2011 Hemodynamics Page 1 of 13 RJ Barsotti, Ph.D.

Hemodynamics

Introduction
The cardiovascular system consists of a muscular pump, the heart that propels blood through a
complex network of branched blood vessels, delivering nutrients to and removing wastes from
each organ and transporting hormones and other messengers between various regions of the
body. Hemodynamics considers the physical forces involved in moving blood through the
circulation. In this section, we consider the forces that the heart must overcome to get this blood
supply where it is needed, and how the body uses these forces to redistribute the supply as local
demands change.

The heart pumps a given volume of blood into the aorta each minute (the cardiac output). The
percentage of the cardiac output that any given organ receives depends upon the resistance that
the organ offers to the flow of blood. Cardiac and vascular function is regulated on a beat to beat
basis by the interaction of the autonomic nervous system and local factors within tissues.

A fluid is a material that flows and that the shape of its containment vessel. It is a substance that
deforms easily when a shearing force is applied and does NOT return to its original form when
the force is removed like a solid would. Thus, in liquids, there are no elastic forces that restore
the original unstressed shape. We also know or should know that liquids are NOT easily
compressed. In addition liquids flow downhill in a gravitational field

Hemodynamics considers the physical forces involved in moving the blood through the
circulation. The cardiac pump adds energy to the circulation which we measure as pressure.
This pressure is dissipated through the circulatory system in overcoming the resistance to blood
flow offered by the blood itself and the blood vessels.

Pressure
Force in a liquid system is manifested as pressure. In the cardiovascular system, the effects of
pressure may be observed in two major ways: first, the pressure differences that moves blood
through blood vessels; and second, the pressure in a liquid at rest can distend arteries and veins.

Blood pressure is given in terms of the height of a liquid in a tube, i.e. in units of the height of a
liquid of known density. If we apply pressure to one side of a column of fluid in a U-shaped tube,
the fluid height in the other column will increase (see Figure 1a). The pressure we apply is
measured as the height of the column of fluid. Arterial pressure is usually expressed in
millimeters of mercury (mm Hg). Mercury was chosen for its relatively high density, making it
possible to measure arterial pressure using a relatively short tube. This is the same principle used
in a sphygmomanometer to measure blood pressure. However, usually pressure is expressed as
force per unit area, and the appropriate basic unit is dyne/cm
2
.






2011 Hemodynamics Page 2 of 13 RJ Barsotti, Ph.D.
Figure 1a Measurement of Pressure
P
1
Measured pressure is the height
of the column (P
2
-P
1
). If the fluid
column is mercury, pressure is mm Hg.
If the fluid column is water, pressure is
cm H
2
O.
P
2
Apply pressure





The pressure at a given depth in a liquid is equal in all directions, also known as Pascals
Principle . The shape of the vessel holding the liquid does not alter this. The pressure (P) below
the surface of the liquid increases with depth such that P = h g, where is the density of the
fluid (g/cm
3
), g is gravitational acceleration (980 cm/sec
2
), and h is the height of the fluid column
(cm). This hydrostatic pressure is caused by the force of gravity on the fluid (see Figure 1b).
Thus when a person is standing, blood pressure is greater in the vessels of the legs than in the
analogous vessels of the arms because hydrostatic pressure is added to the hemodynamic
pressure (the pressure generated by the contraction of the heart and stored in the elastic
walls of the blood vessels).

Figure 1b Gravity acts on columns of fluid such that pressures increases with depth

P
1
P
2
P
2
P
1
P
3
P
2
P
3
Pressures in the same
horizontal plane are equal
Pressures increase with
depth or the height of the
column




2011 Hemodynamics Page 3 of 13 RJ Barsotti, Ph.D.
Gravity also acts on columns of blood within the cardiovascular system. In the individual lying
down, the mean pressure in the root of the aorta might be 100 mm Hg. Mean pressure in a large
artery in the foot might be 95 mm Hg because the large vessels offer little resistance to the flow
of blood. Similarly the average pressure within a large artery in the head might also be 95 mm
Hg.

