Effects of prolonged infusion of human alpha calcitonin gene-related peptide on hemodynamics, renal blood flow and hormone levels in congestive heart failure

We have previously demonstrated that short-term infusion of calcitonin gene-related peptide (CGRP) has beneficial effects in congestive heart failure. The effects of prolonged infusion of CGRP on hemodynamic functions, plasma hormones and renal blood flow were studied in 9 patients with congestive heart failure (New York Heart Association class III or IV, ejection fraction less than 35%). Hemodynamic variables were measured at 30-minute intervals for 8 hours during CGRP infusion (8 ng/kg/min) and for 2 hours after discontinuation. CGRP caused a decrease in right atrial (28%, p less than 0.05), pulmonary artery (22%, p less than 0.02), pulmonary artery wedge (37%, p less than 0.001) and systemic arterial (18%, p less than 0.05) pressures. Systemic vascular resistance decreased more than pulmonary vascular resistance. Cardiac output (72%, p less than 0.001) and stroke volume (60%, p less than 0.02) increased. Heart rate did not change. There was no evidence of tolerance throughout the infusion. The hemodynamic effects were lost within 30 minutes of stopping CGRP. Renal blood flow (34%, p less than 0.01) and glomerular filtration rate (43%, p less than 0.01) increased. Atrial natriuretic peptide decreased (p less than 0.05), while plasma cortisol (p less than 0.02) increased. Plasma epinephrine, norepinephrine, renin activity, aldosterone and growth hormone were unchanged. It is concluded that in patients with severe congestive heart failure, CGRP has sustained beneficial effects on hemodynamic functions and has no adverse effects on hormones. Unlike many other vasodilators, CGRP also increases renal blood flow and glomerular filtration.

Reactive oxygen species modify the structure and function of the cardiac sarcoplasmic reticulum calcium-release channel

Restoration of blood flow to the ischemic myocardium prevents continuing cell necrosis, but reperfusion may cause irreversible damage to potentially salvable tissue, possibly through the generation of toxic reactive oxygen species. Intracellular calcium overload, secondary to membrane lipid peroxidation, has been proposed as a general pathogenic mechanism. However, using the photosensitisation of rose bengal to generate singlet oxygen and superoxide radicals, we demonstrate a direct effect of reactive oxygen species on the cardiac sarcoplasmic reticulum calcium-release channel. Exposure of heavy sarcoplasmic reticulum vesicles to reactive oxygen species in vitro resulted in the progressive loss of specific [3H]ryanodine binding and the degradation of high molecular weight proteins identified by polyacrylamide gel electrophoresis. The gating of single channels incorporated into artificial planar phospholipid bilayers was modified during the exposure to reactive oxygen species: an initial increase in open probability being followed by irreversible loss of channel function. Degradation by reactive oxygen species of specific proteins, such as the calcium-release channel, may contribute to in vivo reperfusion injury.

Cardiovascular and hormonal effects of calcitonin gene-related peptide in congestive heart failure

The effects of infusing human alpha-calcitonin gene-related peptide were studied in eight patients with congestive heart failure, five normal rabbits and five rabbits with adriamycin-induced cardiomyopathy. In patients with heart failure, calcitonin gene-related peptide caused a dose-dependent increase in cardiac output and decrease in pulmonary and systemic vascular resistance and pulmonary artery pressure. The systemic blood pressure and right atrial and pulmonary wedge pressures decreased only at the highest infusion rate (16 ng/kg per min). Heart rate remained unchanged. Plasma epinephrine increased (p less than 0.05), whereas aldosterone, atrial natriuretic peptide and prolactin concentrations decreased (p less than 0.05). Plasma norepinephrine, renin activity, cortisol and growth hormone concentrations remained unchanged. In both groups of rabbits, the drug decreased blood pressure and increased cardiac output and heart rate. There was a significant increase in renal blood flow (p less than 0.05). The peptide did not affect the contraction amplitude of human and rabbit ventricular myocytes. These findings suggest that calcitonin gene-related peptide is a vasodilator in the rabbit and humans with little direct effect on ventricular myocardium. This peptide may be useful in some forms of heart failure.

Direct measurement of skeletal muscle fatigue in patients with chronic heart failure

Skeletal muscle function was measured as force production and fatigue in both the quadriceps (a large locomotive muscle) and adductor pollicis (a small intrinsic hand muscle) in five healthy volunteers, five patients with mild chronic heart failure, and five patients with severe chronic heart failure. The quadriceps of patients with chronic heart failure had a reduced muscle cross sectional area, a reduced maximum isometric force production, and an increased tendency to fatigue. Isometric force production and fatigue of the adductor pollicis, however, were not significantly different between the three groups under control conditions. But during circulatory occlusion fatigue in the adductor pollicis increased more in the patients with severe chronic heart failure. These differing findings in quadriceps and adductor pollicis suggest that skeletal muscle atrophy and reduced isometric force production are not a necessary consequence of chronic heart failure per se, because they were only present in the large locomotive muscle. The normal values for muscle fatigue observed in adductor pollicis in patients with chronic heart failure imply that skeletal muscle blood flow must increase normally during muscle activation when only a small muscle mass is used. These results are not compatible with the concept of a generalised impairment of normal vasodilatation within active skeletal muscle. In contrast, activation of a large muscle, such as quadriceps, results in the rapid onset of fatigue in patients with severe chronic heart failure. This fatigue may be related to the inability of the cardiovascular system to provide the required blood flow for the activation of a large muscle mass. The finding of a relatively greater increase in fatigue of adductor pollicis during circulatory occlusion in patients with severe chronic heart failure supports the hypnosis of an intrinsic abnormality of skeletal muscle in these patients.

