.com/in/dr-vivek-baliga-7b59b0125
Methods: Central Venous Pressure and Physician administration of Intravenous ...Todd Belok
Our study is using the independent variables of low CVP coupled with hypotension and dependent variable of physician administered fluids to test how the Venus 1000 can alter physician actions in the emergency department setting.
Exploring Applied Physiology of the Cardiovascular System
The cardiovascular system is a cornerstone of human health, regulating the circulation of vital nutrients, oxygen, and waste products throughout the body.
Understanding the applied physiology of this system is essential for healthcare professionals to provide effective medical care and interventions.
Importance of Applied Cardiovascular Physiology
Effective healthcare requires a deep comprehension of how the cardiovascular system functions under various conditions.
Applied physiology knowledge empowers healthcare practitioners to make informed decisions, diagnose disorders, and formulate targeted treatment plans.
Focus on Practical Applications in Healthcare
This presentation delves into the practical aspects of cardiovascular physiology that directly impact clinical practice.
We will explore how physiological concepts are translated into real-world medical scenarios and interventions.
By grasping the applied physiology of the cardiovascular system, healthcare providers can optimize patient care, enhance diagnostics, and improve treatment outcomes.
Throughout this presentation, we'll bridge the gap between theoretical understanding and its practical implications in the field of healthcare.
Understanding the Components
The cardiovascular system comprises three crucial components: the heart, blood vessels, and blood.
Heart: A muscular organ that pumps blood, ensuring a continuous flow throughout the body.
Blood Vessels: A network of tubes that transport blood to and from various tissues.
Blood: A specialized fluid that carries nutrients, oxygen, hormones, and removes waste products.
Role in Oxygen and Nutrient Delivery
Oxygen from the lungs and nutrients from the digestive system are transported to body tissues through the bloodstream.
These essential components are required for cellular metabolism and energy production.
Appropriate level of monitoring is important in anaesthesia. Monitors should be sensitive enough to be able to detect early changes in hemodynamics. There have been major advance in non invasive monitoring in the recent past to make them more user friendly & also provide data which was till recently possible by invasive monitors only. Non invasive monitoring has limitations because of physical principle involved and other prerequisites required for accuracy. Thus non invasive monitors may not be sensitive enough to pick early changes in hemodynamic in sick patients. In this review we discuss the limitations of non invasive hemodynamic monitoring and factors that may influence their accurate working.
20.2 Blood Flow, Blood Pressure, and Resistance Get This Book!.docxfelicidaddinwoodie
20.2 Blood Flow, Blood Pressure, and Resistance
Get This Book!
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Summary
By the end of this section, you will be able to:
· Distinguish between systolic pressure, diastolic pressure, pulse pressure, and mean arterial pressure
· Describe the clinical measurement of pulse and blood pressure
· Identify and discuss five variables affecting arterial blood flow and blood pressure
· Discuss several factors affecting blood flow in the venous system
Blood flow refers to the movement of blood through a vessel, tissue, or organ, and is usually expressed in terms of volume of blood per unit of time. It is initiated by the contraction of the ventricles of the heart. Ventricular contraction ejects blood into the major arteries, resulting in flow from regions of higher pressure to regions of lower pressure, as blood encounters smaller arteries and arterioles, then capillaries, then the venules and veins of the venous system. This section discusses a number of critical variables that contribute to blood flow throughout the body. It also discusses the factors that impede or slow blood flow, a phenomenon known as resistance.
As noted earlier, hydrostatic pressure is the force exerted by a fluid due to gravitational pull, usually against the wall of the container in which it is located. One form of hydrostatic pressure is blood pressure, the force exerted by blood upon the walls of the blood vessels or the chambers of the heart. Blood pressure may be measured in capillaries and veins, as well as the vessels of the pulmonary circulation; however, the term blood pressure without any specific descriptors typically refers to systemic arterial blood pressure—that is, the pressure of blood flowing in the arteries of the systemic circulation. In clinical practice, this pressure is measured in mm Hg and is usually obtained using the brachial artery of the arm.
Components of Arterial Blood Pressure
Arterial blood pressure in the larger vessels consists of several distinct components (Figure): systolic and diastolic pressures, pulse pressure, and mean arterial pressure.
