Effects of catecholamines, exercise, and nitroglycerin on the normal and ischemic myocardium in conscious dogs

Management of Chronic Congestive Heart Failure Caused by Myxomatous Mitral Valve Disease in Dogs: A Narrative Review from 1970 to 2020

Simple Summary

Myxomatous mitral valve disease (MMVD) is the most common acquired cardiovascular disease in dogs. The progression of the disease and the increasing severity of valvular regurgitation cause a volume overload of the left heart, leading to left atrial and ventricular remodeling and congestive heart failure (CHF). The treatment of chronic CHF secondary to MMVD in dogs has not always been the same over time. In the last fifty years, the drugs utilized have considerably changed, as well as the therapeutic protocols. Some drugs have also changed their intended use. An analysis of the literature concerning the therapy of chronic heart failure in dogs affected by this widespread degenerative disease is not available; a synthesis of the published literature on this topic and a description of its current state of art are needed. To the authors’ knowledge, a review of this topic has never been published in veterinary medicine; therefore, the aim of this study is to overview the treatments of chronic CHF secondary to MMVD in dogs from 1970 to 2020 using the general framework of narrative reviews.

Abstract

The treatment of chronic congestive heart failure (CHF), secondary to myxomatous mitral valve disease (MMVD) in dogs, has considerably changed in the last fifty years. An analysis of the literature concerning the therapy of chronic CHF in dogs affected by MMVD is not available, and it is needed. Narrative reviews (NRs) are aimed at identifying and summarizing what has been previously published, avoiding duplications, and seeking new study areas that have not yet been addressed. The most accessible open-access databases, PubMed, Embase, and Google Scholar, were chosen, and the searching time frame was set in five decades, from 1970 to 2020. The 384 selected studies were classified into categories depending on the aim of the study, the population target, the pathogenesis of MMVD (natural/induced), and the resulting CHF. Over the years, the types of studies have increased considerably in veterinary medicine. In particular, there have been 43 (24.29%) clinical trials, 41 (23.16%) randomized controlled trials, 10 (5.65%) cross-over trials, 40 (22.60%) reviews, 5 (2.82%) comparative studies, 17 (9.60%) case-control studies, 2 (1.13%) cohort studies, 2 (1.13%) experimental studies, 2 (1.13%) questionnaires, 6 (3.40%) case-reports, 7 (3.95%) retrospective studies, and 2 (1.13%) guidelines. The experimental studies on dogs with an induced form of the disease were less numerous (49–27.68%) than the studies on dogs affected by spontaneous MMVD (128–72.32%). The therapy of chronic CHF in dogs has considerably changed in the last fifty years: in the last century, some of the currently prescribed drugs did not exist yet, while others had different indications.

Importance of diastolic fractional flow reserve and dobutamine challenge in physiologic assessment of myocardial bridging

OBJECTIVES

This study reports a comparative assessment of the hemodynamic relevance of myocardial bridges (MB) using two modalities of fractional flow reserve (FFR), with and without concomitant inotropic challenge.

BACKGROUND

Extravascular coronary compression by means of MB is modulated by myocardial inotropism and causes intracoronary systolic pressure overshooting and negative systolic gradients across the MB. The former characteristic suggests that adequate hemodynamic assessment of MB should include inotropic stimulation. The latter characteristic might interfere with FFR by decreasing the mean pressure gradient.

METHODS

We compared the hemodynamic relevance of 12 lone MB in symptomatic patients using conventional (mean) and diastolic FFR. Diastolic FFR was obtained from post-processed, digitally acquired electrocardiogram and pressure signals. Previously validated cut off values of 0.75 (mean FFR) and 0.76 (diastolic FFR) for hemodynamic relevance were used. Measurements were performed at baseline and after incremental intravenous dobutamine doses.

RESULTS

Fractional flow reserve decreased during dobutamine challenge: mean FFR was 0.90 +/- 0.04 at baseline and 0.84 +/- 0.06 after dobutamine (p = 0.0008); similarly, diastolic FFR was 0.88 +/- 0.05 and 0.77 +/- 0.10 before and after dobutamine, respectively (p = 0.0006). Diastolic FFR identified hemodynamic relevance in five patients, whereas mean FFR did so in only one patient. The discrepancy between mean FFR and diastolic FFR increased with dobutamine challenge: the ratio of mean FFR/diastolic FFR was 1.03 at baseline and 1.09 after dobutamine (p = 0.02). During the administration of dobutamine, the discrepancy was inversely related to the systolic pressure gradient (r = 0.58, P = 0.04).