Hypothesis: inhibition of endothelium-derived relaxing factor by haemoglobin in the pathogenesis of pre-eclampsia

Although the aetiology of pre-eclampsia is unknown, haemodynamic studies suggest that many of the clinical findings may be explained by a generalised vasoconstrictive disorder and abnormal endothelial cell function. Vasoconstriction may be attributed to the increased concentrations of haemoglobin found in pre-eclampsia compared with normal pregnancy. Free haemoglobin may be derived from haemolysis and placental haemorrhage and, at concentrations known to be present in pre-eclampsia, vasodilatation mediated by endothelium-derived relaxing factor is inhibited. Infusion of oxyhaemoglobin into human coronary arteries inhibits acetylcholine-induced vasodilatation. We suggest that an increased free haemoglobin concentration is the cause of vasoconstriction in pre-eclampsia.

Calcium exchange in rabbit myocardium during and after hypoxia: role of sodium-calcium exchange

Calcium uptake was measured using 47Ca2+ in the isolated and arterially perfused interventricular septum of the rabbit. Experiments were undertaken to determine whether calcium uptake on reoxygenation is linked to recovery of mechanical function and whether calcium uptake is through the sodium-calcium exchange mechanism. During substrate-free hypoxia for 45 min total tissue calcium remained unchanged but immediately upon reoxygenation there was a substantial net gain of calcium. Recovery of mechanical function upon reoxygenation was inversely related to the increase in tissue calcium. Activation of sodium-calcium exchange by perfusion with a low-sodium, zero-potassium, sucrose solution also increased tissue calcium and the relation to mechanical recovery was similar to that observed on reoxygenation. The sodium-calcium exchange mechanism was not affected by hypoxia and could be demonstrated during perfusion with a substrate-free hypoxic solution. Lithium (100 mM) substitution for sucrose prevented the calcium influx induced by a low-sodium and zero-potassium perfusate under normoxic conditions. Lithium substitution early during hypoxia or on reoxygenation did not affect the increase in myocardial calcium on reoxygenation. Amiloride (10(-4)M), presumed to inhibit sodium-hydrogen exchange during hypoxia, had no effect upon reoxygenation induced calcium uptake. It is concluded that the increase in calcium uptake that occurs on reoxygenation after a period of substrate-free hypoxia is related to mechanical recovery. Sodium-calcium exchange may contribute to calcium uptake on reoxygenation in this experimental model but is not the major mechanism.

Maximal oxygen uptake in severe aortic regurgitation: a different view of left ventricular function

Respiratory gas exchange was used to assess left ventricular (LV) function in 22 patients with severe aortic regurgitation (19 men and three women, aged 18 and 70 years, mean 49 years). Anaerobic threshold and symptom-limited maximal oxygen consumption (VO2 max) were measured during treadmill exercise, and the results were compared with conventional echocardiographic and radionuclide indices of LV systolic function. The results were considered with respect to the patients' New York Heart Association functional class. Both rest and exercise LV ejection fractions were variable, but the mean results were similar in all classes. The echocardiographic indices of LV cavity dimensions, fractional shortening, radius/thickness ratio, and systolic wall stress also showed a wide range but with similar mean results in each class. In contrast, VO2 max and anaerobic threshold showed a relationship to functional class. VO2 max was 32.4 +/- 3.4 ml/kg/min in age-matched control subjects; in the patients it was 27.9 +/- 4.7 in class I, 24.7 +/- 5.7 in class II, and 14.2 +/- 2 in the combined class III/IV. Results in patients in classes I and II were similar, but both groups were significantly different from control subjects (p less than 0.05) and from patients in class III/IV (p less than 0.01). About half of the patients with moderate LV dysfunction (judged by reduced VO2 max) were asymptomatic, and LV function was impaired in 4 of 10 patients in class I. Thus, unlike conventional indices of LV function, VO2 max appeared capable of distinguishing patients with moderate-to-severe LV dysfunction from those with little or no LV dysfunction. Measurement of respiratory gas exchange appears to be a valid and useful supplementary means of assessing LV function in severe aortic regurgitation. Further long-term evaluation is required.

Reduced beta-agonist sensitivity in single atrial cells from failing human hearts

Human myocytes were isolated from right atrial appendage, and contractile responses to inotropic agents were studied. Responses to inotropic agents of cells isolated from patients with mild heart disease [New York Heart Association (NYHA) classes I and II] were compared with those of myocytes from rabbit atria. Maximally effective concentrations of calcium, forskolin, and isoproterenol increased contraction amplitude to a similar extent (11.9, 11.5, and 11.3% change in cell length, respectively), but histamine produced a smaller effect (7.1%). The maximum responses of rabbit atrial cells to calcium (18.5%) and isoproterenol (15.0%) were significantly greater than human. In human cells, the velocity of contraction or relaxation was accelerated more by isoproterenol (P less than 0.05) or forskolin (P less than 0.01) than by high calcium. Only relaxation velocity was increased by isoproterenol in rabbit cells (P less than 0.05). Rabbit myocytes contracted and relaxed 10-30% faster than human (P less than 0.05). Cells from the atria of patients with New York Heart Association (NYHA) heart failure class III or IV were less responsive to isoproterenol than those from class I or II (P less than 0.01). Omitting data from patients who had been taking calcium-channel blockers or beta-adrenoceptor agonist or antagonist drugs did not affect the conclusions. Analysis of variance revealed a significantly greater between-patient than within-patient variation (P less than 0.001), indicating that cells from the same patient have a tendency to respond in a similar way. Responses to high calcium did not differ among NYHA classes. The effect of forskolin was not reduced in NYHA class III, although there was a decreased response in cells from two patients in NYHA class IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Adriamycin cardiomyopathy in the rabbit: alterations in contractile proteins and myocyte function

STUDY OBJECTIVE

The aim was to determine the mechanism of the cardiotoxic effect of adriamycin, particularly at the level of the function of the cardiac myocyte.

