Influence of vagal stimulation on ventricular contractility, O2 consumption, and coronary flow

Acute vagal stimulation attenuates cardiac metabolic response to β-adrenergic stress

The effects of vagal stimulation (VS) on cardiac energy substrate metabolism are unknown. We tested the hypothesis that acute VS alters the balance between free fatty acid (FFA) and carbohydrate oxidation and opposes the metabolic effects of β-adrenergic stimulation. A clinical-type selective stimulator of the vagal efferent fibres was connected to the intact right vagus in chronically instrumented dogs. VS was set to reduce heart rate by 30 beats min(-1), and the confounding effects of bradycardia were then eliminated by pacing the heart at 165 beats min(-1). [(3)H]Oleate and [(14)C]glucose were infused to measure FFA and glucose oxidation. The heart was subjected to β-adrenergic stress by infusing dobutamine at 5, 10 and 15 μg kg(-1) min(-1) before and during VS. VS did not significantly affect baseline cardiac performance, haemodynamics or myocardial metabolism. However, at peak dobutamine stress, VS attenuated the increase in left ventricular pressure-diameter area from 235.9 ± 72.8 to 167.3 ± 55.8%, and in cardiac oxygen consumption from 173.9 ± 23.3 to 127.89 ± 6.2% (both P < 0.05), and thus mechanical efficiency was not enhanced. The increase in glucose oxidation fell from 289.3 ± 55.5 to 131.1 ± 20.9% (P < 0.05), while FFA oxidation was not increased by β-adrenergic stress and fell below baseline during VS only at the lowest dose of dobutamine. The functional and in part the metabolic changes were reversed by 0.1 mg kg(-1) atropine i.v. Our data show that acute right VS does not affect baseline cardiac metabolism, but attenuates myocardial oxygen consumption and glucose oxidation in response to adrenergic stress, thus functioning as a cardio-selective antagonist to β-adrenergic activation.

Metabolic regulation of in vivo myocardial contractile function: multiparameter analysis

To gain insight into the mechanisms of myocardial regulation as it relates to the interaction of mechanical and metabolic function and perfusion, intact animal models were instrumented for routine physiological measurements of mechanical function and for measurements of metabolism (31P NMR, NADH fluorescence (redox state)) and perfusion (2H NMR and Laser doppler techniques). These techniques were applied to canine and cat models of volume and/or pressure loading, hypoxia, ischemia and cardiomyopathic states. Data generated using these techniques indicate that myocardial bioenergetic function is quite stable under most loading conditions as long as the heart is not ischemic. In addition, these data indicate that there is no universal regulator and that different biochemical regulators appear to mediate stable function under different physiological and pathophysiological conditions: for example; during hypoxia, NADH redox state appears to play a regulatory role; and in pressure loading, ADP, phosphorylation potential and free energy of ATP hydrolysis as well as NADH redox state appear to be regulatory.

Autonomic influences on regional cardiac [14C]2-deoxyglucose uptake in paced dog heart

Sixteen dogs were anesthetized with pentobarbital sodium and placed on positive pressure ventilation. Twelve animals were cardiac paced and four animals were non-paced controls. In four of the paced animals, the left cut peripheral end of the cervical vagus was stimulated electrically. In another four animals, the decentralized left stellate ganglion was stimulated efferently. The four remaining paced animals were controls. The animals were injected i.v. with a single bolus of [14C]2-deoxyglucose, 100 microCi/kg. After 45 minutes of periodic stimulation, the hearts were removed, sectioned and prepared for autoradiography. Cardiac pacing significantly (p less than 0.02) decreased systolic blood pressure, and significantly increased (p less than 0.05) glucose utilization by all regions of the heart, with the exception of the left ventricular endocardium and the left ventricular papillary muscles. Vagal efferent stimulation elicited significant (p less than 0.05) decreases in glucose utilization in both the right atrium and right ventricle. Conversely, efferent stellate ganglion stimulation had no effect on the glucose utilization of any regions of the myocardium studied. This study demonstrates that both cardiac pacing and cardiac vagal efferent neuronal stimulation can produce distinct changes in regional myocardial glucose utilization.

Differences in the electrophysiological response of canine ventricular subendocardium and subepicardium to acetylcholine and isoproterenol. A direct effect of acetylcholine in ventricular myocardium

A prolongation of the ventricular effective refractory period in response to cholinergic agonists or vagal stimulation has been demonstrated in a number of in vivo animal models. However, exposure of isolated myocardial tissues obtained from these hearts to as much as 10(-4) M acetylcholine has been shown to produce essentially no change in action potential duration or effective refractory period. The discrepancy between the in vivo and in vitro findings generally has been explained on the basis of accentuated antagonism, whereby parasympathetic agonists exert their influence through antagonism of the effects of beta-adrenergic tone in vivo. The fact that acetylcholine exerts little if any direct effect on the electrical activity of ventricular myocardium, although well accepted, is based exclusively on studies performed using endocardial preparations. Our recent demonstration of major electrophysiological differences between canine ventricular endocardium and epicardium prompted us to examine the effects of acetylcholine and the role of accentuated antagonism in these two tissue types. Using standard microelectrode techniques, we show that acetylcholine (10(-7)-10(-5) M) has little if any effect in canine ventricular endocardium but a pronounced effect to either prolong or markedly abbreviate action potential duration and effective refractory period in epicardium. These effects of acetylcholine on epicardium are attended by an accentuation of the spike and dome morphology of the action potential, are readily reversed with atropine, fail to appear when epicardium is pretreated with the transient outward current blocker 4-aminopyridine, are accentuated in the presence of isoproterenol (10(-7) to 5 x 10(-6) M), and persist in the presence of propranolol. Isoproterenol-induced abbreviation of action potential duration and effective refractory period is also shown to be more pronounced in epicardium than in endocardium; equimolar concentrations of acetylcholine completely antagonize the effects of isoproterenol in endocardium and epicardium. We conclude that acetylcholine exerts important direct effects on the electrical response of canine ventricular myocardium, which are accentuated in the presence of beta-adrenergic agonists. Our findings suggest the differential response of epicardium and endocardium to acetylcholine is due to the presence of a transient outward current-mediated spike and dome morphology in the epicardial action potential. Finally, the data suggest that acetylcholine may exert antiarrhythmic as well as arrhythmogenic effects through its actions to alter conduction and refractoriness.