CONCLUSIONS

Physiologic assessment of MB should include dobutamine challenge. Because the overshooting of systolic pressure interferes with and is a cause of error in FFR measurements based on mean pressures, diastolic FFR appears to be the technique of choice for MB assessment, whereas mean FFR should be used with caution.

Vasopeptidase inhibition in a canine model of exercise-induced left ventricular dysfunction

1. The present study compared the acute efficacies of vasopeptidase inhibition with omapatrilat, nitroglycerin and angiotensin-converting enzyme (ACE) inhibition in exercise-induced myocardial dysfunction. Omapatrilat, a vasopeptidase inhibitor, inhibits both neutral endopeptidase and ACE. Whereas vasopeptidase inhibitors have demonstrated clinical efficacy in hypertension and heart failure, their effects in myocardial ischaemia remain unclear. 2. Omapatrilat (0.3 mg/kg) was compared with vehicle (saline), an ACE inhibitor (fosinoprilat; 0.44 mg/kg) and nitroglycerin (8.0 microg/kg per min), in an established canine model of exercise-induced myocardial dysfunction induced by progressive closure of an ameroid constrictor placed about the proximal circumflex coronary artery. Maximal treadmill exercise tests, terminated when heart rate failed to increase with increasing workload or failure to continue exercise, were performed in chronically instrumented dogs. 3. During exercise, omapatrilat and nitroglycerin similarly increased ischaemic wall thickening (P< or = 0.0001, ANOVA, 12 d.f.), whereas fosinoprilat and vehicle were without effect. Ischaemic zone ST changes were decreased with nitroglycerin (P = 0.0006, ANOVA, 12 d.f.) and tended to decrease with omapatrilat (P = 0.07, ANOVA, 12 d.f.). Peak exercise capacity was increased with nitroglycerin (9.7 +/- 1.1 vs 11.2 +/- 1.0 kcal, control vs 4 h, respectively; n = 6) and omapatrilat (9.7 +/- 0.8 vs 11.4 +/- 0.6 kcal, control vs 4 h, respectively; n = 6) and was unchanged with ACE inhibition (9.0 +/- 1.2 vs 9.5 +/- 1.1 kcal, control vs 4 h, respectively; n = 7). Omapatrilat differentially increased double product during exercise (P = 0.001, ANOVA, 12 d.f.) compared with other treatments. 4. During exercise-induced myocardial dysfunction, acute ACE inhibition did not attenuate ischaemic changes and failed to improve exercise capacity. Increased exercise capacity with omapatrilat was accompanied by a differential increase in double product, consistent with increased oxygen supply and demand. Improvements in ischaemic function were comparable between omapatrilat and nitroglycerin, suggesting that omapatrilat may represent a novel therapy in demand-induced ischaemia.

Postexercise left ventricular function: a comparative assessment by different noninvasive imaging modalities

The variety of noninvasive imaging modalities now available permits assessment of different aspects of left ventricular function in the postexercise state. Some of these modalities, such as first-pass radionuclide ventriculography, permit a nearly instantaneous assessment of left ventricular function in the early postexercise state. These modalities indicate that most exercise-induced left ventricular wall motion abnormalities resolve quickly after exercise. Resting wall motion abnormalities may also improve in the postexercise period; this response indicates the presence of hibernating myocardium capable of improving in response to myocardial revascularization procedures. On the other hand, all imaging techniques indicate that a certain percentage of exercise-induced wall motion abnormalities may persist into the postexercise period, and this finding signifies that severe coronary disease subtends the region of persisting wall motion abnormality. Further, if there is increased left ventricular size after exercise, both extensive and severe coronary disease are present. A conceptual framework for unifying these disparate findings is provided. These results underscore the importance of postexercise imaging in enhancing clinical assessment and imply that there are important technical considerations to contemplate when performing certain tests such as postexercise echocardiography.

Influence of dobutamine or exercise stress on the results of pulsed-wave Doppler assessment of myocardial velocity

BACKGROUND

Pulsed-wave Doppler assessment of myocardial velocity (MDV) may permit a more quantitative interpretation of stress echocardiography. This technique has been used with dobutamine echo (DbE), but exercise echo (ExE) may be preferred in patients who are able to exercise maximally. The influence of these stressors on the results of MDV are undefined.

PURPOSE

This study sought to determine whether differences between the physiology of DbE and ExE could influence the MDV responses to stress and whether interpretative criteria should be different with exercise or dobutamine stress.