DESIGN

After chronic exposure to adriamycin, the contractile responses of single isolated cardiac myocytes to increasing calcium and isoprenaline were measured, as well as oxygen consumption of myocyte suspensions. Creatine kinase and myosin isoforms were investigated in whole ventricle. The degree of fibrosis of the ventricle was quantified using histological methods.

SUBJECTS

24 white male New Zealand rabbits were treated with adriamycin (1 mg.kg-1) twice a week for eight weeks, and allowed to recover for two weeks. There were 29 untreated controls. Six further rabbits were implanted with mini osmotic pumps delivering a constant infusion of isoprenaline for one week; five controls had pumps containing saline.

MEASUREMENTS AND MAIN RESULTS

Cardiac myocytes were enzymatically isolated, and their contraction amplitude and velocity monitored. Cells isolated from adriamycin treated rabbits had a lower contraction amplitude than those from controls when maximally activated with calcium, at 11.1(0.9)% shortening (n = 11) v 13.6(0.5)% (n = 14), p less than 0.02; or with isoprenaline, at 11.6(0.6)% shortening v 13.1(0.4)%, p less than 0.05. Contraction, but not relaxation, velocity in maximum calcium or isoprenaline was also significantly lower in cells from adriamycin treated animals. Oxygen consumption per 10(6) cells was lower in preparations from treated animals (p less than 0.05), but the relative effects of glucose, acetate, 2,4-DNP, and cyanide were unaffected. There was no significant change in creatine kinase or myosin isozyme composition or in amounts of fibrosis following adriamycin treatment. However, the quantity of myosin per g wet weight of tissue was significantly reduced from 8.04(0.45) mg.g-1 wet tissue, n = 4, in controls to 5.76(1.55) mg.g-1, n = 6, in adriamycin treated animals (p less than 0.001). The EC50 for isoprenaline was unchanged in cells from treated animals. Together with the unaltered maximum isoprenaline/calcium ratio, this implies that there is no change in beta adrenoceptor sensitivity following adriamycin treatment. To confirm that it was possible to desensitise rabbit cardiac beta adrenoceptors, and to detect changes in sensitivity on single cells, rabbits were treated with isoprenaline for one week. Such treatment decreased the maximum isoprenaline/calcium contraction amplitude ratio from 0.97(0.15), n = 5, to 0.47(0.12), n = 6 (p less than 0.05), and increased the EC50 from 7.9 to 224 nM (p less than 0.05).

CONCLUSIONS

Single cardiac myocytes isolated from the hearts of adriamycin treated rabbits show a decrease in contraction amplitude, velocity, and oxygen consumption compared to controls. The decreased contractility of individual myocytes may relate to their low myosin content, and could contribute to the reduced cardiac output produced by adriamycin treatment. Heart failure induced by adriamycin in the rabbit is not accompanied by beta adrenoceptor desensitisation.

Enalapril as initial and sole treatment in severe chronic heart failure with sodium retention

Five patients, who had never received any drug treatment but who had severe chronic congestive heart failure with salt and water retention, were studied before and after a single dose of enalapril (10 mg orally). Three patients continued on enalapril as monotherapy (10 mg b.d. orally) for one month. Central haemodynamics, body fluid volumes, renal function and plasma hormones were measured at rest. The initial mean right atrial pressure was 13 +/- 4 mm Hg, pulmonary wedge pressure 29 +/- 4 mm Hg and cardiac index 1.8 +/- 0.21/min/m2. Enalapril, given acutely, caused only small changes. Two patients were withdrawn after the single dose of enalapril and treated with diuretics for clinical reasons. The remaining three patients each lost more than 4 kg in weight after one month of treatment with enalapril alone. Total body exchangeable sodium and total body water were reduced but central haemodynamics were unchanged. Although enalapril was of some benefit when given alone to patients with severe congestive heart failure, all five patients were finally treated with diuretics for clinical reasons. Enalapril is not recommended as the initial and only therapy for patients with severe congestive heart failure.

Potassium exchange in the human heart: effect of heart rate and myocardial ischemia

The concentration of potassium ions, [K+], in the blood of the coronary sinus was recorded using catheter-tip potassium ion-selective electrodes during fixed rate atrial pacing for up to six minutes in five patients with normal hearts (control group) and in eight with coronary artery disease. Four patients with coronary artery disease developed pain in the chest and changes on the electrocardiogram during atrial pacing (ischemic group). In the control group, the coronary sinus [K+] began to rise after three seconds to a peak increase of 0.33 +/- 0.04 mmol.l-1 (p less than 0.001) and then returned to the resting value. On cessation of pacing, coronary sinus [K+] fell rapidly and transiently below the resting value. In the ischemic group, the coronary sinus [K+] began to rise after three seconds to a peak of 0.42 +/- 0.05 mmol.l-1 (p less than 0.01); it remained elevated throughout the period of atrial pacing (p less than 0.01) and fell rapidly and transiently below the resting value on cessation of pacing. Four patients with coronary artery disease did not develop ST segment depression during atrial pacing; in two the changes in coronary sinus [K+] were the same as those in the ischemic group, and in two they were similar to those in the control group. These data show that in man there is an immediate and transient loss of potassium from the myocardial cells when the heart rate is increased and that this loss is restored the heart rate returns to the resting rate. Myocardial ischemia causes a continuing efflux of potassium from myocardial cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanism of the increased ventilatory response to exercise in patients with chronic heart failure

Minute ventilation, respiratory rate, and metabolic gas exchange were measured continuously during maximal symptom limited treadmill exercise in 30 patients with stable chronic heart failure. The ventilatory response to exercise was assessed by calculation of the slope of the relation between minute ventilation and rate of carbon dioxide production. There was a close correlation between the severity of heart failure, determined as the maximal rate of oxygen consumption, and the ventilatory response to exercise. Reanalysis of the data after correction for ventilation of anatomical dead space did not significantly weaken the correlation but reduced the slope of the relation by approximately one third. These results show that the increased ventilatory response to exercise in patients with chronic heart failure is largely caused by mechanisms other than increased ventilation of anatomical dead space. This finding supports the concept that a significant pulmonary ventilation/perfusion mismatch develops in patients with chronic heart failure and suggests that the magnitude of this abnormality is directly related to the severity of chronic heart failure.

