• •2 basic types: üNervous regulation üHumoral regulation üFeedback control - negative ü - positive ü • autoregulation – local regulation – system regulation •Main function: • • keep relatively constantaneous arterial blood pressure •Keep perfusion of tissues • •Tone of the vessels = basic tension of the smooth muscle inside of the wall • (vasoconstriction x vasodilatation) • •Regulation - local autoregulation • - system regulation •Autoregulation – the capacity of tissues to regulate their own blood flow •Myogenic theory – Bayliss phenomenon (as the pressure rises, the blood vessels are distended and the vascular smooth muscle fibres that surround the vessels contract; the wall tension is proportional to the distending pressure times the radius of the vessels – law of Laplace) • •Metabolic theory – vasodilator substances tend to accumulate in active tissue, and these metabolites also contribute to autoregulation –ending products of energetic metabolism – CO2, lactate acid, K+ –effect of hypoxia (circulation: vasodilatation x pulmonary circulation: vasoconstriction) –Adenosin – coronary circulation: vasodilatation • •by substances which releasing from: – endothelium – tissues • •Substances secreted by the ENDOTHELIUM •Vasodilatation: •Nitric oxide (NO) from endothelial cells •(originally called: EDRF) •Prostacyclin is produced by endothelial cells • •Thromboxane A2 promotes platelet aggregation •(important prostacyclin – thromboxan balance) •Vazoconstriction: • Endothelins (polypeptids – 21peptides) • three isopeptides: ET 1, ET 2 , ET 3 •Substances secreted by the tissues: •Histamine – primarily tissue hormones. •General affect: vasodilatation - decrease periphery resistence, blood pressure • •KININS: 2 related vasodilated peptides •Bradykinin + lysylbradykinin (kallidin). •Sweat glands, salivary glands •10x strongers than histamine •Relaxation of smooth muscle, decrease blood pressure • • •By hormones •Catecholamines – epinephrine, norepinephrine - effect as activation of sympathetic system •RAAS - stress situation •ADH - general vasoconstriction •Natriuretic hormones - vasodilatation •Autonomic nervous system •Sympathetic: vasoconstriction •All blood vessels except capillaries and venules contain smooth muscle and receive motor nerve fibers from sympathetic division of ANS (noradrenergic fibers) -Regulation of tissue blood flow -Regulation of blood pressure •Parasympathetic part: vasodilatation •Only sacral parasympathetic cholinergic fibres (Ach) inervated arteriols from external sex organs • •The regulation of the heart: –Rami cardiaci n. vagi •Cardiac decelerator center - medula oblongata (ncl.dorsalis, ncl. ambiguus) – parasympathetic fibres of nervus vagus • : vagal tone (tonic vagal discharge) • •Negative chronotropic effect (on heart rate) •Negative inotropic effect (on contractility) •Negative dromotropic effect (on conductive tissue) • •The regulation of the heart: – nn. cardiaci •Cardiac accelerator center – spinal cord, sympathetic ganglia – sympathetic NS • •Positive chronotropic effect (on heart rate) •Positive inotropic effect (on contractility) •Positive dromotropic effect (on conductive tissue) • • •Vasomotor centre (regulation for function of vessels) •Medula oblongata ü presoric area (rostral and lateral part –vasoconstriction – increase blood pressure ü üdepresoric area (medio-caudalis part – vasodilatation, decrease of blood pressure) • • • •Influence by central nervous system – cerebral cortex – limbic cortex – hypothalamus •Blood pressure (BP) – pressure of the blood to the wall of the vessels • •Systolic BP, diastolic BP, pulse pressure, mean arterial pressure (MAP) • •BP = CO x R CO – cardiac output, R – resistance • •CO = SV x HR SV – stroke volume, HR – heart rate • Classification BP values according to office BP category Systolic BP Diastolic BP (mmHg) (mmHg) optimal < 120 < 80 normal 120 – 129 80 – 84 high normal pressure 130 – 139 85 – 89 Hypertension – mild – grade 1 140 – 159 90 – 99 Hypertension – moderate-grade 2 160 – 179 100 – 109 Hypertension – severe – grade 3 ≥ 180 ≥ 110 Isolated systolic hypertension ≥ 140 < 90 According the Guidelines of ESC/ESH 2018 •Definitions of hypertension according to •office, ambulatory, and home blood pressure levels •Category SBP(mmHg) DBP(mmHg) •Office BPa >_140 and/or >_90 •Ambulatory BP • Daytime (or awake) mean >_135 and/or >_85 • Night-time (or asleep) mean >_120 and/or >_70 • 24 h mean >_130 and/or >_80 •Home BP mean >_135 and/or >_85 • •BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood •pressure. •aRefers to conventional office BP rather than unattended office BP. BLOOD PRESSURE MEASUREMENT •Direct invasive method –1726 Stephan Hales – horse –Today – during catetrisation – •Indirect non-invasive measurement -palpation method -Auscultation method -Oscilometric method – – – C:\Documents and Settings\ja2\Dokumenty\DEMONSTRACE\krevní