When the
individual stands,
the pressure at
the root of the
aorta will still be
100 mm Hg
because the
measurement is
close to the
source of the
pressure, the left
ventricle.
However, above
the level of the
heart, e.g. at the
cerebral artery,
gravity acts on
the column of
blood to decrease
the blood
pressure in the
cerebral artery by minus gh
1
. Pressure in the cerebral artery might now be approximately 50
mm Hg. Conversely, below the level of the heart, gravity acts on the column of blood to increase
the blood pressure by plus gh
2
. Pressure in a large artery in the foot might be approximately
180 mm Hg. Arteries and veins are elastic. Under the increased transmural pressure they
dilate. This elasticity, especially in the pulmonary artery, serves as a damper in which much of
the blood ejected by the heart in taken by the increased volume of the artery. Thus blood flow
through the lung capillaries is less pulsatile.

Fluid filtration from the capillary (described in detail in later lectures) into the interstitial space
will also increase as the capillary pressure increases. Thus, in the standing individual blood and
extracellular fluid pools in the dependent limbs. This will decrease the amount of blood
returning to the heart (the venous return). This, in turn, will decrease the amount of blood
pumped by the heart (the cardiac output). The perfusion pressure of blood to the brain will be
reduced as the cardiac output is reduced. Cerebral blood flow will decline. If the situation
persists and cerebral blood flow becomes inadequate, you will lose consciousness. Obviously
there are mechanisms to maintain venous return, cardiac output, and cerebral blood flow, and you
will hear about these in subsequent lectures.



2011 Hemodynamics Page 4 of 13 RJ Barsotti, Ph.D.
To understand the relationship between blood pressure, blood flow and the resistance to blood
flow, we need to first consider the pressure relationships within the blood vessel. Within the
vessel here is an intraluminal pressure tending to distend the vessel in all directions. The
pressure in the space outside the vessel is the extraluminal pressure tending to collapse the
vessel. The pressure gradient (A P) is the pressure difference across the vessel wall, i.e. the
pressure inside (P
i
) minus the pressure outside (P
o
). This is the transmural pressure.


Transmural Pressure or AP
tm
= (P
i
P
o
)

















Compliance
The degree to which an elastic vessel dilates when its filled with fluid is determined by the
transmural pressure and its compliance (C)

C = AV / AP
tm


where AV is the change in volume and AP
tm
is the change in transmural pressure. The more
compliant the vessel, the greater the change in its volume for a given change in transmural
pressure. The less compliant or stiffer a vessel, as occurs with aging, the greater the change in
transmural pressure for a given change in volume.

Law of Laplace
In a hollow cylinder the tension in the wall (T) equals the product of the pressure across the wall
(P) and the radius (r):
T ~ P r

This relationship was derived by Bernoulli, but is usually known as Laplace's law. It tells us that,
for a given pressure, the tension in the wall increases in direct proportion to radius. For the wall
to withstand the tension, the thickness must be appropriate. This is the reason a large artery must
have a thicker wall than a small artery.
Intraluminal
Pressure (P
i
)
Extraluminal
pressure (P
o
)
2011 Hemodynamics Page 5 of 13 RJ Barsotti, Ph.D.
A vein, which withstands much lower blood pressure, has a thinner wall. Again, a smaller vein
can withstand the venous pressure with a thinner wall than a larger vein. A capillary has a higher
blood pressure than the veins, but nevertheless, because of its very small radius, a wall consisting
of a single layer of cells has sufficient strength. Thus, the radius of the capillary, which is a
prerequisite for a capillary wall thin enough to permit rapid exchange of material between the
blood and the tissues.

Interrelationship among pressure, flow, and resistance
Blood moves within the cardiovascular system from regions of higher energy or pressure to
regions of lower energy or pressure. Pressure is high at the ventricular exits, e.g. at the aorta and
is low as the blood returns to the atria.