'Non-chronotropic' mechanisms on withdrawal of efferent vagal stimulation in anesthetized dogs

Withdrawal of the efferent vagal tone to the heart is an important factor of the increase of cardiac output (CO) and arterial blood pressure (ABP) in several conditions, such as exercise, emotion, postural changes. Vagal withdrawal enhances cardiovascular performance both by increasing heart rate (HR) and by other mechanisms, which were globally named 'non-chronotropic mechanisms'. The nature of these non-chronotropic mechanisms was studied in open-chest dogs under morphine-chloralose anesthesia. After cutting the cervical vagi and all the branches of the stellate ganglia except for the ansae subclaviae, the animals were prepared for recording HR, ABP, CO and left ventricular pressure (LVP). The experiments started during control vagal stimulations and consisted either in turning the vagal stimulators off (STOP), or in raising HR by atrial placing without withdrawing vagal stimulation (PACE), or in turning the vagal stimulators off while keeping HR constant by atrial pacing since the control vagal stimulation (STPA). Thus, STOP, PACE and STPA produced withdrawal of all vagal effects, of the chronotropic effects and of the non-chronotropic effects, respectively. Non-chronotropic mechanisms were evaluated both as the effects of STPA and as the difference between the effects of STOP and PACE. Experiments were repeated during stellate ganglion stimulation and during simultaneous atrio-ventricular pacing, to evaluate the role of vagosympathetic interactions and of atrial contractility. CO increased by 25% after STOP, by 20% after PACE and by 5% after STPA in the absence of sympathetic stimulation and by 30% after STOP, by 20% after PACE and by 10% after STPA during sympathetic stimulation. Stellate ganglion stimulation doubled non-chronotropic effects probably by potentiating vagal effects on myocardial contractility: after STPA the maximum LVdP/dt increased by 2% without sympathetic stimulation and by 7% with sympathetic stimulation. In all conditions, the increases in ABP after STOP, PACE and STPA were small and not statistically different between STOP and PACE. Simultaneous atrio-ventricular pacing in the absence of sympathetic stimulation nearly abolished non-chronotropic mechanisms, since CO increased to about the same extent both with STOP and with PACE. It is concluded that non-chronotropic mechanisms on vagal withdrawal consist mainly in the enhancement of atrial contractility and in the release of vagal restraint on the sympathetic effects upon the ventricles.

Modulation of an idioventricular rhythm by vagal tone

A 28 year old man with a stable permanent idioventricular rhythm of 80 to 85 beats/min, with all the characteristics of a pacemaker, is described. This pacemaker was slowed by maneuvers that enhanced vagal tone, including carotid sinus massage, the postrelease phase of the Valsalva maneuver and phenylephrine. The pacemaker was also slowed by a cholinesterase inhibitor (edrophonium hydrochloride) and accelerated by a muscarinic receptor blocking drug (hyoscine butylbromide). The actions of these maneuvers and agents were independent of sympathetic tone as propranolol pretreatment did not alter their effects. Similarly, propranolol did not affect the pacemaker rate. The pacemaker was not dependent on a slow inward current because verapamil did not affect its rate. The pacemaker accelerated in response to increased sympathetic tone induced by exercise and upright tilting and to the adrenergic agonist isoproterenol. The pacemaker was localized to the high posterior septal region of the left ventricle underneath the mitral valve. This report describes in a man an idioventicular pacemaker that is innervated by sympathetic and vagal fibers and responsive to alterations in tone of both limbs of the autonomic nervous system. It offers the first clear proof that a ventricular pacemaker can be innervated and controlled by the vagus nerve and provides its location.

Autonomic control of large coronary arteries and resistance vessels

The resistance coronary vessels as well as the large coronary arteries are regulated to a major extent by autonomic mechanisms. Neural and pharmacologic activation of alpha-adrenergic pathways can reduce coronary blood flow and the cross-sectional area of large coronary arteries, despite concomitant increases in coronary distending pressure. Activation of either beta 1- or beta 2-adrenergic receptors can induce potent dilation of both coronary resistance vessels and large coronary arteries, whereas blockade of these receptors can elicit profound constriction in the presence of elevated beta-adrenergic tone. The regulation of the coronary circulation by parasympathetic mechanism remains the most controversial, likely because of major species differences. Parasympathetic coronary dilation is uniformly observed in the dog, but in primates, important aspects of parasympathetic-mediated coronary vasoconstriction have also been demonstrated.

A simple experimental index for the evaluation of inotropic responses

The validity of the first derivative of systemic arterial pressure (SAdP/dt) as an indirect experimental index for the evaluation of inotropic responses was ascertained in rats anesthetized with pentobarbital sodium (40 mg/kg, i.p.), using the first derivative of left ventricular pressure (LVdP/dt) as the reference. We observed highly significant qualitative and quantitative (p less than 0.001) correlations between these two parameters, under five well-established experimental cardiovascular perturbations that are known to promote inotropic actions, viz, vagosympathetic trunk stimulation; intravenous administration of pentobarbital, epinephrine, or phenylephrine; and temporary common carotid artery occlusion. Preliminary experiments using isometric ventricular contraction as the reference also confirmed these observations. It is suggested that the SAdP/dt may qualify, at the systemic level, as an easily accessible experimental index for ventricular contractility.