Systolic and Diastolic Pressures
When systemic arterial blood pressure is measured, it is recorded as a ratio of two numbers (e.g., 120/80 is a normal adult blood pressure), expressed as systolic pressure over diastolic pressure. The systolic pressure is the higher value (typically around 120 mm Hg) and reflects the arterial pressure resulting from the ejection of blood during ventricular contraction, or systole. The diastolic pressure is the lower value (usually about 80 mm Hg) and represents the arterial pressure of blood during ventricular relaxation, or diastole.
Systemic Blood Pressure
The graph shows the components of blood pressure throughout the blood vessels, including systolic, diastolic, mean arterial, and pulse pressures.
Pulse Pressure
As shown in Figure, the difference between the systolic pressure and the diastolic pressure is the pulse pressure. For example, an indivi ...
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
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Macroeconomics- Movie Location
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Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
A Strategic Approach: GenAI in EducationPeter Windle
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2. circuit, which determines the return of blood to the heart
and which Guyton depicted as a venous return curve.
Guyton first clarified the concept of mean circulatory
filling pressure (MCFP) and established an experimental
approach to measure it [4]. He was then able to construct
venous return curves and analyze the factors that affect
them [3]. Finally, to my mind his most important legacy,
he provided a graphical tool that allows one to analyze
the complex interactions that occur between the function
of the heart (cardiac function) and the return of blood to
the heart (venous return function) [2,5,6]. These curves
provide a powerful conceptual tool for analyzing these
interactions and understanding the broad physiological
responses.
Importance of compliance
MCFP is the pressure in the vasculature when there is no
flow and it is determined by the volume that distends all
of the elastic structures in the circulation and the sum of
all their compliances. Guyton measured MCFP by arrest-
ing the circulation and using a pump to rapidly equili-
brate the arterial and venous pressures.
Vascular compliance is a static measurement; that is, it
is a characteristic of the system even when there is no
flowing blood. Yet this static property is a critical deter-
minant of the amount of blood that can flow around the
circulation. The reasoning is as follows. Flow occurs
based on a pressure gradient from the beginning to the
end of a circuit. In the cardiovascular system, pressure
and flow are pulsatile because of the cyclic nature of
cardiac contractions. If the walls of a closed loop system
are noncompliant (stiff), an increase in pressure at the
beginning of the circuit, such as occurs with a contracting
heart, would be immediately transmitted throughout the
system and there would be no gradient for a flow wave to
occur. A flow wave can occur only if some part of the
circuit transiently takes up volume and then releases it;
that is, the circuit must have a compliant region that
allows a change in volume for a change in pressure.
In the vasculature, all vessels have some compliance,
but the small veins and venules, especially those in the
splanchnic circulation, have a compliance that is 30 to 40
times greater than the compliance of other vessels.
Accordingly, approximately 70% of stressed blood volume
resides in the venules and veins at a pressure of around 8
to 10 mmHg. I must emphasize that I have referred to
‘the volume that stretches the vascular walls’, because not
all of the total blood volume acts to distend the elastic
walls of the circulation. Under basal conditions, only
about 30% of total blood volume actually stretches the
vessel walls and creates MCFP [7]. This volume is called
the stressed volume, whereas the volume that rounds out
the vessels but does not produce a pressure is called the
unstressed volume. Contraction of smooth muscles in
the walls of veins and venules by neuro-humeral
mechanisms can recruit unstressed volume into stressed
volume and increase MCFP [8,9] by shifting the vascular
volume–pressure curve to the left along the x axis.
Importantly, this critical hemodynamic reserve of
unstressed volume cannot be measured by any
monitoring device.
When there is blood flow in the circulation, blood
volume redistributes among all of the elastic compart-
ments of the circulation based on their compliances and
the resistances separating them, but the pressure in the
venous compliant region does not usually change very
much because its compliance is so large relative to other
compartments. However, this volume changes when left
heart function is poor and right heart function is
maintained for volume redistribution to the pulmonary
circuit [10]. Even though MCFP is the determinant of the
capacity of the system for flow, the primary determinant
of venous return under flow conditions is the pressure in
the systemic veins. To distinguish the pressure in the sys-
temic venous reservoir under flow conditions from the
static pressure of the vasculature when there is no flow
and complete equilibration of the pressures in all com-
partments, the pressure in systemic veins is called mean
systemic filling pressure (MSFP). This is usually very
close to, but not always the same as, MCFP.