Blood flow through a blood vessel is determined by two factors: (1) pressure difference of the
blood between the two ends of the vessel, also sometimes called "pressure gradient" along the
vessel, which is the force that pushes the blood through the vessel, and (2) the impediment to
blood flow through the vessel, which is called vascular resistance. The figure below
demonstrates these relationships, showing a blood vessel segment located anywhere in the
circulatory system:









P
1
represents the pressure at the origin of the vessel; at the other end, the pressure is P
2
.
Resistance occurs as a result of friction between the flowing blood and the intravascular
endothelium all along the inside of the vessel. The flow through the vessel can be calculated by
the following formula, which is analogous to Ohm's Law (V=IR):

F = AP/ R

in which F is blood flow, P is the pressure difference (P
1
- P
2
) between the two ends of the
vessel, and R is the resistance. This formula states, in effect, that the blood flow is directly
proportional to the pressure difference but inversely proportional to the resistance.

Note that it is the difference in pressure between the two ends of the vessel, NOT the absolute
pressure in the vessel that determines rate of flow. For example, if the pressure at both ends of a
vessel is 100 mm Hg and yet no difference exists between the two ends, there will be no flow
despite the presence of 100 mm Hg pressure.

The equation expresses the most important of all the relations you need to understand to
comprehend the hemodynamics of the circulation. Because of the extreme importance of this
formula, you should also become familiar with its other algebraic forms:
2011 Hemodynamics Page 6 of 13 RJ Barsotti, Ph.D.

AP = F x R

R = AP / F


Pressure declines as the blood moves through the arteries, arterioles, capillaries and veins due to
resistance to flow offered by the vascular structures and blood viscosity. The major sites of
resistance in the vascular system are the arterioles.

Blood leaves the heart via the aorta, which has an internal diameter of about an inch (2.5 cm). It
is then distributed throughout the body by arteries with diameters of around 0.4 cm. On arriving
to the tissues, these arteries branch into smaller arterioles (<100 um diameter) which distribute
oxygenated blood to capillaries. Capillaries are the major site of gas and nutrient exchange
within tissues and although only 4 - 10 m in diameter, the body contains miles of them. After
exchanging O
2
, nutrients, CO
2
and metabolic waste products, blood leaves via venules (about 40
um diameter) and is carried back to the heart through the larger veins and the vena cava (3 cm).
Thus, there are significant changes in the size and length of the vessels as blood is carried away
from the heart, both of which have major effects on flow rates.
The velocity (v) of blood flow is defined as the distance that it moves in a given period of time
(i.e. cm/sec or cm/min). We define blood flow (F) as the volume moved in a given time (i.e.
ml/sec or L/min). Flow and velocity are related by the following:

F = v x A

where v is the velocity or speed of the blood passing through a vessel and A is the cross-sectional
area of the vessel through which the blood flows, calculated from t r
2
; where r is the vessel
radius.

The circulation is a closed system. This means that the total volume of blood contained within
the heart and vasculature cannot change as it moves through the various classes of vessel. This
presents a problem when you consider that blood has to travel through progressively narrower
vessels as it moves away from the heart, because if the heart is pumping out blood at e.g. 10
ml/sec, the velocity has to increase markedly to maintain constant flow, i.e., if 10ml are to
squeeze through vessels as small as arterioles or capillaries to maintain constant flow. This is
demonstrated in the Figure which shows that as the cross-sectional area of the vessel drops from
10 cm
2
to 2 cm
2
, the velocity has to increase five-fold (from 1 to 5 cm/sec) to maintain the flow.
A further two-fold decrease in area causes a corresponding doubling (from 5 to 10 cm/sec) in
velocity.






2011 Hemodynamics Page 7 of 13 RJ Barsotti, Ph.D.
Summarizing:
F
a
= F
b
= F
c
or v
a
A
a
= v
b
A
b
= v
c
A
c
a b c
Flow (ml/sec) 10 10 10
Area (cm
2
) 10 2 1
Velocity (cm/sec) 1 5 10




The body solves this problem by having a branched network of blood vessels in which the
characteristic branching pattern is that the total cross-sectional area of the branches is larger than
that of the parent truck. This means that the total cross-sectional area of the cardiovascular
system increases as the
aorta branches to arteries,
arterioles and capillaries.
Correspondingly, the
average blood flow
velocity in the small
vessels is less than in large
arteries or veins. The
adjacent figure illustrates
the relationships among
blood pressure, velocity
and cross-sectional area of
the blood vessels of the
systemic circulation. The
important features are
the inverse relationship
between velocity and
cross-sectional area, the
major pressure drop
across small arteries
(SA) and arterioles
(ART), and both the maximal cross-sectional area and minimal flow velocity in the
capillaries (CAP).