The hemodynamic effects of sympathetic stimulation combined with parasympathetic blockade in man

To define the effects of circulating norepinephrine and epinephrine on cardiac function and to determine whether left ventricular function is influenced by parasympathetic mechanisms during catecholamine stimulation, hemodynamic changes were investigated in healthy young human subjects who were supine and awake during infusion of intravenous norepinephrine alone (125 ng/kg/min) (n = 6), norepinephrine (125 ng/kg/min) plus epinephrine (50 ng/kg/min) (n = 6), and norepinephrine plus epinephrine plus parasympathetic blockade induced by atropine (2 mg intravenously) (n = 5). Ejection fraction and changes in cardiac volumes were measured by radionuclide ventriculography. During the infusion of norepinephrine plus epinephrine, plasma norepinephrine increased from 358 +/- 35 to 1782 +/- 123 pg/ml (mean +/- SE) and plasma epinephrine increased from 31 +/- 5 to 355 +/- 90 pg/ml (both p less than .01 vs baseline). These increases in plasma catecholamines were associated with increases in the heart rate (58 +/- 3 to 67 +/- 2 beats/min, p = NS), systolic blood pressure (113 +/- 3 to 140 +/- 6 mm Hg, p less than .01), ejection fraction (0.64 +/- 0.02 to 0.72 +/- 0.02 ejection fraction units, p less than .01), stroke volume (+41 +/- 5%, p less than .01), and cardiac output (+54 +/- 8%, p less than .01), and a decrease in systemic vascular resistance (-31 +/- 3%, p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

The Inotropic Actions of N-Acetylprocainamide: Blockade and Reversal by Propranolol

The inotropic actions of N-acetylprocainamide (NAPA) were studied in chloralose-urethane anesthetized dogs. Myocardial contractile force was measured with a Walton-Brodie strain gauge sutured to the right ventricle. A low-dose NAPA infusion (12 mg/kg i.v.) increased myocardial force by a maximum of 11.6±2.4% (mean±SEM), whereas a high dose of NAPA (60 mg/kg i.v.) increased myocardial force by 33.3±2.6% at the peak of the effect. The high-dose NAPA infusion also caused significant reductions in heart rate and blood pressure, while the low-dose NAPA infusion lacked significant chronotropic or hypotensive actions. Pretreatment with propranolol (0.5 mg/kg i.v. loading, followed by a 10 μg/kg/min infusion) did not block the positive inotropic actions of NAPA 12 mg/kg, but these actions were blocked in dogs pretreated with both propranolol and atropine (1 mg/kg). On the other hand, pretreatment with propranolol blocked and reversed the inotropic actions of NAPA 60 mg/kg, and potentiated its negative chronotropic effects. Thus, the positive inotropic actions of NAPA are indirect and more than one mechanism is involved; a component due to direct action related to the lengthening of cardiac repolarization is not discounted. At low doses, the increase in myocardial force seems related to NAPA's vagolytic properties, whereas at high doses the positive inotropic actions appear to be catecholamine-mediated. Furthermore, a negative inotropic action of high-dose NAPA is apparent after beta-adrenergic receptor blockade.

Cardiovascular effects of atropine in postoperative cardiac patients receiving digoxin for ventricular dysfunction

Digoxin is clinically useful as a cardiac antiarrhythmic and inotropic agent. Its antiarrhythmic actions are mediated through the cholinergic nervous system. The cholinergic system, when activated, can depress ventricular function. We have sought to further increase the cardiovascular effects of digoxin by blocking its cholinergic effects with atropine. Atropine, 1 mg intravenously, was given to 10 postoperative cardiac patients. The cardiovascular time course was monitored by an ECG, radial arterial line, and pulmonary artery thermodilution catheter for 8 hours. A significant increase (p less than 0.05) in the cardiac output (CO), from 5.98 +/- 0.24 L/min to 6.60 +/- 0.34 L/min, was evident within 2 hours after atropine administration. The CO returned to control levels by 6 hours. There were no significant changes in heart rate, systemic vascular resistance, pulmonary artery wedge pressure, or systemic blood pressure. The results indicate that the cholinergic blockade of digoxin with atropine will acutely increase the cardiac output in postoperative cardiac patients.

Myocardial oxygen consumption with isoproterenol versus calcium chloride in hypocalcemic ventricular failure in dogs

In 30 dogs on right heart bypass we compared the effects of isoproterenol with those of calcium chloride on myocardial oxygen consumption and on left ventricular function in the setting of ventricular depression produced by ionized hypocalcemia. In 22 dogs (Groups A and B) either isoproterenol or calcium chloride was infused, left ventricular function curves were generated, and end-diastolic pressure vs segment length plots were obtained. In 8 dogs (Group C), with initial hypocalcemia, both isoproterenol and calcium chloride were infused separately in random order to produce an equal decrease in left ventricular end-diastolic pressure at constant mean aortic pressure, heart rate, and cardiac output. Myocardial oxygen consumption and indices of left ventricular function were obtained. In Groups A and B, both drugs, when administered to the ventricle depressed by hypocalcemia, displaced left ventricular function curves upward and to the left. Left ventricular stroke work at constant left ventricular end-diastolic pressure increased (from 13.0 +/- 1.3 to 31.2 +/- 2.3 g X m for isoproterenol; from 13.9 +/- 2.5 to 32.5 +/- 2.5 g X m for calcium chloride). In Group C, there were no significant differences between left ventricular end-diastolic pressure, end-diastolic internal diameter, myocardial oxygen consumption, or peak left ventricular dP/dt in the hypocalcemic periods preceding isoproterenol and calcium chloride infusion. When the two drugs caused matched decreases in left ventricular end-diastolic pressure (-7.4 +/- 0.5 cm H2O for isoproterenol; -7.3 +/- 0.8 cm H2O for calcium chloride) there were similar decreases in end-diastolic internal diameter. However, isoproterenol was associated with a significantly greater (P less than 0.001) myocardial oxygen consumption (13.7 +/- 0.4 ml X 100 g-1 X min-1) than calcium chloride infusion (11.9 +/- 0.4 ml X 100 g-1 X min-1), as well as a greater peak left ventricular dP/dt (P less than 0.005).

