Vasomotor center

Glonidine. Clonidine decreases blood pressure, heart rate, cardiac output, stroke volume, and total peripheral resistance. It activates central a2 adrenoceptors ia the brainstem vasomotor center and produces a prolonged hypotensive response. Clonidine, most efficaciously used concomitantly with a diuretic in long-term treatment, decreases renin and aldosterone secretion. 

Figure 15.4 Effects of the autonomic nervous system on mean arterial pressure. The baroreceptors, chemoreceptors, and low-pressure receptors provide neural input to the vasomotor center in the brainstem. The vasomotor center integrates this input and determines the degree of discharge by the sympathetic and parasympathetic nervous systems to the cardiovascular system. Cardiac output and total peripheral resistance are adjusted so as to maintain mean arterial pressure within the normal range.

Vasomotor center. Autonomic nervous activity to the cardiovascular system is regulated by the vasomotor center (see Figure 15.4). Located in the lower pons and the medulla of the brainstem, the vasomotor center is an integrating center for blood pressure regulation. It receives several sources of input, processes this information, and then adjusts sympathetic and parasympathetic discharge to the heart and blood vessels accordingly. 

Because baroreceptors respond to stretch or distension of the blood vessel walls, they are also referred to as stretch receptors. A change in blood pressure will elicit the baroreceptor reflex, which involves negative feedback responses that return blood pressure to normal (see Figure 15.6). For example, an increase in blood pressure causes distension of the aorta and carotid arteries, thus stimulating the baroreceptors. As a result, the number of afferent nerve impulses transmitted to the vasomotor center increases. The vasomotor center processes this information and adjusts the activity of the autonomic nervous system accordingly. Sympathetic stimulation of vascular smooth muscle and the heart is decreased and parasympathetic stimulation of the heart is increased. As a result, venous return, CO, and TPR decrease so that MAP is decreased back toward its normal value. 

Figure 15.6 The baroreceptor reflex. Baroreceptors are the most important source of input to the vasomotor center. The reflex elicited by these receptors is essential in maintenance of normal blood pressure.

Low-pressure receptors. The low-pressure receptors are located in the walls of the atria and the pulmonary arteries. Similar to baroreceptors, low-pressure receptors are also stretch receptors however, stimulation of these receptors is caused by changes in blood volume in these low-pressure areas. An overall increase in blood volume results in an increase in venous return an increase in the blood volume in the atria and the pulmonary arteries and stimulation of the low-pressure receptors. These receptors then elicit reflexes by way of the vasomotor center that parallel those of baroreceptors. Because an increase in blood volume will initially increase MAP, sympathetic discharge decreases and parasympathetic discharge increases so that MAP decreases toward its normal value. The simultaneous activity of baroreceptors and low-pressure receptors makes the total reflex system more effective in the control of MAP. 

Baroreceptors are sensitive to changes in MAP. As VR, CO, and MAP decrease, baroreceptor excitation is diminished. Consequently, the frequency of nerve impulses transmitted from these receptors to the vasomotor center in the brainstem is reduced. This elicits a reflex that will increase HR, increase contractility of the heart, and cause vasoconstriction of arterioles and veins. The increase in CO and TPR effectively increases MAP and therefore cerebral blood flow. Constriction of the veins assists in forcing blood toward the heart and enhances venous return. Skeletal muscle activity associated with simply walking decreases venous pressure in the lower extremities significantly. Contraction of the skeletal muscles in the legs compresses the veins and blood is forced toward the heart. 

At the onset of exercise, signals from the cerebral cortex are transmitted to the vasomotor center in the medulla of the brainstem. This central command inhibits parasympathetic activity and also initiates the mass sympathetic discharge associated with exercise. Sympathetic activity (including release of catecholamines from the adrenal medulla) increases proportionally with the intensity of exercise. 

A decrease in plasma volume leads to decreased MAP, which is detected by baroreceptors in the carotid sinuses and the arch of the aorta. By way of the vasomotor center, the baroreceptor reflex results in an overall increase in sympathetic nervous activity. This includes stimulation of the heart and vascular smooth muscle, which causes an increase in cardiac output and total peripheral resistance. These changes are responsible for the short-term regulation of blood pressure, which temporarily increases MAP toward normal. 