Species dependence of contraction velocity in single isolated cardiac myocytes

Single myocytes were isolated from mouse, rat, guinea-pig, rabbit, sheep and human ventricle, and the amplitude and velocity of their unloaded contraction measured using a video camera and a system for measuring their length. Measurements were done at 32 degrees C in solutions containing either low calcium (1-1.3mM) or a concentration of calcium (usually 8mM) that produced a maximum amplitude of contraction. Unlike the cells of the majority of species, human cells could be successfully isolated only by using protease in addition to collagenase. To determine the effect of protease, guinea-pig cells were prepared with or without this enzyme. There was no significant difference in the characteristics of the cells prepared by either method. There was little species variation in the length of the cells or the length of resting sarcomeres. However, there were considerable species differences in the velocity of shortening and of relaxation. Myocytes from larger animals tended to contract and relax more slowly than those from smaller animals, although there was little systematic variation in the absolute amplitude of contraction. There was a significant correlation between the normalised contraction velocity of single cells and the average heart rate reported for that species. The trend for decreased relaxation velocity with lower heart rate did not reach statistical significance. Right ventricular cells from rat heart contracted more rapidly than those from the left ventricle, a finding similar to that reported for intact muscle strips. We conclude that species and left/right differences observed in the contraction velocity of whole muscle can be detected at the level of the single myocyte.

Familial restrictive cardiomyopathy with atrioventricular block and skeletal myopathy

Five generations of an Italian family with an autosomal dominant restrictive cardiomyopathy are described. Members of four generations were examined. Symptoms usually developed in the third or fourth decade but the disease did occur in childhood. Initially the condition was characterised by normal ventricular size and systolic function with increased diastolic filling pressures in both ventricles and consequent bi-atrial enlargement. Cardiac catheterisation showed a left ventricular filling pattern of "dip and plateau". The electrocardiogram typically showed non-specific changes in the ST segment and T wave and changes indicating considerable atrial enlargement, which were confirmed by echocardiography. Light microscopy of two endocardial biopsy specimens showed no specific features but excluded the endomyocardial fibrosis of eosinophilic heart disease, amyloid, and specific heart muscle diseases. At necropsy in one case examined under light microscopy extensive patchy fibrosis was found throughout the endocardium, myocardium, and subepicardium, but there were no features typical of eosinophilic heart disease. Histopathological and biochemical examination of skeletal muscle identified no abnormality. The disease often had an insidious course over five to ten years after presentation. Bundle branch blocks, leading to complete atrioventricular block, however, often occurred and may be the first manifestation. Some individuals who survived into the fifth decade developed a progressive, non-wasting skeletal myopathy.

Pulmonary artery pressure changes during exercise and daily activities in chronic heart failure

Long-term continuous pulmonary artery pressure monitoring was used to investigate pressure changes during different types of exercise and normal daily activities in patients with chronic heart failure. Nine men (mean age 55 years) with treated chronic heart failure underwent continuous pulmonary artery pressure measurement with use of a micromanometer-tipped catheter with in vivo calibration and frequency-modulated recording. The mean (+/- SD) maximal systolic pulmonary artery pressure (in mm Hg) was 59.4 +/- 26.1 on treadmill exercise, 54.9 +/- 30.6 on bicycle exercise, 52.5 +/- 26.1 walking up and down stairs and 43.5 +/- 23.9 walking on a flat surface. The mean maximal diastolic pressure (in mm Hg) was 27.8 +/- 14.6 on treadmill exercise, 25.5 +/- 14.9 on bicycle exercise, 24.9 +/- 14.8 walking up and down stairs and 20.4 +/- 12.5 walking on a flat surface. The increase in pulmonary artery pressure did not correlate with the severity of the limiting symptoms except during walking on a flat surface. All patients had marked postural changes in pressure, with the systolic pressure difference from lying to standing ranging from 8 to 25 mm Hg and the diastolic pressure difference ranging from 3 to 13 mm Hg. Eating meals caused an increase in pressure in three patients, but less than that when lying flat. There was an increase in pressure during urination in four patients equal to that when walking on a flat surface. None of these activities was associated with symptoms. Neither symptoms nor pulmonary artery pressure during maximal exercise is the same as during daily activities. This may restrict the value of maximal exercise tests in assessing patients with chronic heart failure.

Drug treatment of heart failure

The objectives of treatment for patients with chronic heart failure are the prevention of the initial occurrence, the alleviation of signs and symptoms, the delay of the progression of damage to heart muscle and the reduction of the mortality rate. Many drugs are used in severe heart failure. Current controversy is concerned with which drugs to use in patients with mild heart failure or with left ventricular dysfunction. There is a trend towards the earlier introduction of an angiotensin-converting enzyme inhibitor combined with a diuretic.

Contractile abnormalities of single right ventricular myocytes isolated from rats with right ventricular hypertrophy

The contractile properties of single rat cardiac myocytes isolated from normal and hypertrophied right ventricles have been investigated and then correlated with the isoenzyme pattern of ventricular myosin. The isoprenaline-stimulated contraction and the beta-adrenoceptor sensitivity were also investigated. Right ventricle hypertrophy was obtained by injecting monocrotaline, an alkaloid which induces severe pulmonary hypertension. The contractile parameters, namely contraction amplitude and speed of shortening, were obtained by means of an inverted microscope TV-system and edge-detection-device. Hypertrophied cells showed a significantly decreased speed of shortening and contraction amplitude when contraction was induced by maximum calcium and maximum isoprenaline. A statistically significant correlation existed between myosin alpha-chain percentage and both contraction parameters. Isoprenaline sensitivity expressed in terms of ED50, p kappa a and Hill coefficient were similar in the control and monocrotaline treated animals. Moreover no correlation between the degree of ventricular hypertrophy and ED50 existed. These results suggest that, in this animal model, the depressed contractile function which characterizes the hypertrophic myocardium depends on changes in isomyosin pattern while beta-adrenoceptor desensitization does not occur.