An infusion of volume increases MSFP and thereby
increases the gradient for venous return. This increase
can also occur by recruitment of unstressed volume into
stressed volume by baroreceptor-induced activation of
sympathetic output or by the infusion of α-adrenergic
agonists [9,11-13]. This process is called a change in
capacitance, which refers to total pressure for total
volume. The slope of the relationship of the vascular
pressure–volume relationship is elastance, which is the
inverse of compliance. In the physiological range this
slope usually does not change. As already noted, the
reserve of unstressed volume cannot be measured in an
intact person and must be predicted from a patient’s
clinical status by considering factors that could have
resulted in volume loss and use of the body’s reserves in
unstressed volume. Furthermore, arterial pressure does
not determine MSFP because MSFP is determined by the
volume that flows into the veins relative to the volume
that leaves the veins. The upstream pressure needed for a
given flow is dependent upon the upstream resistance.
MSFP by itself does not determine flow. Flow depends
upon the difference between MSFP and right atrial
pressures, and the right atrial pressure is regulated by the
heart and – another key concept in Guyton’s analysis –
by the venous resistance. The pressure drop from the
compliant veins to the right heart is small but crucial
because this pressure drop is one of the major
determinants of the emptying of venous blood back to
Magder Critical Care 2012, 16:236
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Page 2 of 7
3. the heart. Although some have disputed the significance
of venous resistance [14,15] as a determinant of venous
return and cardiac output, we used a computational
model of the circulation to show that venous resistance
can indeed have very important effects and including it
can result in very different conclusions on outcome [16].
Our results were also consistent with Guyton’s observa-
tions from a study in dogs in which he produced the
equivalent of a marked decrease in left ventricular func-
tion [17]. These studies indicate the importance of
considering the effects of drugs on venous resistance.
Nitroglycerine and nitroprusside [18,19] as well as β-
adrenergic agonists can decrease venous resistance [20],
and these drugs will increase venous return with a
constant stressed volume. Venous resistance can be
increased by α-adrenergic agonists such as phenyl-
ephrine, which will decrease cardiac output. This explains
why phenylephrine can raise arterial pressure but does
not usually increase cardiac output [13].
In summary, Arthur Guyton identified four determi-
nants of venous return: stressed volume, venous compli-
ance, venous resistance, and right atrial pressure. He
graphically represented the return function by putting
right atrial pressure on the x axis, because right atrial
pressure is regulated by the function of the heart, and he
put venous flow, which in the steady state is equal to the
cardiac output, on the y axis (Figure 1). When venous
flow is zero, the right atrial pressure equals MSFP and,
depending upon how flow is stopped and how much time
is allowed for equilibrium of all compartments, it also
can equal MCFP. Lowering the right atrial pressure
allows venous blood to return to the heart. The lower the
right atrial pressure, the greater the venous return up to a
maximum flow. This limit to venous return occurs when
the pressure inside vessels entering the thorax is less than
the pressure outside, which limits but does not stop flow
because the vessels flutter between opening and closing
in what is called a vascular waterfall [21].
The axes of Guyton’s plot of venous return are the same
as the same axes of Starling’s cardiac function curve.
Cardiac and venous return functions can thus be plotted
on the same graph and their intersection gives the
solution for how these two functions determine cardiac
output (Figure 1). This plot identifies two limits to the
circulation. There is a plateau to the cardiac function
relationship. When the venous return curve intersects
this region of the cardiac function curve, giving more
volume will not increase cardiac output because the
volume simply shifts the venous curve to the right, which
increases right atrial pressure but does not appreciably
increase end-diastolic volume. On the left side of the
relationship, when the heart is functioning on the flat
part of the venous return curve, increasing cardiac
function – including increasing the heart rate – does not
Figure 1. Arthur Guyton’s graphical approach to the factors regulating cardiac output. Upper left: venous return curve. At zero flow (cardiac
output (Q)), the right atrial pressure (Pra) is equal to the mean circulatory filling pressure. (MCFP) The lower Pra, the greater Q up to a maximum (flat
line), in which case the flow is limited. Upper right: cardiac function curve (Starling curve). The greater Pra, the greater Q up to a plateau, in which
case flow is limited by cardiac function. Lower: Since both graphs have the same axes, they can be put together with the working cardiac output
and working Pra (or central venous pressure (CVP)) given by the intersection.