2011 Hemodynamics Page 8 of 13 RJ Barsotti, Ph.D.
Poiseuille's Law
We need to examine the principles that govern blood flow in more detail. These are nicely
summarized by Poiseuille's Law that describes the relationship between pressure, resistance and
fluid flow through rigid tubes:
F = AP t r
4

8Lq

where F again represents blood flow, AP the pressure gradient across the vessel, r vessel radius,
L vessel length, and q (the Greek letter eta) the viscosity of blood.

Thus flow or resistance (R = AP/F or 8Lq/tr
4
) can be altered by changing vessel geometry L or
r or blood viscosity q. Blood viscosity can be altered by changing hematocrit or temperature.
Increases in hematocrit and decreases in temperature increase the viscosity of the blood and the
resistance to blood flow. Changes in vessel length are not very important in determining
resistance to flow. Changes in radius are the major mechanism for regulating blood flow!
Vessel radius can be altered by active or passive changes in wall tension. Note that a small
change in vessel radius produces a substantial change in flow. Raising radius to the 4
th
power means that a doubling of radius produces a 16-fold increase in flow.

In future lectures, we will discuss this in more detail, but a close examination of the
microcirculation reveals that the arterioles have a thick coat of smooth muscle. When these
muscles contract, in response to local or neural factors, they cause the arterioles to narrow and
flow to the capillaries is reduced greatly. Conversely, relaxation of these muscles causes the
arterioles to dilate, thereby allowing increased blood flow to the capillaries.

The more viscous a fluid, the greater its resistance to flow. Viscosity is usually measured in
poise (after Poiseuille, or dyne sec/cm
2
). Water has a viscosity of 0.01 poise (one centipoise or
1cp), and this provides an easy standard against which other fluids are measured: relative
viscosity. Blood is a complex fluid, and the presence of plasma proteins alone increases its
viscosity by about 20% over that of water. Blood also contains cells, causing relative viscosity to
increase steeply with hematocrit (the concentration of red cells in blood). The relative viscosity
of blood is 3.5 to 5.5.

There are several conditions that increase blood viscosity and make the heart work harder. For
example:
- Life at high altitudes increases the hematocrit to compensate for the reduced
availability of oxygen,
- Polycythemia vera is a disease that causes overproduction of red blood cells, thereby
increasing hematocrit and blood viscosity,
- Sickle-Cell Anemia reduces the pliability of red blood cells and makes them harder to
push through smaller vessels. This also increases its apparent viscosity.





2011 Hemodynamics Page 9 of 13 RJ Barsotti, Ph.D.

Series and Parallel Resistances
The resistance of a system of tubes
arranged in series will be the total of the
individual resistances. The addition of
another resistor in series will always
increase the total network resistance.
Thus the combined resistance of vascular
beds that are plumbed in series is equal to
the sum of these resistances:

R
total
= R
1
+ R
2
+ R
3
+

if the resistances of each component were equal R
1
= R
2
= R
3
then: R
total
= 3R
The addition of another component will increase R
total
to 4R

In contrast, the resistance of a system of tubes arranged in parallel will be proportional to the
reciprocal of the resistances. The addition of another component in parallel will always
decrease the total network resistance. In a parallel system, the total resistance is less than
that of the individual components. The combined resistance of vascular beds that are plumbed
in parallel is calculated as:

1 = 1 + 1 + 1 +
R
total
R
1
R
2
R
3


if the resistances were equal R
1
= R
2
= R
3
then: 1/R
total
= 3/R or R
total
= R/3
The addition of another component will decrease R
total
to R/4

When dealing with parallel vascular arrangements it is more convenient to use conductance
which is the reciprocal of resistance or C = 1/ R. So the above equation becomes

C
total
= C
1
+ C
2
+ C
3
+

or the total conductance is the sum of the individual conductances. So, the addition of another
conduit increases flow and decreases resistance! This accounts in part for the lower resistance
through the set capillaries than through the set of arterioles in the systemic circulation, despite
the smaller caliber of the individual capillaries than of the individual arterioles. The number of
parallel capillaries far exceeds the number of parallel arterioles (the cross-sectional area of
capillaries bed is much greater than of the arteriole bed). The much greater number of systemic
capillaries than of systemic arterioles accounts for the lower resistance to flow through the
capillaries than the arterioles.