METHODS

DbE or ExE was performed in 105 patients tested for known or suspected coronary artery disease. Pulsed-wave MDV was obtained in basal segments of anteroseptal, septal, anterior, posterior, lateral, and inferior walls in the apical views at rest and at peak doses of dobutamine or immediately after exercise. Segments were classified as normal or abnormal (ischemia or scar) according to results of 2-dimensional echocardiography, and MDV obtained at rest and stress was compared by using analysis of variance.

RESULTS

Resting heart rate was similar before both dobutamine and exercise, but heart rate at peak dobutamine exceeded that after exercise (137 +/- 10 vs 115 +/- 22, P <.01). For both ExE and DbE, MDV was significantly greater at rest and stress in normal than in abnormal segments. Stress MDV in both normal and abnormal segments was greater with DbE than with ExE (17.0 +/- 4.8 cm/s vs 10. 3 +/- 3.4 cm/s, P <.001 for normal segments and 10.7 +/- 4.4 cm/s vs 7.9 +/- 3.3 cm/s, P <.001 for abnormal segments. Increase in MDV/Deltaheart rate induced by DbE was greater than by ExE in normal (0.14 +/- 0.07 cm/s. beat for DbE and 0.09 +/- 0.08 cm/s. beat for ExE; P <.05) but similar in abnormal segments (0.06 +/- 0.07 cm/s. beat for DbE and 0.05 +/- 0.09 cm/s. beat for ExE). MDV correlated better with peak heart rate at ExE (r = 0.56, P <.01) than at DbE (r = 0.28, P <.01).

CONCLUSIONS

MDV responses to exercise and pharmacologic stress appear to be different, reflecting differences in inotropy, loading, and the timing of imaging. These findings may influence the ability of MDV to differentiate normal from abnormal stress echocardiography responses.

Effects of dobutamine on coronary stenosis physiology and morphology: comparison with intracoronary adenosine

BACKGROUND

The mechanisms leading to dobutamine-induced ischemia are not fully understood. In the present study, we investigated the effects of high-dose intravenous dobutamine on morphological and physiological indexes of coronary stenoses.

METHODS AND RESULTS

Twenty-two patients with normal left ventricular function and isolated coronary stenoses were studied. At catheterization, mean aortic pressure (P(a)), mean distal coronary pressure (P(d)), and P(d)/P(a) as an index of myocardial resistance were recorded at rest, after intracoronary adenosine, and during intravenous infusion of dobutamine (10 to 40 micrograms . kg(-1). min(-1)). Reference vessel diameter and minimal luminal diameter, as assessed by coronary angiography, did not change during dobutamine infusion compared with baseline (2.84+/-0.49 versus 2.77+/-0.41 mm and 1.35+/-0.38 versus 1. 27+/-0.31 mm, respectively; both P=NS). During peak dobutamine infusion, P(d) and P(d)/P(a) reached similar levels as during adenosine infusion (60+/-18 versus 59+/-18 mm Hg and 0.68+/-0.18 versus 0.68+/-0.17, respectively; all P=NS). In 9 patients, an additional bolus of intracoronary adenosine given at the peak dose of dobutamine failed to further decrease P(d)/P(a). Furthermore, in patients with dobutamine-induced wall motion abnormalities, the maximal decrease in P(d)/P(a) was similar during dobutamine and adenosine infusions.

CONCLUSIONS

High-dose intravenous infusion of dobutamine does not modify the dimensions of the epicardial coronary stenosis. However, much like the direct coronary vasodilator adenosine, dobutamine fully exhausts myocardial resistance regardless of the presence of mechanical dysfunction.

[The predictive signs of multivessel coronary disease in echocardiography with dobutamine]

AIMS

To assess the ability of dobutamine echocardiography to detect multivessel coronary artery disease and to determine predictive factors for multivessel disease with or without beta-blockers.

PATIENTS AND METHODS

A total of 101 patients underwent dobutamine stress echocardiography and coronary angiography (evaluation of chest pain 76, extent of coronary disease after myocardial infarction 19, other indications 6).

RESULTS

Ten patients in whom the test was prematurely terminated were excluded. Out of 91 patients who underwent dobutamine echocardiography, 54 patients had multivessel disease (sensitivity of dobutamine test 93%, specificity 46%). Heart rate at the maximum dose of dobutamine or atropine was 88 +/- 21 beats/min for multivessel diseases and 104 +/- 21 beats/min without multivessel disease (p < 0.001). A cut-off value < 94 beats/min discriminated patients at risk for multivessel disease. After adjusting for treatment with beta-blockers, heart rate < 94 beats/min, ECG signs of ischemia, and abnormalities on baseline echocardiogram with remote asynergies during dobutamine testing were independent predictors of multivessel disease in the multivariate analysis (probability > 90% when at least two factors were present).