Magder Critical Care 2012, 16:236
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Page 3 of 7
4. increase cardiac output. Under this condition cardiac
output can only be increased by increasing the stressed
volume or decreasing venous resistance. This also brings
up a key implication of Guyton’s work. The heart can
never pump out more than it receives from the venous
reservoir, and the volume the heart receives is limited by
venous collapse. When collapse occurs it becomes
evident that circuit factors determine the maximum
possible cardiac output because any value of right atrial
pressure above the venous collapse pressure actually
decreases the return of blood to the heart.
Although it is not possible at the bedside to obtain fully
developed cardiac function–venous return curves, the
general concepts can still be very helpful for understand-
ing the physiological significance of changes in cardiac
output that occur with changes in right atrial pressure (or
central venous pressure (CVP), which is essentially
synonymous with right atrial pressure), as will be
discussed next.
Guyton’s graphical analysis of the interaction of venous
return and cardiac function makes it clear that a single
value of CVP cannot predict blood volume or cardiac
status. For example, low CVP is the norm in healthy
individuals. In the resting upright posture, CVP usually is
less than atmospheric pressure because of the negative
pressure in the thorax at functional residual capacity and
optimal cardiac function (Figure 2). On the contrary, a
low CVP can be seem in someone with loss of volume
and low cardiac output and normal or even impaired
cardiac function.
A Guyton-guided approach to the management of
shock and hemodynamic monitoring
A good place to begin is by considering the relationship
of pressure to flow as described by Poieseuille’s law,
which indicates that blood pressure is approximately
equal to the product of cardiac output and systemic
vascular resistance (Figure 3). This simple relationship
indicates that a low blood pressure must be explained by
a decrease in cardiac output or a decrease in systemic
vascular resistance. Since vascular resistance is
calculated, the variable one needs to know is cardiac
output. If blood pressure is low, and cardiac output is
normal or elevated, the primary reason for low blood
pressure is that the systemic vascular resistance is low. If
the cardiac output is decreased this can – based on
Guyton’s graphical analysis of the circulation – be due to
a decrease in cardiac function or a decrease in the venous
return function (Figure 4). Since the cardiac and venous
return functions intersect at the right atrial pressure, the
right atrial pressure/CVP helps to determine whether a
decrease in cardiac function or a decrease in return
function is the primary problem. If the CVP is high, the
problem is primarily decreased cardiac function – and
diagnostic and therapeutic interventions should be aimed
at explaining why cardiac function is reduced. If the CVP
is low (Figure 2), the primary problem is the venous
return – and providing more volume will probably solve
the problem.
The question then arising is what constitutes a high
CVP. The plateau of the cardiac function curve can occur
even at low values of CVP [22] (Figure 2) but, as a useful
guide, when CVP >10 mmHg (that is, when the reference
level is 5 cmH2
O below the sternal angle, or ~13 mmHg
relative to the mid-axillary line) the probability of an
increase in cardiac output in response to a fluid bolus is
low, unless there is high positive end-expiratory pressure,
longstanding pulmonary hypertension, or high intra-
abdominal pressure [22]. When one is not sure whether
volume might help, the solution is to give a fluid
challenge. Essential components of this challenge are that
sufficient fluid is given to raise the CVP by 2 mmHg or
more so that it is clear Starling’s law has been tested and
then whether or not there is an increase in cardiac output
is monitored. This is most easily done when cardiac
output is directly measured, in which case an increase in
cardiac index in the range of 0.3 l/minute/m2
can be
considered to indicate that the heart is volume responsive
and that the change is not just measurement variation. If
the triggers for giving volume are still not corrected,
boluses can be repeated until the triggers are corrected
or until there is no further increase in flow with the
volume despite an increase in CVP. If the CVP rises by
2 mmHg and the cardiac index does not change, however,
it is very unlikely that further volume infusions will help
and some other therapy is indicated. We successfully
Figure 2. Central venous pressure can be low with different
cardiac outputs. Venous return cardiac function curves indicating
three ways in which central venous pressure can be low with
different cardiac outputs. See text for more details. Q, cardiac output;
Pra, right atrial pressure.
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5. used an algorithm based on these principles to show that
a colloid solution for resuscitation following cardiac
surgery significantly reduced the need for catecholamines
the morning after surgery compared with a crystalloid
solution and with less fluid being given [23].