2011 Hemodynamics Page 10 of 13 RJ Barsotti, Ph.D.

Total Peripheral Resistance
The sum of all the vascular resistances that lie between the aorta and the vena cava is referred to
as systemic vascular resistance (SVR) or total peripheral resistance (TPR).

How do we calculate SVR or TPR?
We know that flow F = AP / R
F is this case is better known as cardiac output or CO - about 5 L/min in an average resting
person. AP is the pressure gradient that drives flow - the difference between aortic pressure and
pressure in the right atrium - about 5 mm Hg). Aortic pressure fluctuates greatly between systole
and diastole, so a better and more common measure is Mean Arterial Pressure or MAP - about
95 mm Hg in a normal person. Thus,

TPR = MAP - CVP = 95mmHg 5mmHg = 18 mm Hg/L/min
CO 5 L/min
A digression on arterial blood pressures: the aortic pressure curve shown below defines
systolic and diastolic blood
pressures. The difference between
the two is known as pulse pressure.
Pulse pressure is largely determined
by heart stroke volume and by the
compliance of the arterial tree.
Thus, as the arteries harden with age (for example), the heart has to generate increased
pressures to ensure that the required stroke volume is ejected into the vasculature. From the
aortic pressure trace over time, the shape of the pressure trace yields a mean arterial pressure
value MAP that is less than the arithmetic average of the systolic and diastolic pressures as
shown above. At normal resting heart rates, MAP can be approximated from the diastolic
blood pressure (P
dias
) plus one third of pulse pressure (P
sys
- P
dias
) or
MAP = P
dias
+ (P
sys
- P
dias
)
3

MAP = 85mmHg + (115mmHg 85mmHg) = 95 mm Hg
3mmHg

Viscosity, laminar flow, turbulent flow, and noise
When a fluid such as water or blood moves through a tube, it experiences drag caused by friction
between the fluid and the walls of the tube. This causes a layer of slower-moving fluid to form
against the wall of the tube, which in turn exerts drag on the fluid closer to the center. This
causes another slowed layer to form which exerts its own drag - and so on toward the center of
the tube. The net result is that fluid movement in tubes occurs in concentric layers, with fastest
flow at the center and slowest flow up against the walls of the tube. This is referred to as laminar
or streamline flow. Fluid with viscosity independent of tube size or velocity of flow is said to be
"Newtonian." Blood is a non-Newtonian fluid and shows anomalous viscosity. In small tubes
(< 0.3 mm in diameter) the viscosity of blood decreases.
2011 Hemodynamics Page 11 of 13 RJ Barsotti, Ph.D.

Laminar flow (B in
adjacent Figure) is
actually very efficient
and obeys Poiseuilles
law for as long as it is
maintained. As blood
velocity increases,
however, this flow
pattern becomes
increasingly unstable
and can become
turbulent (C in
adjacent Figure). This
might occur when blood
is forced through a constriction for example, because velocity has to increase to maintain flow (F
= v A).

Turbulent flow is less efficient than laminar flow because it contains cross-currents and eddies
and the fluid particles move from one region of the tube to another in an irregular fashion. This
means that a correspondingly greater pressure gradient is required to push turbulent blood
through a vessel, and it no longer conforms to Poiseuilles law.

The transition from laminar to turbulent flow is determined by several factors in addition to
velocity. These are combined into the non-dimensional Reynolds number (N
R
):

N
R
= v d
q

where v is mean velocity, d is vessel diameter, (rho) is blood density and q is viscosity. Thus,
turbulence is more likely where flow velocities are high and vessel diameter is large, or when
blood viscosity drops or density increases significantly. Generally, flow becomes turbulent when
N
R
exceeds 2000. Consider the Reynolds number as a threshold. Values greater than 2000
indicate that flow is turbulent.