CONCLUSION

A heart rate < 94 beats/min at peak dose of dobutamine or after atropine, ECG signs of ischemia, and the presence of abnormalities on echocardiogram at rest with remote asynergies during dobutamine stress testing were independent predictive factors of multivessel coronary artery disease.

Comparison of exercise electrocardiography and dobutamine echocardiography with invasively assessed myocardial fractional flow reserve in evaluation of severity of coronary arterial narrowing

This study compares side-by-side exercise electrocardiography and dobutamine echocardiography with an invasively assessed index of myocardial flow (pressure-derived myocardial fractional flow reserve). The data show that ST-segment depression > or = 0.1 mV and the occurrence of new wall motion abnormalities during dobutamine infusion reflect a similar impairment of myocardial blood flow.

Dobutamine-induced wall motion abnormalities: correlations with myocardial fractional flow reserve and quantitative coronary angiography

OBJECTIVES

This study evaluated both the relation between dobutamine-induced wall motion abnormalities and the physiologic and morphologic features of epicardial coronary artery stenoses and the impact of the extent of the area at risk on the sensitivity of dobutamine echocardiography.

BACKGROUND

The accuracy of dobutamine echocardiography has traditionally been assessed by comparing results with stenosis geometry. Myocardial fractional flow reserve is a functional index of coronary stenosis severity that takes into account both antero-grade and collateral flow and may therefore be a more appropriate standard for comparison.

METHODS

Seventy-five patients with normal left ventricular function, good echocardiographic images and an isolated coronary stenosis underwent, within 6 h, dobutamine echocardiography, quantitative coronary angiography and intracoronary pressure measurements. Myocardial fractional flow reserve was calculated as the ratio of mean hyperemic distal coronary to aortic pressure.

RESULTS

The degree of dobutamine-induced dyssynergy correlated significantly with percent diameter stenosis (r = 0.68), area stenosis (r = 0.68) and minimal lumen diameter (r = -0.60) and markedly better with myocardial fractional flow reserve (r = -0.77). However, marked dispersion of the individual data was observed. The sensitivity of dobutamine echocardiography in detecting lesions with a minimal lumen diameter < or = 1 mm and diameter stenosis > or = 50% was 83% and 80%, respectively. All but one patient with a myocardial fractional flow reserve >0.75 had a normal stress test result. Among patients with a myocardial fractional flow reserve < or = 0.75, the sensitivity of dobutamine echocardiography was significantly lower for lesions in vessels with a reference diameter < or = 2.6 mm than for lesions in larger vessels (58% vs. 90%, p = 0.008).

CONCLUSIONS

1) The magnitude of wall motion abnormalities induced by dobutamine infusion correlates with angiographic and, more closely, with functional indexes of stenosis severity, even though a wide scatter is observed. 2) In patients with a functionally significant stenosis, the amount of myocardium at risk is a critical determinant of the accuracy of dobutamine echocardiography.

Stress echocardiography: comparison of exercise, dipyridamole and dobutamine in detecting and predicting the extent of coronary artery disease

OBJECTIVES

This study was designed to compare exercise, dipyridamole and dobutamine echocardiography in the same patients and to evaluate, by measuring physiologic and echocardiographic variables, the mechanisms by which exercise and dobutamine induce ischemia.

BACKGROUND

The diagnostic value of stress echocardiography has been widely reported, but the specific effects of exercise, dipyridamole and dobutamine have not been directly compared. Furthermore, no echocardiography study has evaluated left ventricular volume changes at ischemic threshold during exercise and dobutamine administration.

METHODS

One hundred patients with suspected (Group A, n = 60) or known (Group B, n = 40) coronary artery disease underwent all three tests in random order.

RESULTS

In Group A, the sensitivities of exercise (mean 76%, 95% confidence interval [CI] 58% to 94%) and of dobutamine echocardiography (72%, 95% CI 53% to 91%) were higher than that of dipyridamole (52%, 95% CI 31% to 73%; p = 0.01 and p = 0.02, respectively). Specificity did not differ significantly among tests (94% for exercise [95% CI 86% to 100%] and 97% for dipyridamole and dobutamine [95% CI 91% to 100%]). Accuracy was identical for exercise and dobutamine (87%) and higher than that for dipyridamole (78%, p = 0.06). In Group B, the accuracy in predicting coronary disease extent was 71% for exercise, 33% for dipyridamole and 75% for dobutamine. At ischemic threshold, end-systolic volume index and the ratio of systolic blood pressure to end-systolic volume, a variable related to myocardial contractility, were significantly lower and higher, respectively, with dobutamine than during exercise (p < 0.05).