Effects of acetylcholine on action potential characteristics of atrial and ventricular myocardium after bilateral cervical vagotomy in the cat

Acetylcholine, the parasympathetic neurotransmitter, shortens the action potential duration of cat atrial muscle cells, but not ventricular muscle cells. In mammalian species, atrial tissue receives a richer cholinergic nerve supply than ventricular tissue. To determine whether chronic withdrawal of cholinergic tone might influence the subsequent response of these tissues to cholinergic stimulation, we examined the effect of acetylcholine on the action potentials of atrial and ventricular myocytes from cats with intact vagi and cats after chronic bilateral cervical vagotomy. Following bilateral cervical vagotomy, physostigmine (10(-6) M) failed to alter atrial tension development or action potential duration. Acetylcholine produced shortening of the action potential duration in atrial muscle from cats with intact vagi and in cats following bilateral cervical vagotomy. However, the degree of shortening produced by acetylcholine after bilateral cervical vagotomy was significantly greater (P less than 0.001). In ventricular muscle from cats with intact vagi, acetylcholine did not alter action potential duration. In ventricular muscle from cats after bilateral cervical vagotomy, acetylcholine shortened the action potential duration. Maximal effect was seen at a concentration of 10(-5) M where acetylcholine shortened action potential duration at 90% repolarization from a control value of 179 +/- 4 to 150 +/- 7 msec. Atropine (10(-6) M) reversed the effects of acetylcholine. Addition of propranolol (10(-6) M) to the superfusate or pretreatment of the animals with reserpine (2 mg/kg, ip) 24 hours before sacrifice failed to alter the response of ventricular muscle cells to acetylcholine.(ABSTRACT TRUNCATED AT 250 WORDS)

Cholinergic mechanisms in human coronary artery preparations: implications of species differences

Acetylcholine dilates most arteries, including dog coronaries, if the endothelium is intact. The present study has shown only contraction of human coronary arteries to acetylcholine. Both strip and ring preparations of human coronary epicardial vessels, the latter done particularly to protect the intimal surface from unintentional denudation, contracted to acetylcholine at low to high concentrations (6.84 X 10(-9)-2.05 X 10(-5) M). These responses were blocked by atropine (3.45 X 10(-6) M). Acetylcholine contracted the arteries about as much as ergonovine and considerably more than noradrenaline. Field stimulation of coronary artery strips caused a vasoconstriction which was partially antagonized by atropine (3.45 X 10(-6) M). The release of [3H]noradrenaline from superfused coronary artery preparations during field stimulation was inhibited by methacholine (6.24 X 10(-6) M), a stable muscarinic analogue of acetylcholine. Dog coronary arteries relaxed to acetylcholine but not if the endothelium was intentionally denuded, in which case there was either no response at all or a weak relaxation. Coronary arteries of sheep, pig and cattle always contracted to acetylcholine, and those of monkey contracted in two out of three responsive preparations. Histological examination of the intimal surface of human coronary vascular segments confirmed the presence of an intact endothelial cell layer. Rabbit aorta gave dilator responses to acetylcholine even after being left in the animal for as long after death as the human arteries had been; they did not give dilator responses after the endothelium was rubbed off. It is concluded that cholinergic vasoconstriction of coronary arteries occurs in humans, though not in the dog, and is probably important in some cases of coronary artery spasm.

Autonomic mechanisms regulating myocardial contractility in conscious animals

In this review some of the issues and controversies involved in the neural control of the myocardial inotropic response to stress have been discussed. For example, it is surprising that either direct or reflex activation of the sympathetic nerves induces a relatively small increase (20-40%) in the left ventricular inotropic state when compared with the three-five-fold increase associated with maximal dynamic exercise. Studies contrasting the levels of circulating catecholamines with the left ventricular inotropic responses induced by hemorrhage, exercise and exogenously administered catecholamines, suggest that the catecholamine concentration at the synaptic cleft is the primary determinant of the left ventricular inotropic response. Although parasympathetic neural activation alone appears to have little direct influence on the left ventricular inotropic state and central nervous system integration of the autonomic nervous system usually insures there is a reciprocal relationship between sympathetic and parasympathetic neural activity, the potential for parasympathetic inhibition of the response to sympathetic or sympathomimetic augmentation of the intropic response exists. The importance of sympathetic-parasympathetic nervous system interaction in physiologic and pathologic conditions has yet to be defined. It is this type of knowledge of the interactions of reflex pathways which will be critical to the full understanding of autonomic reflex control of myocardial performance under physiologic and pathologic conditions.