Measurements of CVP and cardiac output are most
useful when there has been a change in a patient’s clinical
status (Figure 3). Based on Guyton’s concepts, the direc-
tion of changes in cardiac output and CVP can be used to
indicate the dominant process that has occurred. I say
dominant because more than one process can happen at
the same time. For example, there can be a decrease in
cardiac function at the same time as there is a decrease in
venous return. The analysis again starts with what
happed to cardiac output. If blood pressure fell with a
rise or no change in cardiac output, the primary problem
is a decrease in systemic vascular resistance and,
although increasing cardiac output may help to some
extent, it may be necessary to pharmacologically increase
systemic vascular resistance with a drug such as nor-
epinephrine. If blood pressure fell with a fall in cardiac
output, then the primary problem is the fall in cardiac
output and the next question is whether cardiac output
fell because of a decrease in cardiac function or in the
return function. This is answered by examining the CVP.
If cardiac output fell and CVP fell too, the primary
problem is a decrease in the return function, which
usually means that volume is needed. If the cardiac
output fell with a rise in CVP, the primary problem was
probably a decrease in cardiac function and use of
inotropic drugs such as dobutamine, epinephrine or
milrinone is indicated.
The approach outlined above requires measurement of
cardiac output, or at least a surrogate, which limits its
utility. At the more basic level, clinical signs of adequate
cardiac output can often be sufficient and high CVP
values can even be identified in many patients by
examining jugular venous distension or inferior vena
cava diameter by echocardiography. If the patient has a
clear sensorium, warm extremities, and normal renal
function, cardiac output probably is adequate for tissue
needs. The next level of assessment involves obtaining
laboratory values that support adequate tissue perfusion
and cardiac output. These include blood lactate, normal
base excess – or even a negative base excess if it can be
explained by elevated chloride – or central venous
oxygen saturation. When normal, these values support
adequate tissue perfusion but do not rule out inadequate
tissue perfusion, especially a normal central venous
saturation; however, abnormal numbers almost always
indicate insufficient cardiac output for tissue needs. Until
recently, measurement of cardiac output required the use
of a pulmonary artery catheter, but there are now a
number of less invasive and even completely non-invasive
devices that can be used to at least analyze the dynamic
response to a fluid challenge or inotropic or vasoactive
drug [24,25]. This analysis should allow algorithms in the
future that have a physiological approach to hemo-
dynamic management and are based on Guyton’s analysis
of the circulation.
Inspiratory variations in central venous pressure
An example of ‘applied Guyton’ at the bedside comes
from the use of respiratory variations in CVP to predict
fluid responsiveness (Figure 5) [26]. During spontaneous
Figure 3. Approach to management of hypotension. Blood
pressure is determined by cardiac output (Q) and systemic vascular
resistance (SVR). If Q is normal, the primary reason for a low Q is a
decrease in SVR. If Q is decreased, this is the primary problem and Q
could be decreased because of a decrease in cardiac function or a
decrease in return function. These can be separated by examining
the central venous pressure (CVP). Potential therapies are also shown.
NE, norepinephrine. Pra, right atrial pressure.
Figure 4. Three ways in which central venous pressure can
increase with different cardiac output responses. See text for
more details. Q, cardiac output; Pra, right atrial pressure.
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6. inspiratory efforts, whether the person is breathing
unassisted or is intubated and mechanically ventilated,
the pleural pressure falls. Importantly, the hydrostatic
pressures measured with bedside transducers are made
relative to a reference level and a reference pressure
value. Since the transducers are surrounded by atmos-
pheric pressure, hemodynamic pressures are referenced
relative to atmospheric pressure and a level that is relative
to the mid-point of the right heart [27]. However, the
heart is not surrounded by atmospheric pressure, but
rather by pleural pressure, and the pressure that counts
for the preload of the heart is the pressure inside the
heart relative to the outside.
To use Guyton’s graphical approach during the respira-
tory cycle, the cardiac function curve must therefore
move relative to the venous return curve to account for
the changing surrounding pressure. During a negative
pleural pressure inspiration this means that the cardiac
function curve moves to the left of the venous return
curve. If the venous return curve intersects the ascending
part of the cardiac function curve, CVP falls during
inspiration relative to atmospheric pressure (Figure 5)
and output from the right heart transiently increases
because the heart is effectively lowered relative to the
venous reservoir, which allows more blood to come back
to the heart. However, if the venous return curve
intersects the plateau portion of the cardiac function
curve, CVP does not change during inspiration (Figure 5).