tlak u koně001.jpg • •An Austrian physician •Von Basch • „aneroid sfygmomanometr“ •Balloon in the wrist •1876 • • • • •Italian physician •Riva Rocci •„mercury sfygmomanometr“ •The cuff on the arm •1896 •Palpatory methods •Auskultatory method • • • •A Russian army surgeon •Nikolai Korotkoff •1904 • •„mercury sfygmomanometr“ •The cuff on the arm •Stethoscope at the elbow 03 •Špinar, J. a kol. Propedeutika a vyšetřovací metody vnitřních nemocí, 2008 The size of the cuff in adults •Small adult • • •Adult • • •Large • •Tight cuff Ambulatory blood pressure monitoring •Circadial rhythm – fluctuation during 24 h •The highest values – the morning, 6 –10 a.m. - the afternoon, 4 – 6 p.m. •The lowest values – 3 – 4 a.m. • •Diurnal rhythm – differences between day – night •Dippers - nondippers • C:\Documents and Settings\ja2\Dokumenty\DEMONSTRACE\ABPM 3004.jpg •Record during 24 h or 48h or 7 days • •Dif.dg. : white coat hypertension •Control of treatment of hypertension • •Evaluation: •Mean values during 24 h: less than 125/80 •Mean values during day period:less than 135/85 •Mean values during night period:less than 120/70 •Hypertension: –More than 40% values above 140/90 at day, 120/80 at night Regulation of blood pressure Short - term regulation - baroreflex Middle - term regulation - humorals regulation • sympathetic - catecholamines • RAAS • ADH Long – term regulation - kidney regulation Short term regulation BAROREFLEX msoDBE03 Stanovení citlivosti baroreflexu Valsalvův manévr Ganong WF, 2005 Noninvasive continuously beat-to-beat measurement of finger arterial pressure •Prof. Jan Peňáz, MD, PhD • •Teacher and researcher on the Department of Physiology, Masaryk university, Brno • •Patent 1969 Finapres (Ohmeda, USA) IMG_0869 P2290051 Finometr (FMS, Nizozemí) •We need than pressure in the cuff corresponded to the pressure of the digital artery •Method: photopletysmography •Recorded photoelectric plethysmogram •The new term: Transmural pressure – Pt (the pressure across the wall of the artery) •BP, Pc (pressure in cuff), Pt •We estimated: BP=Pc - - - Pt=0 - - - photoplethysmogram registered the highest amplitude of oscilation --- we measure the MAP •Step by step increase of Pc, in the moment of the highest amplitude – feed-back loop started for obtained(keeping) the constant volume of the finger Records of circulatory parameters obr11 parasympathicus Classification BP values according to office BP category Systolic BP Diastolic BP (mmHg) (mmHg) optimal < 120 < 80 normal 120 – 129 80 – 84 high normal pressure 130 – 139 85 – 89 Hypertension - mild 140 – 159 90 – 99 Hypertension - moderate 160 – 179 100 – 109 Hypertension - severe ≥ 180 ≥ 110 Isolated systolic hypertension ≥ 140 < 90 According the Guidelines of ESC/ESH 2018 •Definitions of hypertension according to •office, ambulatory, and home blood pressure levels •Category SBP(mmHg) DBP(mmHg) •Office BPa >_140 and/or >_90 •Ambulatory BP • Daytime (or awake) mean >_135 and/or >_85 • Night-time (or asleep) mean >_120 and/or >_70 • 24 h mean >_130 and/or >_80 •Home BP mean >_135 and/or >_85 • •BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood •pressure. •aRefers to conventional office BP rather than unattended office BP. grafy001 Zdravotní a očkovací průkaz dítěte a mladistvého, 2011 Krevní tlak •bezprostředně po narození je vysoký: –poporodní stres – vyplavení katecholaminů a kortizolu •po 1.dnu se ustálí 70/50 mmHg: –otevření pulmonálního a intestinálního řečiště •další mírný vzestup až k hodnotám pro dospělé • v období puberty: –postupné dozrávání regulačních mechanismů –stimulace z vnějšího prostředí E7C22FD0 Estimation of baroreflex sensitivity Invasive methods Furlan R et al. Circulation 2003;108:717-723 Estimation of baroreflex sensitivity non – invasive technique – neck suction Kontinuální neinvazivní měření tep po tepu - Peňázova metoda •Profesor MUDr. Jan Peňáz, CSc. •Fyziologický ústav LF MU •Čs. patent z roku 1969 P2290047 msoDBE03 Stanovení citlivosti baroreflexu Valsalvův manévr Ganong WF, 2005 První spektrální analýza krevního tlaku u člověka msoD4C5E mso2BF36 Prolongation of RR intervals in ms due to changes of systolic blood pressure about 1 mmHg Physiology values: 6 – 16 ms/mmHg Sensitivity of baroreflex Variabilita v krevním oběhu a BRS – ukazatelé rizika srdeční smrti po infarktu myokardu mso40FAC mso25496 mso7AE0C 40 Zadání – u bodu 1 znamená odvozeného že vycházet nejen z analyzovaných dat, ale také z charakteristik jednotlivých veličin … • •zavedení stanovení BRS u hypertenzních pacientů (BRS nižší než 5 ms/mmHg) • •využití pro studium časných či pozdních změn účinků léčby kardiotoxicky a neurotoxicky působícími antracykliny u onkologicky nemocných • •předurčení rizika změn autonomního nervstva s dopadem na hladiny krevního tlaku u nemocných • s diabetes mellitus • Víteček a Růženka 0001538.jpg Děkujeme za pozornost