The effect of cholinergic agonists on coronary flow rate and oxygen consumption in isolated perfused rat heart

The metabolic and circulatory consequences of activation of the muscarinic receptor(s) were investigated by local administration of acetylcholine and its three analogues (bethanechol, carbachol and methacholine) into beating and KCl-arrested perfused rat hearts. Acetylcholine and the three other choline esters caused vasoconstriction in both types of preparations and this vasoconstriction was accompanied by a decrease in oxygen consumption. In most cases the dose-response curves were biphasic and changes in coronary flow paralleled those in oxygen consumption. Both phenomena were abolished by administration of atropine and either removal of calcium or infusion of verapamil but were unaffected by addition of the adrenergic alpha-blocker, prazosin, and the adrenergic beta-blocker, propranolol. Infusions of low concentrations of the cholinergic agonists were accompanied by increases in the myocardial phosphorylation state ratio [( ATP]free/[ADP]free[Pi]) which correlated with the simultaneous decreases in oxygen consumption and coronary flow. It is suggested that muscarinic receptors responsible for vasoconstriction in perfused rat heart are located not only on coronary vessels but also on the cardiac muscle cells. Activation of the former receptors induces vasoconstriction by direct action on the vascular smooth muscle while activation of the latter receptors induces vasoconstriction indirectly by decreasing cardiac work and increasing the myocardial [ATP]free/[ADP]free[Pi] ratio. The results also show that stimulation of muscarinic receptor(s) and the consequent metabolic and vasoregulatory responses are coupled to calcium movements.

Direct effects of cholinergic stimulation on ventricular automaticity in guinea pig myocardium

The purpose of these experiments was to determine whether muscarinic cholinergic agonists exerted a negative chronotropic effect in the absence of endogenous norepinephrine in isolated guinea pig ventricular myocardial strips. The chronotropic response to physostigmine (10(-6) M) in control, reserpine-pretreated animals, and in the presence of increased norepinephrine release induced by superfusion of tyramine (10(-5) M), was studied. The control rates in the control, reserpine-pretreated, and tyramine-treated groups were 106 +/- 40, 93 +/- 31, 109 +/- 28/min, respectively. Propranolol (10(-6) M) produced a 23% slowing in rate in control animals and an 8% slowing in reserpine pretreated animals (P less than 0.01), suggesting basal secretion of norepinephrine. Tyramine (10(-5) M) produced a 28% increase in rate in control animals (P less than 0.05) and tyramine (10(-4) M) produced no increase in reserpine-pretreated animals. Physostigmine produced similar negative chronotropic response in control, reserpine-pretreated, and tyramine-treated groups of 45, 49, and 28%, respectively. Physostigmine produced no change in measured Purkinje fiber action potential characteristics, except for a decreased rate of spontaneous diastolic depolarization. Our results demonstrate that physostigmine slows the spontaneous rate in control, reserpine-pretreated and tyramine-treated groups, indicating that muscarinic cholinergic agonists exert a direct negative chronotropic effect at postjunctional cell surface receptors, independent of the presence or level of adrenergic tone.

Effect of supramaximal vagal stimulation in combination with hypoxia, respiratory acidosis and deep halothane anaesthesia on cardiovascular function in dogs

Vagal reflexes are generally recognized as a possible cause of cardiac arrest during anaesthesia. Studies were performed to determine whether hypoxia, respiratory acidosis or deep halothane anaesthesia modify the cardiovascular effect of vagal stimulation (VS) in dogs. The animals were anaesthetized with intravenous urethane and chloralose, and paralysed with metocurine. Normal temperature and arterial blood gas variables were maintained and supramaximal VS was applied to the distal end of both vagus nerves for 5 min. No differences were found in any of the variables measured among the time periods when VS was repeated five times in six control dogs receiving urethane-chloralose basal narcosis only to determine the effects of time. VS resulted in 15 +/- 3 s (mean +/- s.e. mean) of asystole. Heart rate, cardiac output (CO) and mean arterial pressure (MAP) were still significantly decreased (P less than 0.001) and central venous pressure, right atrial pressure, pulmonary capillary wedge pressure (PCW), systemic (SVR) and pulmonary vascular resistance significantly increased (P less than 0.01--P less than 0.001) at the end of stimulation when compared to values before VS in all 24 dogs. Neither hypoxia [PaO2 5.3 kPa (40 mmHg)] nor respiratory acidosis [pH 7.00, PaCO2 10.6 kPa (80 mmHg)] modified these effects of VS. VS during halothane anaesthesia (1.6% end-tidal concentration) resulted in further significant decreases (P less than 0.05--P less than 0.001) in CO, MAP, mean pulmonary arterial pressure, PCW and SVR when compared to VS under basal narcosis. VS under halothane anaesthesia combined with hypoxia or respiratory acidosis did not decrease the cardiovascular parameters as much as VS under halothane anaesthesia alone. VS alone, or in combination with hypoxia or respiratory acidosis, failed to cause persistent asystole.

Ventricular fibrillation after intravenous atropine in a patient with atrioventricular block

A 69-year-old black woman with complete AV block developed ventricular fibrillation following an IV injection of 1 mg of atropine sulphate. After a successful DC countershock, the ECG showed a polymorphous ventricular tachycardia which subsided spontaneously. Cardiac catheterization revealed a small left ventricular diverticulum and normal coronary arteries. This seems to be the first reported case of atropine-induced ventricular fibrillation in a patient with complete AV block. The fact that this occurred without previous change of the ventricular rate suggests that the adverse action of atropine was mediated through a mere vagolytic effect at the ventricular level.