Clonidine, guanabenz, guanfacine, and methyldopa lower BP primarily by stimulating a2-adrenergic receptors in the brain, which reduces sympathetic outflow from the vasomotor center and increases vagal tone. Stimulation of presynaptic oq-receptors peripherally may contribute to the reduction in sympathetic tone. Consequently, there may be decreases in heart rate, cardiac output, total peripheral resistance, plasma renin activity, and baroreceptor reflexes. 

Hydralazine and minoxidil cause direct arteriolar smooth muscle relaxation. Compensatory activation of baroreceptor reflexes results in increased sympathetic outflow from the vasomotor center, producing an increase in heart rate, cardiac output, and renin release. Consequently, the hypotensive effectiveness of direct vasodilators diminishes over time unless the patient is also taking a sympathetic inhibitor and a diuretic. 

In 1967, Henning and Van Zwieten provided conclusive evidence that the most important effect of methyldopa is on the vasomotor centers in the central nervous system(22). This central effect results in a decrease in sympathetic tone to the periphery. 

In general, the introduction of antihypertensive agents acting on the vasomotor center in the brain appears to be a major advance in the treatment of hypertension. The well balanced hemodynamic effect is far superior to what is observed with inhibition of sympathetic transmission at peripheral sites. Orthostatic hypotension is no longer a problem. It is predicted that pharmacologic progress in this line of compounds will make further contributions to our antihypertensive armamentarium. 

A cnp of coffee can contain 50-150 mg of caffeine, and cola drinks can have 35-55 mg. Theophiline,l,3-dimethylxanthine, a principal, characteristic alkaloid of tea, and theobromine, 3,7-dimethylxanthine (23.3.19), a principal alkaloid of cocoa, are among a number of methylxanthines. In small doses, caffeine is a relatively weak psychostimulant and is used for increasing awareness as well as for relieving headaches associated with blood flow disorders of the brain. Caffeine has a stimulatory effect on the respiratory and vasomotor centers, and it stimnlates centers of the vagus nerve. It has a direct stimulatory effect on the myocardium, and in large doses can cause tachycardia and arrhythmia. 

Analeptics are drugs that have a stimulatory effect on the respiratory and vasomotor centers of the medulla. Analeptics are primarily used as antagonists in depressant drug overdose (hypnotics, narcotics). Having a relatively small range of therapeutic action, they can stimulate other parts of the CNS even in minor overdoses, causing a number of undesirable side effects such as stimulation of the cardiovascular system, hyperreflexia, vomiting, and seizures. 

Their efficacy in many illnesses is explained by the competitive binding of )3-adrenore-ceptors in the autonomic nervous system by basically any of the employed drags of the l-aryloxy-3-aminopropanol-2 class, which result in reduction of heart rate and strength of cardiac beats, slowing of atrioventricular conductivity, reduction of the level of renin in the plasma, and reduction of blood pressure. The main effects of 8-adrenoblockers are expressed at the level of the vasomotor center in the hypothalamus, which result in a slowing of the release of sympathetic, tonic impulses. Included in the main group of... 

The mechanism of action of these drugs is caused by stimulation of o -adrenoreceptors in the inhibitory structure of the brain. It is believed that interaction of these drugs with adrenergic receptors is expressed in the suppression of vasomotor center neurons of the medulla, and reduction of hypothalamus activity, which leads to a decline in sympathetic impulses to the vessels and the heart. In summary, cardiac output and heart rate are moderately reduced, and consequently arterial pressure is reduced. 

Methyldopa is an a-methoxylated derivative of levodopa that exhibits hypotensive action by reducing overall peripheral vascular resistance and reducing heart work. Antihypertensive action of methyldopa consists of the biotransformation of methyldopa into methylnoradrenaline (methylnorepinephrine), which acts as a pseudo neurotransmitter. The current, universally accepted point of view is that the action of methyldopa is carried out through the CNS, where methylnorepinephrine, a powerful stimulant of a-adrenergic receptors of the medulla, inhibits the vasomotor center. 