The absence of an inspiratory fall in CVP when there is a
fall in pleural pressure thus indicates that the patient’s
heart is functioning on the plateau of the cardiac function
curve and should not respond to fluids. In a prospective
trial we found that this was indeed the case [26].
There are some caveats to this approach. Pleural
pressure must fall sufficiently to know whether or not the
patient is on the flat part of the curve. If conscious, the
person can be asked to make a stronger effort to test this
situation. Second, the test is most useful in the negative
sense. That is, lack of an inspiratory fall in CVP indicates
that the patient is unlikely to respond, whereas the
presence of a fall does not indicate that the patient will
respond because it depends on how close the intersection
of venous return curve is to the plateau of the cardiac
function curve. Finally, it is important to rule out whether
the fall in CVP is actually due to the release of an active
expiration and use of abdominal muscles. This is
recognized by noting whether or not there is a rise in
CVP during expiration.
Effect of positive pressure
An implication of Guyton’s cardiac function–venous
return analysis is that the cardiac function curve is
shifted to the right with positive-pressure breathing. If
the venous return curve intersects the ascending part of
the cardiac function curve, cardiac output will fall and
the CVP will rise with the positive pleural pressure.
However, if the venous return curve intersects the flat
part of the cardiac function curve, there could be an
Figure 5. Inspiratory variations in central venous pressure predict response of cardiac output to a volume infusion. Patients who have an
inspiratory (insp.) fall in central venous pressure (CVP) (left side) can have an increase in cardiac output (Q) with a volume infusion, but not always
because it depends how close to the plateau of the cardiac function the venous return intersects. Patients who do not have an inspiratory fall in
CVP are unlikely to respond to a volume infusion because this indicates that the venous return curve is intersecting the flat part of the cardiac
function curve. Pra, right atrial pressure.
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7. increase in pleural pressure without a fall in cardiac
output. This would indicate that patients whose CVP falls
with a negative-pressure breath should always have a fall
in cardiac output when positive pleural pressure is
applied because they should be operating on the
ascending part of the cardiac function curve. On the
other hand, patients who do not have an inspiratory fall
in CVP may or may not have a fall in cardiac output
depending on how much the cardiac function curve is
shifted to the right of the venous return curve with the
increase in pleural pressure.
We tested these predictions in patients who had spon-
taneous inspiratory efforts and in whom positive end-
expiratory pressure was going to be increased [28]. The
test worked for the groups but had a low predictive value
in individual patients, most probably because the positive
pleural pressure triggered reflex adjustments that changed
the volume status by recruiting unstressed volume into
stressed volume. Furthermore, the magnitude of these
adjustments depends upon the reserves in vascular
capacitance [29,30]. In contrast, the variations during
single breaths that we used for volume responsiveness are
too short for there to be reflex adjustments.
Conclusion
Guyton provided a comprehensive analysis of the
interaction of cardiac function and the venous return
function. He showed that the cardiac output and CVP
values are determined by the intersection of these two
functions. Knowledge of these processes can help guide
clinicians in their resuscitative strategies for treatment of
hemodynamic instability. Guyton’s concepts help one
understand the limits of the cardiovascular system and
thus what is physiologically possible. The development of
newer devices for measuring cardiac output will make
direct application of these principles more feasible.
Abbreviations
CVP, central venous pressure; MCFP, mean circulatory filling pressure; MSFP,
mean systemic filling pressure.
Competing interests
The author declares that he has no competing interests.
Published: 29 October 2012
References
1. Rushmer RF, Smith OA, Jr: Cardiac control. Physiol Rev 1959, 39:41-68.
2. Guyton AC: Determination of cardiac output by equating venous return
curves with cardiac response curves. Physiol Rev 1955, 35:123-129.
3. Guyton AC, Lindsey AW, Bernathy B, Richardson T: Venous return at various
right atrial pressures and the normal venous return curve. Am J Physiol
1957, 189:609-615.
4. Guyton AC, Polizo D, Armstrong GG: Mean circulatory filling pressure
measured immediately after cessation of heart pumping. Am J Physiol
1954, 179:261-267.
5. Coleman TG, Manning RD, Jr, Norman RA, Jr, Guyton AC: Control of cardiac
output by regional blood flow distribution. Ann Biomed Eng 1974,
2:149-163.