Morphological and functional characteristics of myocytes isolated from human left ventricular aneurysms

Isolated single myocytes were prepared from myocardium of developing ventricular aneurysms and from myocardium within the scar of chronic ventricular aneurysms. The morphology and function of the individual cells were compared. The cells from developing aneurysms were rod-shaped, with a distinct sarcomeric structure, but did not contract even in the presence of high calcium concentrations. The sarcomere length was significantly higher than that of cells from chronic aneurysms and approached the theoretical point at which no contraction can occur. Cells from chronic aneurysms were either rod-shaped and contractile, or rounded due to hypercontracture of the myofilaments. Electron microscopy of cells from developing aneurysms confirmed the presence of elongated sarcomeres, a loss of the actin-myosin interdigitation, and damage to the contractile proteins which was particularly evident in the thin filaments. Cells with similar characteristics have also been isolated from a ruptured, ischaemic papillary muscle. These changes, which are due either to ischaemia or to overstretching of cells, may account for the weakness of the wall of developing aneurysms and be a cause of rupture or enlargement.

Isoproterenol sensitivity of isolated cardiac myocytes from rats with monocrotaline-induced right-sided hypertrophy and heart failure

Rats treated with the alkaloid monocrotaline developed right ventricular hypertrophy with a left:right ventricle weight ratio of 1.35 +/- 0.10 (mean +/- s.e.m., n = 25) compared with 3.83 +/- 0.40 (n = 14) in diet-matched controls (P less than 0.001). Urine volume and sodium content were reduced and body water increased consistent with heart failure. In 10 out of 26 treated rats pleural, pericardial or peritoneal effusions were present. Urine norepinephrine content was significantly raised (P less than 0.02) but epinephrine was unchanged. Plasma norepinephrine levels were raised though not significantly. Myocytes isolated from the right ventricle had a reduced myosin Ca2+-activated ATPase (P less than 0.05) activity and a shift towards slower V2 and V3 myosin isoforms. There was no decrease in maximum contraction amplitude with calcium or isoproterenol in either left or right ventricular cells of treated rats. Right ventricular cells from treated rats showed a reduced rate of contraction in maximum isoproterenol (P less than 0.05) and a significant rightward shift in PD2 (P less than 0.05) representing a two-fold increase in EC50 for isoproterenol compared with right ventricular cells from control animals. There was no shift in EC50 for isoproterenol in left ventricle cells. In parallel experiments, myocytes isolated from both ventricles of rats treated with isoproterenol for one week showed a rightward shift of more than 50-fold in the isoproterenol concentration-response curve and a depressed response to maximum isoproterenol. In the rat monocrotaline model of right-sided cardiac hypertrophy and failure, changes in sensitivity to beta-adrenoceptor agonists are slight, and present only in the right ventricle. The lack of change in the left ventricle seems to suggest that this functional desensitisation is not a consequence of raised circulating catecholamines.

Regulation of intracellular pH in the myocardium; relevance to pathology

Intracellular pH affects the contractile function of the heart, metabolic reactions, ion exchange and calcium homoeostasis. Numerous studies have concluded that a fall of extracellular pH, by whatever mechanism, causes a fall of contractility by alteration of intracellular pH. Measurement of cytosolic intracellular pH using microelectrodes has confirmed that earlier deduction. Acidosis reduces the slow calcium current and the release of calcium from the sarcoplasmic reticumul but, because the cytosolic calcium does not fall, the major site of action of hydrogen ions appears to be on the calcium sensitivity of the contractile proteins. In man acidosis can be detected 15 s after the occlusion of a coronary artery and is a major mechanism for the simultaneous loss of contractility in ischaemia. A transient alkalosis is not detected in man but has been reported in isolated heart preparations where ATP consumption is low. An imposed mild respiratory acidosis during hypoxia increases the subsequent recovery of mechanical function on reoxygenation whereas a severe acidosis can be harmful. Acidosis in ischaemic may be advantageous due to a cardioplegic effect, inhibition of transsarcolemmal calcium fluxes or a reduction of mitochondrial calcium overload. Calcium uptake on reperfusion or reoxygenation has been linked to an inward movement of sodium in exchange for hydrogen ions on reperfusion and subsequent sodium-calcium exchange. Such a mechanism in its simplest form cannot account for the similar uptake of calcium on reoxygenation and reperfusion. Acidosis is a cause of early contractile failure in ischaemia but the role of acidosis in causing cell necrosis is not established.

Comparison between isomyosin pattern and contractility of right ventricular myocytes isolated from rats with right cardiac hypertrophy

The contractile properties of single rat cardiac cells isolated from normal and hypertrophied right ventricles have been investigated. These have been correlated with the isoenzyme composition of the whole ventricle. Right cardiac hypertrophy was induced by injecting rats with monocrotaline, an alkaloid which induces severe pulmonary hypertension. Ca2+ ATPase activity and myosin alpha-chain percentage were decreased in the hypertrophied right ventricle as compared with that of control rats. The contraction amplitude and speed of shortening of the isolated cells were measured using an inverted microscope, video camera, and edge detection device. Cells from the hypertrophied ventricle showed a significantly decreased contraction amplitude and speed of shortening in maximally activating concentrations of isoprenaline. A statistically significant correlation existed between myosin alpha-chain percentage and both contraction amplitude and speed of shortening in maximum isoprenaline. This was true when all cells studied were included, as well as within the hypertrophy group. A similar, although not always statistically significant, correlation was observed when cells were maximally activated with calcium. These results suggest that changes in isomyosin pattern that occur in cardiac hypertrophy produce alterations in contraction amplitude and speed of shortening which can be detected in single cells isolated from the hypertrophied ventricles. Isolated cells appear to give responses representative of the function of the whole heart.