Beneficial effects of vagal stimulation on the ischaemic myocardium during beta-receptor blockade

The effect of vagal stimulation on the myocardial ischaemia produced by acute coronary occlusion during beta-receptor blockade has been examined. Epicardial ST-segment elevation, myocardial surface temperature and regional blood flow were determined 10 min after coronary occlusion in the dog. Coronary occlusion after beta-receptor blockade alone raised the average ST-segment from 0.5 +/- 0.3 to 3.1 +/- 0.5 mV (SEM) (p less than 0.001). Subsequent vagal stimulation with beta-receptor blockade, which reduced heart rate from 129 to 50 beats/min, mean arterial pressure from 123 to 78 mmHg, but increased cardiac output from 1164 to 1855 ml/min, resulted in marked reduction in ST-segment elevation to 0.3 +/- 0.2 mV which was not different from the control before occlusion. Epicardial temperature was markedly decreased in the ischaemic area following coronary occlusion. The temperature difference between central ischaemic and surrounding areas became smaller after beta-receptor blockade, and vanished during vagal stimulation. Vagal stimulation caused a 55% decrease of blood flow in all non-ischaemic regions. A smaller reduction took place in the border zone where flow values close to those of the non-ischaemic myocardium were obtained. In the central ischaemic area blood flow remained unchanged despite the reduction in arterial pressure. Thus, vagal stimulation resulted in decreased collateral resistance in the ischaemic area and a marked reduction of myocardial oxygen requirement of both non-ischaemic and border zone myocardium, additional to that obtained with beta receptor blockade. The provision of energy to the ischaemic myocardium is therefore very favourably balanced with its actual demand during vagal stimulation.

Relation between ionized calcium concentration and ventricular pump performance in the dog under hemodynamically controlled conditions

The effect of plasma ionized calcium concentration on left ventricular function was studied in the canine heart on right heart bypass. Stroke volume, mean arterial pressure and heart rate were controlled. Plasma ionized calcium was lowered to 0.58 +/- 0.01 mM by citrate infusion and raised to 1.70 +/- 0.01 mM by calcium chloride infusion in random order in each dog. Left ventricular function at each of these ionized calcium levels was compared with that in an immediately preceding normocalcemic period. At a constant stroke work (16.9 +/- 0.2 g-m), sustained hypercalcemia was associated with a small decrease in left ventricular end-diastolic pressure (1.7 +/- 0.7 cm H2O, p less than 0.05) despite a marked increase in peak left ventricular dP/dt (first derivative of ventricular pressure) averaging 34 percent (p less than 0.001). Coronary blood flow, tension-time index and myocardial oxygen consumption were not significantly altered. Stroke work determined at a left ventricular end-diastolic pressure of 14 cm H2O, by interpolation in left ventricular function curves, was 11 +/- 4.4 percent above that at control normocalcemia (p less than 0.05). At a constant stroke work (16.9 +/- 0.2 g-m), sustained hypocalcemia was associated with a marked depression of left ventricular function as demonstrated by a substantial increase (from 4.9 +/- 0.3 to 12.7 +/- 1.1 cm H2O, p less than 0.0001) in left ventricular end-diastolic pressure (p less than 0.0001), decreased mean systolic ejection rate (p less than 0.01) and decreased peak left ventricular dP/dt (p less than 0.0001). Coronary blood flow increased (p less than 0.05) whereas myocardial oxygen consumption did not change significantly. A marked displacement of left ventricular function curves to the right (compared with curves obtained during normocalcemia) was observed, and stroke work determined at a left ventricular end-diastolic pressure of 14 cm H2O was 52 +/- 5.4 percent below control level (p less than 0.001). It appears that hypercalcemia, when initiated from a normal control level, provides only a small enhancement of ventricular pump performance (as indexed by the stroke work-left ventricular end-diastolic pressure relation) despite a marked increase in peak left ventricular dP/dt, whereas marked improvement of left ventricular performance may be expected when calcium infusion is initiated from an ionized calcium level that is below normal.

Utilization of leucine by working rat heart

Leucine provided substrate to partially support mechanical activity of working rat hearts; the beneficial effect on peak systolic pressure development was more marked as leucine concentration was increased to 10 mM. In Langendorff preparations that had been exposed to 5 mM [U-14C]leucine, the imposition of cardiac work was accompanied by a threefold increase in the rate of 14CO2 production within the first 30 s; however, the rate decreased 40% in the next 10 min. This transient acceleration of 14CO2 production was not observed when [1-14C]leucine was provided and appeared to be due to oxidation of a tissue pool of radioactive intermediates that was present after 10 min of Langendorff perfusion. Over a period of 1 h, oxidation of either [U-14C]- or [1-14C]leucine increased 25-40% in working compared to Langendorff preparations that were supplied 5 mM leucine and 11 mM glucose. In working hearts that were supplied a substrate and hormone mixture that simulated normal plasma and 1 mM leucine, a concentration found in the plasma of diabetic but not normal rats, leucine oxidation was accelerated 73% by work but amounted to only 3.3% of oxygen consumption.

Vagal control of coronary blood flow in dogs

The experiments were performed on open-chest mongrel dogs, the hearts being paced at a constant rate. Both vagi were cut in the neck and the peripheral ends were stimulated with frequencies of 1, 5, 10, 15, 20, 25, 30, 35, 40 and 50 cycles per sec (30 sec, 8 V, 2 msec). Adrenergic beta-receptors were blocked with propranolol and adrenergic alpha-receptors with dihydroergotamine. Coronary flow was measured with electromagnetic flowmeters on the descending branch of the left coronary artery. A significant increase in coronary flow was observed with rising frequency of stimulation. This increase was 15 percent with 30 Hz and decreased with higher frequencies. The total coronary resistance reached its lowest level at the frequency of 30 cycles per sec. The results clearly indicate the parasympathetic control of myocardial blood flow.

Acetylcholine antagonism of the electrophysiological effects of isoproterenol on canine cardiac Purkinje fibers

The purpose of these experiments was to determine whether or not acetylcholine modulated the electrophysiological effects of isoproterenol on canine cardiac Purkinje fibers. Conventional microelectrode techniques were used. Predictably, isoproterenol produced shortening of action potential duration; acetylcholine significantly blunted this effect of isoproterenol. Isoproterenol restored excitability to fibers exposed to 22 mM potassium solutions, and acetylcholine abolished this isoproterenol-restored excitability. Both of these antagonistic effects of acetylcholine were blocked by atropine. Acetylcholine alone did not affect action potential duration in polarized fibers or excitability in potassium-depolarized fibers. Furthermore, acetylcholine had no effect on the decrease in action potential duration induced by premature electrical stimulation or by acetylstrophanthidin administration, or on excitability of fibers exposed to a zero sodium, high calcium superfusant. These data demonstrate a direct cellular basis for cholinergic antagonism of the electrophysiological effects of beta-adrenergic stimulation of canine cardiac specialized intraventricular conducting tissue.