6. Magder S: The classical Guyton view that mean systemic pressure, right
atrial pressure, and venous resistance govern venous return is/is not
correct. J Appl Physiol 2006, 101:1523-1525.
7. Magder S, De Varennes B: Clinical death and the measurement of stressed
vascular volume. Crit Care Med 1998, 26:1061-1104.
8. Rothe CF: Reflex control of veins and vascular capacitance. Physiol Rev 1983,
63:1281-1295.
9. Deschamps A, Magder S: Baroreflex control of regional capacitance and
blood flow distribution with or without alpha adrenergic blockade. J Appl
Physiol 1992, 263:H1755-H1763.
10. Magder S, Veerassamy S, Bates JH: A further analysis of why pulmonary
venous pressure rises after the onset of LV dysfunction. J Appl Physiol 2009,
106:81-90.
11. Thiele RH, Nemergut EC, Lynch C III: The physiologic implications of isolated
α1
adrenergic stimulation. Anesth Anal 2011, 113:284-296.
12. Thiele RH, Nemergut EC, Lynch C III: The clinical implications of isolated α1
adrenergic stimulation. Anesth Analg 2011, 113:297-304.
13. Magder S: Phenylephrine and tangible bias. Anesth Analg 2011,
113:211-213.
14. Brengelmann GL: Counterpoint: the classical Guyton view that mean
systemic pressure, right atrial pressure, and venous resistance govern
venous return is not correct. J Appl Physiol 2006, 101:1525-1526.
15. Brengelmann GL: A critical analysis of the view that right atrial pressure
determines venous return. J Appl Physiol 2003, 94:849-859.
16. Burkhoff D, Tyberg JV: Why does pulmonary venous pressure rise after
onset of left ventricular dysfunction: a theoretical analysis. Am J Physiol
1993, 265:H1819-H1828.
17. Lindsey AW, Guyton AC: Continuous recording of pulmonary blood
volume: pulmonary pressure and volume changes. Am J Physiol 1959,
197:959-962.
18. Pouleur H, Covell JW, Ross J, Jr: Effects of nitroprusside on venous return
and central blood volume in the absence and presence of acute heart
failure. Circulation 1980, 61:328-337.
19. Ogilvie RI: Effect of nitroglycerin on peripheral blood flow distribution and
venous return. J Pharmacol Exp Ther 1978, 207:372-380.
20. Green JF: Mechanism of action of isoproterenol on venous return. Am J
Physiol 1977, 232:H152-H156.
21. Permutt S, Riley S: Hemodynamics of collapsible vessels with tone: the
vascular waterfall. J Appl Physiol 1963, 18:924-932.
22. Magder S, Bafaqeeh F: The clinical role of central venous pressure
measurements. J Intensive Care Med 2007, 22:44-51.
23. Magder S, Potter BJ, Varennes BD, Doucette S, Fergusson D: Fluids after
cardiac surgery: a pilot study of the use of colloids versus crystalloids. Crit
Care Med 2010, 38:2117-2124.
24. de Waal EE, Wappler F, Buhre WF: Cardiac output monitoring. Curr Opin
Anaesthesiol 2009, 22:71-77.
25. Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, Pinsky MR,
Hofer CK, Teboul JL, de Boode WP, Scolletta S, Vieillard-Baron A, De Backer D,
Walley KR, Maggiorini M, Singer M: Clinical review: Update on
hemodynamic monitoring – a consensus of 16. Crit Care 2011, 15:229.
26. Magder SA, Georgiadis G, Cheong T: Respiratory variations in right atrial
pressure predict response to fluid challenge. J Crit Care 1992, 7:76-85.
27. Magder S: Central venous pressure: a useful but not so simple
measurement. Crit Care Med 2006, 34:2224-2227.
28. Magder S, Lagonidis D, Erice F: The use of respiratory variations in right
atrial pressure to predict the cardiac output response to PEEP. J Crit Care
2002, 16:108-114.
29. Nanas S, Magder S: Adaptations of the peripheral circulation to PEEP. Am
Rev Respir Dis 1992, 146:688-693.
30. Fessler HE, Brower RG, Wise RA, Permutt S: Effects of positive end-expiratory
pressure on the gradient for venous return. Am Rev Respir Dis 1992,
146:4-10.
doi:10.1186/cc11395
Cite this article as: Magder S: Bench-to-bedside review: An approach
to hemodynamic monitoring - Guyton at the bedside. Critical Care 2012,
16:236.
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