Hemodynamic, hormonal, and renal effects of atrial natriuretic peptide in untreated congestive cardiac failure

We report the effects of intravenous infusion of the atrial natriuretic peptide analogue, met-ANP-26 (2 micrograms/min for 2 to 4 hours), in four patients with cardiomyopathy and severe congestive cardiac failure who had not received any previous cardiac therapy. The average cardiac index before infusion was 1.8 L/min/m2. Severe sodium and water retention was confirmed by high levels of total body water and extracellular liquid, whereas renal blood flow and glomerular filtration rate were reduced. Plasma concentration of ANP, norepinephrine, cortisol, and growth hormone were significantly increased before infusion. The infusion had no significant hemodynamic effect. After 2 hours urine volume had increased significantly from 51 to 76 ml/hr, urinary concentration of sodium from 72 to 90 mmol/L, and sodium excretion from 4.5 to 8.2 mmol/hr. The infusion was accompanied by a significant increase in plasma ir-ANP from 193 to 980 pg/ml. There were no significant effects on the plasma concentrations of norepinephrine, epinephrine, aldosterone, vasopressin, cortisol, growth hormone, or prolactin and no significant change in plasma renin activity. After 2 hours of infusion one patient had a severe sinus tachycardia and another had a sinus bradycardia. Both arrhythmias disappeared without harmful effects soon after the infusion was stopped.

Edema of cardiac origin. Studies of body water and sodium, renal function, hemodynamic indexes, and plasma hormones in untreated congestive cardiac failure

This study provides data on plasma hormone levels in patients with severe clinical congestive cardiac failure who had never received therapy and in whom the presence of an accumulation of excess water and sodium had been established. Eight patients were studied; two had ischemic cardiac disease, and six had dilated cardiomyopathy. Mean hemodynamic measurements at rest were as follows: cardiac index, 1.8 l/min/m2; pulmonary wedge pressure, 30 mm Hg; right atrial pressure, 15 mm Hg. Total body water content was 16% above control, extracellular liquid was 33% above control, plasma volume was 34% above control, total exchangeable sodium was 37% above control, renal plasma flow was 29% of control, and glomerular filtration rate was 65% of control. Plasma norepinephrine was consistently increased (on average 6.3 times control), whereas adrenaline was unaffected. Although plasma renin activity and aldosterone varied widely, they were on average above normal (renin 9.5 times control, aldosterone 6.4 times control). Plasma atrial natriuretic peptide (14.3 times control) and growth hormone (11.5 times control) were consistently increased. Cortisol was also increased on average (1.7 times control). Vasopressin was increased only in one patient.

Diurnal variation of pulmonary artery pressure in chronic heart failure

Variation in pulmonary artery pressure has important consequences for the interpretation of isolated pressure measurements in patients with chronic heart failure. To investigate the nature of diurnal variation in pulmonary artery pressure in chronic heart failure, eight angina-free men (aged 50-72 years) with treated chronic heart failure caused by ischaemic heart disease underwent continuous ambulatory pulmonary artery pressure recording by a transducer tipped catheter. The mean (1 SD) daytime pulmonary artery pressure was 29.6 (5.0) mm Hg systolic and 13.7 (5.6) mm Hg diastolic. The mean change in pressure from day to night was +5.1 (3.2) mm Hg systolic and +3.8 (1.7) mm Hg diastolic; and the mean change from standing to lying +9.3 (2.3) mm Hg systolic and +6.4 (2.1) mm Hg diastolic. In six of the eight patients there was considerable rise in pulmonary artery pressure at night, but in the two patients with the most severe symptoms there was no nocturnal rise. In patients with chronic heart failure, nocturnal pulmonary artery pressure is not determined by postural change alone. But interpretation of isolated pulmonary artery pressure measurements must take the posture of the patient into account.

Relevance of the aetiology of heart failure to drug therapy

The phrase 'heart failure' is used as a shorthand by medical practitioners to describe a wide variety of medical conditions ranging from acute heart failure with pulmonary oedema to terminal chronic heart failure. The medical treatment of these entities varies widely and is dependent on an understanding of the haemodynamics, pathophysiology and aetiology of the conditions, and on the pharmacology of the drugs selected. Important distinctions should be made between systolic and diastolic, acute and chronic, and extracellular and cellular heart failure. Drugs often used for treatment include diuretics, angiotensin-converting enzyme (ACE) inhibitors, nitrates and digoxin. Pure positive inotropic drugs are of value in the treatment of circulatory collapse, post-operatively and in terminal heart failure. Drugs with a mild positive inotropic effect which also possess other properties such as systemic vasodilation, renal vasodilation and alteration of diastolic function may be of wider value in the treatment of mild to moderate chronic heart failure but that prediction awaits proof from controlled clinical trials.

Treatment of heart failure with diuretics: body compartments, renal function and plasma hormones

Body fluid compartments, renal function and plasma hormones were measured in 13 patients with severe chronic heart failure, when the referring physician considered the patient to be appropriately treated. Although renal function was substantially impaired and plasma noradrenaline, aldosterone and renin activity were elevated, fluid compartments were within the normal range. These results show that careful clinical assessment of patients by an experienced physician is a reliable method of assessing restoration of 'normal' body fluid volumes with diuretics.