Turbulent flow is fairly uncommon in a healthy cardiovascular system. Usually, it only occurs
where blood is being forced at high velocity into large-diameter vessels, such as from the left
ventricle into the aorta. There are three examples where this turbulence is noteworthy, however.
When blood flow becomes turbulent, it sets up vibrations in walls of the vessel. These vibrations
travel to the body surface where they can be detected as murmurs using a stethoscope:
- Congenital and pathological changes in the heart valves may prevent them from
opening normally. The heart responds by pumping at increased pressure to maintain
adequate flow to the body, causing blood to be forced at high velocity through the
restricted opening. The resultant turbulence generates characteristic murmurs that are
useful in diagnosing the condition.
A, Two fluids (one dyed red, and the other clear) before flow begins; B,
the same fluids 1 second after flow begins; C, turbulent flow, with
elements of the fluid moving in a disorderly pattern.
2011 Hemodynamics Page 12 of 13 RJ Barsotti, Ph.D.
- Pregnancy causes a substantial increase in blood volume and cardiac output to
support the developing fetus. Red blood cell production lags behind this increase,
however, causing the hematocrit to fall. This, together with an increase in blood
velocity associated with increased cardiac output, causes the mothers (healthy) heart
to generate murmurs, even without a structural change in the heart.
- Partial occlusion of the brachial artery with a pressure cuff causes murmurs that
reflect blood spurting at high velocity through the constriction. These murmurs
(Korotkoff sounds) can be heard with a stethoscope placed downstream of the cuff,
providing a convenient way of approximating systolic and diastolic blood pressures.


Note especially that another of the important factors in Poiseuille's equation is the viscosity of the
blood. The greater the viscosity, the less the flow in a vessel if all other factors are constant.
Furthermore, the viscosity of normal blood is about three times as great as the viscosity of
water. But what makes the blood so viscous? It is mainly the large numbers of suspended red
cells in the blood, each of which exerts frictional drag against adjacent cells and against the wall
of the blood vessel. The percentage of the blood that is cells is called the hematocrit. Thus, if a
person has a hematocrit of 40, this means that 40 per cent of the blood volume is cells and the
remainder is plasma. The hematocrit of men averages about 42, while that of women averages
about 38. These values vary tremendously, depending on whether the person has anemia, on the
degree of bodily activity, and on the altitude at which the person resides.


The viscosity of blood increases
drastically as the hematocrit
increases, as shown in the Figure.
below. The viscosity of whole
blood at normal hematocrit is about
3; this means that three times as
much pressure is required to force
whole blood as to force water
through the same blood vessel.
When the hematocrit rises to 60 or
70, which it often does in
polycythemia, the blood viscosity
can become as great as 10 times
that of water, and its flow through
blood vessels is greatly retarded.









2011 Hemodynamics Page 13 of 13 RJ Barsotti, Ph.D.



Effects of Pressure on Vascular Resistance and Tissue Blood Flow

From the discussion thus far, one
might expect an increase in arterial
pressure to cause a proportionate
increase in blood flow through the
various tissues of the body.
However, the effect of pressure on
blood flow is greater than one
would expect, as shown by the
upward curving lines in the Figure.
The reason for this is that an
increase in arterial pressure not
only increases the force that pushes
blood through the vessels but also
distends the vessels at the same
time, which decreases vascular resistance. Thus, greater pressure increases the flow in both of
these ways. Therefore, for most tissues, blood flow at 100 mm Hg arterial pressure is usually four
to six times as great as blood flow at 50 mm Hg instead of two times as would be true if there
were no effect of increasing pressure to increase vascular diameter.


Note also in the Figure that the large changes in blood flow that can be caused by either increased
or decreased sympathetic nerve stimulation of the peripheral blood vessels. Thus, as shown in the
figure, inhibition of sympathetic activity greatly dilates the vessels and can increase the blood
flow twofold or more. Conversely, very strong sympathetic stimulation can constrict the vessels
so much that blood flow occasionally decreases to as low as zero for a few seconds despite high
arterial pressure.