The activation a2-adrenoceptors is particularly important in the negative feedback control of adrenergic outflow, centrally in the vasomotor centers and peripherally at the presynaptic axonal membrane of adrenergic neurons. 

Injection of a drug that causes a fall in the mean arterial blood pressure triggers diametrically opposite reflex changes. There is decreased impulse traffic from the cardiac inhibitory center, stimulation of the cardiac accelerator center, and augmented vasomotor center activity. These changes in cardiac and vasomotor center activity accelerate the heart and increase sympathetic transmission to the vasculature thus, the drug-induced fall in blood pressure is opposed and blunted. 

Sympathetic arc involved in blood pressure regulation and sites where drugs may act to influence the system. A. Receptors on effector cell. 6. Adrenergic varicosity. C. Nicotinic receptors (postganglionic fibers). D. Brainstem nuclei. NTS, nucleus of the tractus solitarii VMC, vasomotor center ACh, acetylcholine NE, norepinephrine a, a-adrenoceptors (3, 13-adrenoceptors P2, P2-purinoceptors ATR adenosine triphosphate. 

The inhibition of MAO enzymes increases the concentrations of these neurotransmit-ters at storage sites throughout the CNS. Side effects of MAOIs include hypotensive effects from the inhibition of central vasomotor centers and cholinergic effects. 

These agents reduce sympathetic outflow from vasomotor centers in the brain stem but allow these centers to retain or even increase their sensitivity to baroreceptor control. Accordingly, the anti hypertensive and toxic actions of these drugs are generally less dependent on posture than are the effects of drugs that act directly on peripheral sympathetic neurons. 

Considerable evidence indicates that the hypotensive effect of clonidine is exerted at a adrenoceptors in the medulla of the brain. In animals, the hypotensive effect of clonidine is prevented by central administration of a antagonists. Clonidine reduces sympathetic and increases parasympathetic tone, resulting in blood pressure lowering and bradycardia. The reduction in pressure is accompanied by a decrease in circulating catecholamine levels. These observations suggest that clonidine sensitizes brain stem vasomotor centers to inhibition by baroreflexes. 

Methyldopa and clonidine produce slightly different hemodynamic effects clonidine lowers heart rate and cardiac output more than does methyldopa. This difference suggests that these two drugs do not have identical sites of action. They may act primarily on different populations of neurons in the vasomotor centers of the brain stem. 

Neurohumoral (extrinsic) compensation involves two major mechanisms (previously presented in Figure 6-7)—the sympathetic nervous system and the renin-angiotensin-aldosterone hormonal response—plus several others. Some of the pathologic as well as beneficial features of these compensatory responses are illustrated in Figure 13-2. The baroreceptor reflex appears to be reset, with a lower sensitivity to arterial pressure, in patients with heart failure. As a result, baroreceptor sensory input to the vasomotor center is reduced even at normal pressures sympathetic outflow is increased, and parasympathetic outflow is decreased. Increased sympathetic outflow causes tachycardia, increased cardiac contractility, and increased vascular tone. Vascular tone is further increased by angiotensin II and endothelin, a potent vasoconstrictor released by vascular endothelial cells. The result is a vicious cycle that is characteristic of heart failure (Figure 13-3). Vasoconstriction increases afterload, which further reduces ejection fraction and cardiac output. Neurohumoral antagonists and vasodilators... 

At doses up to those causing hypnosis, no significant effects on the cardiovascular system are observed in healthy patients. However, in hypovolemic states, heart failure, and other diseases that impair cardiovascular function, normal doses of sedative-hypnotics may cause cardiovascular depression, probably as a result of actions on the medullary vasomotor centers. At toxic doses, myocardial contractility and vascular tone may both be depressed by central and peripheral effects, leading to circulatory collapse. Respiratory and cardiovascular effects are more marked when sedative-hypnotics are given intravenously. 

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