A new exercise test for the assessment of heart failure: use of a self powered treadmill

Time limited exercise on a self powered treadmill was evaluated as a method of assessing functional capacity in patients with mild heart failure. The characteristics of the treadmill were established by exercising 11 controls at three speeds and two inclinations and comparing oxygen consumption with that on a motorised treadmill under the same conditions. Oxygen consumption on the self powered treadmill at an equivalent speed and inclination was significantly higher because of the work needed to overcome the friction of the belt. Unlike a conventional treadmill, increasing the gradient on the self powered treadmill did not increase oxygen consumption. The distance walked in 12 minutes on the self powered treadmill was measured in eight patients with mild heart failure and ten controls. Maximal oxygen consumption was measured in the same group on a conventional treadmill by a mass spectrometer. There was a significant correlation between the distance walked and maximum oxygen consumption. In patients with mild heart failure the distance travelled in 12 minutes on a self powered treadmill provides a practical, inexpensive, and sensitive method of assessing functional capacity.

Unpredictable zero drift in intravascular micromanometer tipped catheters during long term pulmonary artery pressure recording: implications for catheter design

Zero drift may be a cause of imprecision when micromanometer tipped catheters are used for intravascular pressure measurement over long periods of time. Drift of only a few mm Hg may represent a significant error when accurate recording of low vascular pressures is required. To overcome this problem a micromanometer tipped catheter has been modified so that it can be calibrated easily while it is in the circulation. Laboratory testing has demonstrated that when zero drift occurs this intravascular "reference calibration" is a valid linear function of true zero (r = 0.999). As the sensitivity of the catheter is unaffected by zero drift, it is possible to measure pressure accurately by compensating for this zero drift. During dynamic testing of two catheters, there was a mean net drift over 24 h of -0.54 mm Hg. Clinical evaluation of the catheter was undertaken in the human pulmonary circulation in eight patients (two for 48 h, five for 24 h and one for 8 h). In contrast to the laboratory findings, over the first 4 h after catheterisation there was a phase of rapid zero drift: the net drift was -1.9 (SD 3.3) mm Hg with a range of drift of 5.5 (7.4) mm Hg. Subsequently there was gradual drift: the net drift between 4 and 24 h was -0.44 (2.1) mm Hg with a range of drift of 2.8(1.0) mm Hg; and the net drift between 24 and 48 h was 3.7(2.1) mm Hg with a range of drift of 4.1(1.9) mm Hg. During long term intravascular pressure measurement with micromanometer tipped catheters, zero drift may occur unpredictably and should be quantified.

Digoxin--a redundant drug in congestive cardiac failure

Controversy continues concerning the use of digoxin as a positive inotropic agent in the treatment of heart failure in patients in sinus rhythm. Digoxin is properly used to control the heart rate in patients in atrial fibrillation. The findings from 14 uncontrolled and 6 controlled clinical trials have been examined. Digoxin does exert a small chronic positive inotropic effect. Although some individual patients, particularly those with fluid overload, appear to benefit from digoxin, controlled clinical trials in patients, most of whom have been treated with diuretics, have failed to demonstrate an increase of exercise capacity. No mortality trial has been attempted. Digoxin has the potential to be harmful in patients with ischemic heart disease. Alternative and safer therapies have been shown to be equal or superior to digoxin.

Exercise as a means of assessing heart failure and its response to treatment

Exercise testing was originally applied to healthy subjects and to patients who had, or were suspected of having, ischemic heart disease. Its extension as a means to evaluate heart failure and the response to treatment was logical. Unfortunately, interpreting these tests when done on patients with heart failure is considerably more complicated, being greatly affected by the severity of heart failure, the exercise protocol employed and numerous other factors. An ideal exercise test for use in evaluating heart failure has not yet been designed. Expired gas analysis adds objectivity to the test, but interpretation is more complex than originally thought.

Regional blood flow, muscle strength and skeletal muscle histology in severe congestive heart failure

Regional blood flow to exercising skeletal muscle is reduced in patients who have undergone treatment for severe congestive heart failure, and is a key factor determining the limitation of exercise capacity. Recent studies have shown that the histology, contractile function and biochemistry of skeletal muscle are also abnormal. The mechanisms for both the reduced blood flow and the intrinsic abnormality of skeletal muscle are unknown. The interpretation of experimental data is complicated by different etiologies of heart failure, drug treatment, exercise protocols, the limitations of methods for the measurement of blood flow and metabolism in intact humans, and by the selection of particular groups of muscles for study that may not reflect changes in other muscles in the body.

Current therapeutic principles in the acute management of severe congestive heart failure

The phrase "heart failure" encompasses many clinical entities. The therapeutic principles determining the treatment of these entities vary according to the etiology of congestive heart failure (CHF), the existing hemodynamics, and the mode of action of different drugs. In acute CHF due to myocardial ischemia, intracellular acidosis and the accumulation of phosphate may be the initial underlying causes of contractile failure while, minutes later, lack of high-energy compounds may be an important contributory factor. The cause of contractile failure in chronic syndromes is less well understood. There is evidence for the desensitization of beta receptors on the cell surface but the precise location of the defect is unclear. The receptors may be down-regulated but, in addition, abnormalities have been reported in several other parts of the contractile pathway including the contractile proteins and the sarcoplasmic reticulum. Deficiency of cyclic adenosine monophosphate has also been suggested as a mechanism of contractile failure. In both acute and chronic CHF, there is a redistribution of blood flow to the body organs. Of particular significance is the reduction of blood flow to the kidneys, and a reversal of this defect is one of the major therapeutic objectives. Positive inotropic drugs, vasodilators and drugs altering relaxation of the heart, have been evaluated in the treatment of CHF. Pure inotropic drugs can cause tachycardia, ischemia and "metabolic exhaustion" of the myocardium. The most advantageous profile for an "inotropic" drug in many patients with CHF would be a drug combining systemic vasodilatation, renal vasodilatation, increased relaxation of the myocardium only a mild positive inotropic effect and no chronotropic effect.