Clinical evaluation of the enhancement of vagal tone in acute myocardial infarction by edrophonium hydrochloride: effects on ventricular arrhythmias, His bundle electrography, and left ventricular function

Enhanced electrical stability of acutely ischemic myocardium with vagal stimulation and acetylcholinesterase inhibition has been demonstrated experimentally. To extend these findings clinically, within 24 hours of acute myocardial infarction, 11 patients underwent continuous 10 hour Holter monitoring: 2.5 hour control before and after 5 hour constant edrophonium infusion (0.25 to 2.00 mg./minute). Continuous infusion of the agent lowered heart rate 92 to 78 b.p.m. (p less than 0.01). Although mean total ventricular extrasystoles (PVC's) per 5 hours per patient (131) and PVC's per 1,000 beats (4.7) were unchanged (p greater than 0.05), potentially lethal tachyarrhythmias (malignant PVC's: multifocal, R on T, paried, greater than 5 per minute or ventricular tachycardia) were terminated in six of 10 patients by edrophonium. However, serious ventricular arrhythmias continued in three patients and appeared in four despite the agent. Ventricular fibrillation did not occur during the 10 hour period of study. In addition, the patients were evaluated hemodynamically and by His bundle electrograms before and after a 10 mg. bolus of edrophonium prior to the 10 hour constant infusion: heart rate declined (88 to 72 b.p.m., p less than 0.01), while mean arterial pressure (98 mm. Hg), left ventricular filling pressure (14 mm. Hg), cardiac index (2.4 L. per minute per square meter), and stroke work index (36 Gm.m./M.2) were unchanged (p greater than 0.05). The edrophonium bolus prolonged the A-H interval (117 to 135 msec., p less than 0.01) while the H-Q interval was unaltered (48 msec; p greater than 0.05). It is concluded that increased vagal tone with edrophonium did not reduce the over-all presence of premature ventricular contractions in the entire study group; however, the malignant nature of PVCs and ventricular tachycardia appeared to be lessened by the parasympathomimetic agent in certain patients. In addition, no adverse hemodynamic or intraventricular conduction effects were produced by edrophonium administration.

Regulation of coronary blood flow

A very schematic summary of possible factors that affect coronary vascular resistance is illustrated in Fig. 11. These factors are mechanical, myogenic, metabolic, and neural. Mechanical influence is passive and is essentially determined by the extravascular compression which is important only during systole and particularly in the subendocardial layers of the left ventricular myocardium. With respect to the myogenic factor it is controversial whether it plays a role in adjustments of coronary vascular tone. Metabolic processes are possibly integrated at the level of the myocardial cell PO2 which is the resultant of oxygen supply and need, which in turn depend on the myocardial contractile activity as well as other biochemical processes. A decrease in myocardial PO2 gives rise to the release of the vasodilator metabolite adenosine. Nevertheless, other chemical factors (H+, K+, osmolarity) known to be released by the heart (which by themselves are poor and transient coronary vasodilators and whose release does not correspond with changes in coronary resistance) may play a role by modulating the coronary sensitivity to adenosine and other factors.

Interaction between cyclic adenosine monophosphate and cyclic gunaosine monophosphate in guinea pig ventricular myocardium

The purpose of this study was to examine the mechanisms underlying adrenergic-cholinergic antagonism in ventricular myocardium. Myocardial contractility, cyclic adenosine monophosphate (AMP) levels, and cyclic guanosine monophosphate (GMP) levels were measure in isolated guinea pig ventricles after treatment with various inotropic agents given alone and simultaneously with acetylcholine. Acetylcholine alone markedly elevated cyclic GMP levels but did not substantially change myocardial contractility. However, the same concentration of acetylcholine significantly attenuated the inotropic effect of isoproterenol and histamine, two drugs that may act by increasing myocardial levels of cyclic AMP. The decrease in the inotropic response to isoproterenol did not appear to be due to a decrease in the generation of cyclic AMP, because cyclic AMP levels were similar in hearts receiving isoproterenol alone and those receiving isoproterenol with acetylcholine. Dibutyryl cyclic GMP also antagonized the intropic action of isoproterenol. Acetylcholine did not alter the inotropic effects of ouabain, an agent that increases myocardial contractility without changing cyclic AMP levels. These results suggest that cyclic GMP mediates the antiadrenergic effects of acetylcholine by specifically antagonizing the inotropic actions of cyclic AMP.

Reflex parasympathetic coronary vasodilation elicited from cardiac receptors in the dog

Veratrum alkaloids injected into the coronary circulation stimulate myocardial receptors to produce reflex bradycardia and arterial hypotension (the Bezold-Jarisch reflex). This study investigated the hypothesis that parasympathetic coronary vasodilation occurs as part of the Bezold-Jarisch reflex. Blood flow in the circumflex coronary artery was measured in chloralose-anesthetized, closed-chest dogs with a newly developed cannula-tip flow transducer. Alpha-receptor blockade with Dibozane (2 mg/kg) was used to prevent peripheral vasodilation, and beta-receptor blockade with propranolol (1 mg/kg) was used to prevent adrenergic cardiac effects. Electrical pacing was used to maintain a constant heart rate. Under these conditions, veratridine injected into the anterior descending coronary artery but not into the circumflex coronary artery produced a 63% increase in circumflex coronary blood flow and an 88% increase in diastolic coronary conductance. The effect was abolished when the reflex arc was interrupted by either vagotomy or atropine administration. It is concluded that a cardiocoronary reflex parasympathetic coronary vasodilation can be elicited by stimulating cardiac receptors with veratridine.

