The effect of regional myocardial ischemia on Doppler echocardiographic indexes of left ventricular performance: influence of heart rate, aortic blood pressure, and the size of the ischemic zone

Continuous measurement of left ventricular performance during and after maximal isometric deadlift exercise

BACKGROUND

Isometric exercise produces a reflex increase in arterial blood pressure that is proportional to the intensity and mass of muscle used during contraction. Little is known about the transient effects of heavy weight lifting on left ventricular performance. In this study, we measured continuous changes in left ventricular performance during maximal large-muscle isometric exercise using the standing deadlift position.

METHODS AND RESULTS

Ten healthy young men performed serial deadlifts at 50% of maximal voluntary effort for 90 seconds and 100% of maximal effort for 30 seconds. Echocardiographic imaging (apical four-chamber view), arterial blood pressure (brachial artery catheter), and electrocardiographic monitoring were recorded throughout the deadlift and for 30 seconds of recovery. Aortic flow velocity was also monitored during a separate series of deadlifts. During 100% maximal deadlift, mean arterial pressure increased from 108 +/- 4 to 164 +/- 6 mm Hg. Left ventricular ejection fraction declined initially (from 57 +/- 2% to 49 +/- 3%) at 15 seconds into the lift and recovered (56 +/- 1%) due to significant increases in end-diastolic volume (104 +/- 11 ml to 132 +/- 16 ml) by the end of the lift. The peak systolic pressure/end-systolic volume ratio did not change during the deadlift. After cessation of the deadlift, mean arterial pressure declined precipitously (to 88 +/- 4 mm Hg) within 5 seconds and gradually returned to baseline after 30 seconds. Left ventricular performance indexes all increased significantly during the recovery phase (ejection fraction to 68 +/- 3%, peak systolic pressure/end-systolic volume ratio to 5.9 +/- 0.9). Findings were qualitatively similar for the 50% deadlift.

CONCLUSIONS

During an intense isometric deadlift, left ventricular performance declines initially but is restored by the Frank-Starling mechanism. Upon release of the deadlift, increased left ventricular performance develops in conjunction with a rapid decrease in arterial pressure. The combined effects of increased wall stress during the lift phase and enhanced contractility during the release phase probably contribute to left ventricular hypertrophy associated with repetitive weight training.

Changes in Doppler indices of cardiac function during and after percutaneous transluminal coronary angioplasty

OBJECTIVE

To assess the sensitivities of Doppler indices to changes in global cardiac function during and after controlled myocardial ischaemia induced by coronary angioplasty.

DESIGN

Continuous wave Doppler signals of aortic flow were recorded during coronary angioplasty. The following Doppler indices of cardiac function were measured before, during, and after balloon inflation: V (peak velocity), MA (mean acceleration), V2/T (T = time from onset to peak ejection), and MD (minute distance corrected for baseline heart rate).

SETTING

A tertiary care cardiological unit in a university hospital.

PATIENTS

Sixteen patients undergoing coronary angioplasty of the left anterior descending coronary artery. Eight patients had multivessel disease.

MAIN OUTCOME MEASURES

The primary outcome measures were planned before data collection began.

RESULTS

12 patients showed a significant fall of three or more Doppler indices from their baseline values during balloon inflation. This occurred in all patients with multivessel disease. The Doppler indices V2 T, MD, V, and MA fell by 43.7%, 37.7%, 27.4%, and 23% respectively from their baseline values (p less than 0.0001). The relative sensitivities of the Doppler indices to ischaemia were V2/T greater than MD (p less than 0.02), MD greater than (p less than 0.001), and V greater than MA (p less than 0.01). The impairment of global left ventricular function resulting from brief balloon inflation during single vessel angioplasty was reversible in all the patients.

CONCLUSIONS

The Doppler indices V2/T, MD, V, and MA are all sensitive, in order of magnitude, to falls in global cardiac function resulting from ischaemia. They may prove useful for assessing cardiac function during ischaemia in the clinical setting.

Doppler echocardiographic evaluation of left ventricular function

Invasive measurements of maximum acceleration of aortic blood flow are sensitive indicators of left ventricular function. Doppler echocardiography provides noninvasive measurements of aortic blood flow acceleration. Our studies establish the accuracy of Doppler-derived indices of aortic blood flow velocity for evaluation of left ventricular function. Doppler-derived peak velocity and mean acceleration showed excellent correlation with invasively measured peak left ventricular dP/dt and maximum aortic blood flow (dQ/dt) under varying heart rate, preload, afterload, and inotropic states. Similar correlations were observed between Doppler-derived peak velocity and mean acceleration and invasively measured left ventricular dP/dt and dQ/dt under conditions of varying degrees of myocardial ischemia. Thus, Doppler echocardiography provides an accurate noninvasive method to evaluate left ventricular performance.

Effect of blood pressure and afterload on Doppler echocardiographic measurements of left ventricular systolic function in normal subjects

Doppler echocardiographic measurements of blood flow velocity and acceleration in the ascending aorta have been shown to be useful descriptors of left ventricular (LV) systolic function. Few data exist, however, regarding the influence of loading conditions, particularly afterload, on these Doppler measurements in human subjects. Therefore, 14 normal volunteers (mean age 28 years) were studied using continuous wave Doppler echocardiography performed from the suprasternal notch both at baseline and during a controlled infusion of methoxamine. LV peak systolic (delta pk) and end-systolic (delta ES) wall stresses were calculated noninvasively using blood pressure and echocardiographic dimensions. Heart rate was kept constant by transesophageal atrial pacing. Methoxamine resulted in significant increases in mean systolic (163 +/- 8 vs 129 +/- 10 mm Hg) and diastolic (93 +/- 7 vs 71 +/- 12 mm Hg) blood pressure, as well as delta pk (277 +/- 25 vs 222 +/- 40 g/cm2 x 10(3] and delta ES (97 +/- 26 vs 77 +/- 19 g/cm2 x 10(3] (p less than or equal to 0.0004 for all). Conversely, peak velocity decreased from 0.91 +/- 0.18 m/s at baseline to 0.8 +/- 0.18 m/s (p less than or equal to 0.002) and peak acceleration decreased from 22 +/- 5 m/s2 at baseline to 19 +/- 5 m/s2 (p less than or equal to 0.006) during methoxamine infusion. Flow velocity integral and LV end-diastolic dimension remained unchanged. Thus, aortic flow velocity and peak acceleration are inversely related to afterload. This relation should be considered when using serial determinations of these Doppler parameters for patients in whom changing levels of afterload might occur.