Right Atrial Pressure: Determinant or Result

of Change in Venous Return?

Karim Bendjelid

Chest 2005;128;3639-3640
DOI 10.1378/chest.128.5.3639
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 critical care reviews
Right Atrial Pressure*
Determinant or Result of Change in Venous
Return?
Karim Bendjelid, MD, MS

According to the concept of Guyton, cardiac output is largely controlled by venous return, which
is determined by the difference between mean systemic venous pressure and right atrial
pressure. In the analysis of the venous return curve, other authors have suggested that right
atrial pressure is the dependent variable and venous return is the independent variable (right
atrial pressure decreased because cardiac output increased). The present report analyzes this
historical debate, which has already lasted > 50 years. (CHEST 2005; 128:3639 –3640)

“There are two kinds of truth, small truth and great truth.
You can recognize a small truth because its opposite is a
falsehood. The opposite of a great truth is another truth”
Niels Bohr (1885–1962)
O ne“theofscience
the definitions of physiology is that it is
of how the body works.” The key to
obtaining a full understanding of the human circu-
latory function is the determination of its autoregu-
lation. In the steady state, the traditional teaching is
that pulsatile BP is the result of cardiac function
(output), and vascular structure and function (large
vessel compliance and peripheral arterial resistance).
As cardiac output must equal venous return, a
decrease in cardiac output means a decrease in
venous return.1 Since this has been taught to three
generations of intensivists, venous return is defined
as the result of a constant mean circulatory pressure
(ie, pressure under the condition of no flow) and an
independently variable “back pressure” right atrial
pressure.2 The venous return-right atrial pressure
illustration was used to argue that venous return
increases because right atrial pressure decreases,
*From the Surgical Intensive Care Division, Geneva University
Hospitals, Geneva, Switzerland.
Manuscript received March 29, 2005; revision accepted March
30, 2005.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Karim Bendjelid, MD, MS, Chef de Clinique
Scientifique, Surgical Intensive Care Division, Geneva University
Hospitals, CH-1211 Genève 14, Switzerland; e-mail: Karim.
Bendjelid@hcuge.ch
given a constant mean circulatory pressure.3 Stated
in this way, right atrial pressure-mean circulatory
pressure is the gradient for venous return (driving
force).3–5
After a theoretical analysis, with the development
of a mathematical model, Levy6 questioned the
statement that venous return increases because of a
decrease in right atrial pressure. Using a mathemat-
ical model, he suggested that in the analysis of the
venous return curve, right atrial pressure is a depen-
dent variable and venous return is an independent
variable (ie, right atrial pressure decreased because
cardiac output increased).6 Experimental animal re-
sults have also come to the same conclusion.7 Even
Guyton4 noted that in the animal an inverse change
in right atrial pressure was observed when he in-
duced a change in the cardiac output by use of an
artificial pump, in the absence of the collapsible tube
(ie, Starling resistor). In the absence of cardiac
dysfunction, venous return is more essential in de-
termining cardiac output that the pump itself. How-
ever, when venous return and cardiac output are not
identical (for short periods of time), and the total
vascular volume is fixed, the difference is made up by
a reciprocal exchange of volume between compliant
compartments.8 In this situation, the illustration of
venous return-right atrial pressure that was used to
argue that venous return increases because right
atrial pressure decreases, given a constant mean
circulatory pressure,3 could be questioned. Indeed,
the switch in vascular volume between compliant

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compartments affects mean circulatory pressure,
right atrial pressure, the resistance to venous return,
and ultimately venous return.9 Stated in this way,
right atrial pressure-mean circulatory pressure
should be the pressure gradient caused by flow
rather than the gradient for venous return.6
When cardiac output increases, venous pressure
decreases because the venous reservoir is depleted.
As stated by Levy,6 the development of a mathemat-
ical model is an abstraction, and hence the assign-
ment of dependent and independent variables may
be arbitrary. Thus, right atrial pressure may be the
consequence of the cardiac flow value around the
circuit. In a review article, Tyberg9 demonstrated
how changing venous tone modulates cardiac output
both in physiologic conditions and in disease states.
Preferring the interpretation of Levy,6 Tyberg9 has
extended his concepts and developed a modified
pressure-volume mode of circulation.9 Also, in the
hope of clarifying this issue, Brengelmann8 reexam-
ined this question through a review of the original
experiments on venous return. He emphasized the
fact that Guyton et al5 did not record venous return
in dynamic states but that their data were all taken
from steady states. In a different experimental prep-
aration (from the one employed by Guyton et al5), he
maintained a fixed blood volume to illustrate the
consequences of and the differences between dy-
namic and steady-state conditions.8 This experiment
indicated that an increase in right atrial pressure
causes increased cardiac output in the cardiac sub-
division and that an increase in cardiac output causes
decreased right atrial pressure in the vascular subdi-
vision.
The role of the normal heart in regulating cardiac
output is to lower right atrial pressure, allowing
better drainage of blood from the compliant veins
and venules,1,10 which means that venous return and
right atrial pressure are dependent variables. This
statement is in agreement with the relatively more
recent point of view given by Guyton when review-
ing the article by Levy6 (see the editors’ note at the
end of the article). For Guyton, the question “is right
atrial pressure the stimulus (independent variable)
and the cardiac flow the response (dependent vari-
able) or vice versa” is not a good question. The
independent variables are such factors as heart rate,
contractility, and the resistance and capacitance of
each segment of the circulation.11 Considering re-
3640
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Copyright © 2005 by American College of Chest Physicians
flexes and hormones, even the independent variables
cited above become dependent variables. Therefore,
both right atrial pressure and venous return are
dependent variables,11 and both may be displayed on
the horizontal axis or the vertical axis.
When teaching, the senior lecturer has to choose a
particular way of describing the relationship between
two dependent variables in order to avoid confusing
medical students.12 We may expect that the question
of what would happen to cardiac output if the venous
pressure value changed equals what would happen to
the venous pressure if the cardiac output changed, as
the two variables are dependent and interdependent.
Therefore, we imagine that Guyton has not imposed
plots of these open-loop relationships of two vari-
ables. He has preferred one question in regard to
another. He has made the choice of a teacher.13
References
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128
Critical Care Reviews
 Right Atrial Pressure: Determinant or Result of Change in Venous
Return?
Karim Bendjelid
Chest 2005;128;3639-3640
DOI 10.1378/chest.128.5.3639
This information is current as of December 29, 2007

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