Causes of symptoms in chronic congestive heart failure and implications for treatment

The most common symptoms of patients with heart failure are shortness of breath and fatigue. The causes of these symptoms may be different in various entities encompassed by the general term heart failure, such as acute pulmonary edema, circulatory collapse and chronic heart failure. In patients with acute heart failure, shortness of breath is closely related to left atrial pressure. In patients with chronic heart failure, optimally treated with diuretics, the body fluid compartments are usually of normal size. Recent work strongly suggests that, in such patients, central hemodynamic abnormalities are not the sole determinants of symptoms. Impaired vasodilation and altered metabolism in skeletal muscle, circulating metabolites and pulmonary ventilation-perfusion mismatch with consequent increased physiologic dead space may all contribute to the genesis of symptoms. Consequently, it may be possible to alleviate symptoms by treatments that are not aimed directly at improving central hemodynamics. Whether such an approach could also modify prognosis is unknown.

Contractile responses of isolated adult rat and rabbit cardiac myocytes to isoproterenol and calcium

Myocytes were isolated by Langendorff perfusion of rat or rabbit hearts with low calcium solution followed by collagenase and hyaluronidase, or by incubation of chunks of rat ventricular tissue in similar media. Cells were then placed in a bath on a microscope stage, superfused and electrically stimulated. Contraction amplitude and rate of change of length during contraction were measured using a video camera and edge detection monitor. Cells were selected for study using a number of criteria developed to identify and define a cell population able to give consistent inotropic responses over a long period. The maximum contraction amplitude with isoproterenol in rabbit cells was 0.244 micron (sarcomere length change) or 13.1% (percentage change in cell length), and the EC50 was 12.8 nM. The maximum contraction amplitude with isoproterenol did not differ significantly between rat and rabbit, between cells prepared by perfusion and those made from chunks, or when determined from non-cumulative rather than cumulative curves. The EC50 for isoproterenol in rat cells made by the perfusion method (cumulative curves) was 3.81 nM, significantly lower than in rabbit. The maximum amplitude obtained with increasing concentrations of calcium was not significantly different from that with isoproterenol under any condition. The EC50 for calcium averaged 2.78 mM in rat cells made by the perfusion method (cumulative curves) and was significantly greater than that in rabbit (1.4 mM). Maximum rates of contraction for rat cells averaged 4.59 micron/s in 8 mM calcium. Rat cells contracted faster than they relaxed, whereas rabbit cells in 8 mM calcium relaxed faster than they contracted. Rat cells, maximally activated by either calcium or isoproterenol, contracted significantly faster than rabbit. There was no difference in rates of contraction (or relaxation) between rat cells prepared by perfusion and those made from chunks of tissue.

The origin of symptoms in patients with chronic heart failure

Severe shortness of breath is a prominent symptom in acute heart failure (pulmonary oedema) and is related to left atrial pressure. A reduction of this pressure almost always leads to an improvement in symptoms. Patients with chronic heart failure complain of both shortness of breath and tiredness even when fluid overload has been corrected by the appropriate use of diuretics. Shortness of breath under these circumstances is not related simply to central haemodynamics but is determined more by the interaction of changes in respiratory pattern and the metabolic consequences of reduced perfusion of exercising skeletal muscle. An important clinical consequence is that when such patients are optimally treated with diuretics, further improvement of symptoms would not be expected from drugs which merely alter central haemodynamics without influencing other factors such as skeletal muscle blood flow on exercise, or lung perfusion.

Perforation thresholds and safety factors in in vivo coronary laser angioplasty

Laser angioplasty can cause early (acute perforation) or late (stenosis or aneurysm) complications. To find how much intravascular laser energy can be delivered via a 100 microns core optical fibre passed down a balloon angioplasty catheter without causing angiographic abnormalities up to 10 days later, argon laser energy was delivered percutaneously under radiographic screening to the coronary circulation of 12 normal closed chest dogs. With the balloon inflated, sequential laser pulses were delivered to the same site. Angiograms were recorded before, immediately, and again at one week, after laser delivery. There were two laser-induced perforations (both fatal). Mechanical perforation with the 100 microns fibre occurred four times, but there were no haemodynamic sequelae. To find the acute perforation threshold of similar sized arteries to energy delivered via the bare 100 microns core fibre, the tip of which was held in contact with the luminal surface, 32 argon laser pulses were delivered transluminally in vivo to separate sites in normal rabbit iliac and canine coronary arteries. The acute perforation threshold with energy delivered via the angioplasty catheter lay between 6 and 10 J and that without the balloon angioplasty catheter lay between 3 and 4 J. After delivery of up to 6 J via a balloon angioplasty catheter, there were no angiographic abnormalities at one week. Fibre optic transluminal delivery of laser energy may improve the primary success rate of, and perhaps widen the indications for, coronary angioplasty.

Sodium exchange during hypoxia and on reoxygenation in the isolated rabbit heart

Sodium exchange was examined during and after a period of hypoxic and substrate free perfusion in the isolated but arterially perfused interventricular septum of the rabbit heart. Temperature was 35 degrees C and muscles were stimulated at a mean rate of 90 beats/min. The uptake and washout of isotopes of sodium were followed during hypoxia and on reoxygenation. The extracellular space was estimated from the distribution volume of 51Cr-EDTA. During 45 mins hypoxia the intracellular sodium increased from 9.6 +/- 1.1 to 22.6 +/- 1.9 mmol/kg wet tissue. At this time maximal contracture had developed and recovery of mechanical function on reoxygenation was small. No increased efflux of sodium could be detected on reoxygenation. A net efflux of sodium could be detected when conditions were chosen to stimulate sodium--calcium exchange. These experiments do not support the hypothesis that the previously reported influx of calcium on reoxygenation is directly linked to a net loss of sodium.