Vagally mediated suppression of premature ventricular contractions in man

Twelve patients with PVC's were studied to assess the possible role of the vagus nerves in suppressing PVC's. All were without significant heart disease and under forty years of age. A series of five autonomically active drugs, including vagotonic and vagolytic agents, was administered intravenously, each drug being given after the effects of the previous one had abated. Two of the patients did not have PVC's at the time of study. Of the remaining ten patients, five showed vagally mediated suppression of PVC's. Phenylephrine (40 to 60 mug per minute) reduced HR, from an average of 63.2 bpm to 48.5 bpm by a vagally mediated reflex, and decreased PVC incidence in all five patients. The per cent of ventricular heart beats which were PVC's (per cent PVC) decreased from an average of 18.2 per cent to 3.2 per cent in these patients (p smaller than 0.005 in each case). Edrophonium (10 mg.) produced less bradycardia and less reliable PVC suppression. In two of these five patients, atropine (1.5 mg.) increased PVC incidence markedly, although the per cent PVC did not change significantly because of the concomitant tachycardia. These data suggest that strongly increased vagal tone can suppress PVC's in a significant percentage of such patients. This finding in man extends previous animal work which has shown a protective role of the vagus against ventricular arrhythmias under certain conditions.

The inotropic effect on the heart of stimulating the vagus in the dog, duck and toad

1. The chronotropic and inotropic effects of stimulating the vagus on the hearts of the dog, duck and toad were studied.2. The maximum rate of rise of pressure in the left ventricle (dP/dt max) measured at a constant heart rate and mean aortic pressure was used as an index of the inotropic changes.3. The sensitivity of dP/dt max as an index of inotropic changes brought about by stimulating the vagus was established in the toad where a 49% reduction in heart rate was associated with a 30% reduction in dP/dt max.4. In the dog stimulation of the vagus resulted in a reduction in heart rate of 38% and only a small reduction in dP/dt max of 6%.5. Results similar to those found in the dog were obtained in the duck where the reduction in heart rate of 44% was associated with reduction in dP/dt max of only 3%.6. It is concluded that the vagus has only a small and negligible negative inotropic effect on the ventricles of the dog and duck.

Relative contributions of the atrial systoleventricular systole interval and of patterns of ventricular activation to ventricular function during electrical pacing of the dog heart

In areflexic canine right heart bypass preparations, little difference in ventricular function was observed as a result of atrial pacing, sequential atrioventricular pacing, or atrial-His bundle pacing at an appropriate atrial systole-ventricular systole (As-Vs) interval. Ventricular function was depressed during ventricular pacing and during atrioventricular pacing with an inappropriate As-Vs interval. In areflexic isovolumic left ventricle preparations, ventricular function was depressed during ventricular pacing compared to atrial pacing, and changes in the As-Vs interval during atrioventricular pacing were accompanied by changes in ventricular function only in association with changing patterns of ventricular activation. In animals with heart block under conditions of right heart bypass, wherein changes in the pattern of ventricular activation were precluded during atrioventricular pacing, ventricular function deteriorated pari passu with shortening of the As-Vs interval. These data indicate that both the temporal relation between atrial and ventricular contraction and the pattern of ventricular activation importantly influence ventricular function during cardiac pacing. The marked changes in ventricular function observed as a function of the As-Vs interval, for any given pattern of electrical activation, suggest that the As-Vs interval is the more important determinant of ventricular function during cardiac pacing.

The pharmacological basis of coronary and systemic vasodilator actions of diazepam (Valium)

1. The effects of alpha and beta-adrenoceptor blockade, depletion of catecholamine stores, vagotomy, atropine, and ganglionic blockade on diazepam-induced vasodilatation were investigated in forty-six anaesthetized dogs.2. Coronary blood flow was measured by timed collections of coronary venous efflux from fibrillating, decompressed ventricles; coronary and systemic vascular resistances were determined during total cardiopulmonary bypass under conditions of normothermia and constant aortic (coronary artery) pressure.3. No significant alteration in the vasodilatation produced by diazepam was observed following either vagotomy or alpha-adrenoceptor blockade; partial inhibition of vasodilatation occurred after beta-adrenoceptor blockade or catecholamine depletion, and nearly total inhibition was observed after small doses of atropine or ganglion-blocking agents.4. The results suggest that diazepam may act as a specific ganglion-stimulant, causing active sympathetic and cholinergic vasodilatation.

Parasympathetic control of coronary blood flow in dogs

The role of the vagus in the control of coronary blood flow was studied in chloralose-anesthetized dogs with open chests. Propranolol, 1.0 mg/kg iv, was used for beta-receptor blockade. Heart rate was maintained at a constant level with atrial and ventricular pacing. Left circumflex coronary artery blood flow was measured with an electromagnetic flowmeter. The experimental design accounted for the four major determinants of coronary blood flow: (1) aortic pressure, (2) myocardial systolic compression, (3) alterations in myocardial oxygen tension and metabolism secondary to changes in contractile force, (4) neural control. Efferent stimulation of the cut cervical vagi (30 Hz, 2 msec, 8-10 v) resulted in decreased aortic blood pressure and increased coronary blood flow. Late diastolic coronary artery resistance fell to 58% of the control value after 5 seconds of vagal stimulation. Atropine, 0.5 mg/kg iv, blocked these effects. It is concluded that direct parasympathetic coronary vasodilation results from vagal stimulation, which is independent of vagal chronotropic and inotropic effects.