CONCLUSIONS

In a clinical setting, exercise echocardiography should represent the first diagnostic approach because it has high diagnostic efficacy and provides additional information on exercise capacity; pharmacologic stress, particularly that of dobutamine, provides a pivotal diagnostic tool when exercise is not feasible or its results are nondiagnostic. Our preliminary data on echocardiographic evaluation at ischemic threshold support the view that myocardial contractility is a major factor in inducing ischemia during dobutamine infusion.

Comparison of dobutamine and exercise echocardiography for detecting coronary artery disease

There has been no study comparing the efficacy of dobutamine and exercise echocardiography in detecting coronary artery disease (CAD) or their physiologic effects at ischemic threshold in the same group of patients. To accomplish this, 52 patients presenting for coronary angiography underwent supine ergometer exercise and dobutamine echocardiography. Compared with angiography, the overall sensitivity of detecting CAD was 78% for exercise and 86% for dobutamine echocardiography (p = NS). The sensitivities of detecting patients with 1-, 2-, 3- and multivessel CAD with exercise echocardiography were 63, 80, 100 and 90%, respectively, and with dobutamine echocardiography 75, 90, 100 and 95%, respectively (p = NS, exercise vs dobutamine). The specificity of both tests was 87%. At ischemic threshold, heart rate was significantly lower with dobutamine than with exercise echocardiography (91 +/- 3 vs 114 +/- 3 beats/min; p < 0.001), systolic blood pressure was significantly lower with dobutamine testing (155 +/- 5 vs 176 +/- 6 mm Hg; p < 0.01), and rate-pressure product was significantly lower with dobutamine stress (14.1 +/- 0.7 vs 19.8 +/- 0.8 x 10(3) beats/min x mm Hg; p < 0.001). It is concluded that the efficacy of detecting CAD by exercise and dobutamine echocardiography is comparable, and the physiology at ischemic threshold of the 2 methods is significantly different and suggests a different means of inducing myocardial ischemia.

Clonidine improves perioperative myocardial ischemia, reduces anesthetic requirement, and alters hemodynamic parameters in patients undergoing coronary artery bypass surgery

The purpose of this study was to determine if clonidine reduces myocardial ischemia or alters anesthetic requirement and perioperative hemodynamic parameters during coronary artery bypass grafting (CABG) surgery. Forty-three patients were randomized in a prospective, double-blind fashion to receive either clonidine (5 micrograms/kg) or placebo. Anesthetic induction and maintenance was accomplished with intravenous sufentanil-midazolam (S-M) in a 1:20 ratio; up to 1.0% enflurane was added during surgery when repeated boluses of S-M failed to maintain the blood pressure within 20% of preinduction values. Continuous ST segment analysis of leads II and V5 was performed throughout surgery with maximal ST segment deflection from baseline recorded every 5 minutes. Catecholamine levels were measured intermittently throughout the perioperative period and myocardial lactate use or excretion was determined just prior to cardiopulmonary bypass (CPB) and at 1, 5, 10, 30, and 60 minutes after release of the aortic cross-clamp. Patients who received clonidine required significantly less sufentanil for their surgical procedure (11.82 +/- 0.66 micrograms/kg v 14.55 +/- 0.90 micrograms/kg, P < 0.05) and also needed less enflurane for blood pressure control, particularly during CPB (P < 0.05). Baseline hemodynamic parameters were similar for both groups prior to induction. In the period between anesthetic induction and the initiation of CPB, patients treated with clonidine had a significantly slower heart rate (HR) (P < 0.01), a lower cardiac output (CO) (P < 0.05), and transiently higher systemic vascular resistance (SVR) (P < 0.05) than placebo-treated patients. Immediately after CPB, patients receiving clonidine continued to have a significantly lower CO (P < 0.01) and a higher SVR (P < 0.01) than placebo-treated patients. Clonidine treatment significantly increased the percentage of patients who required pacing after CPB (P < 0.05). In the intensive care unit, clonidine-treated patients displayed a persistently increased requirement for pacing (P < 0.01), decreased systolic blood pressures, and reduced sodium nitroprusside requirements relative to patients treated with placebo. Epinephrine and norepinephrine levels were lower in clonidine-treated patients throughout the perioperative procedure with significant differences noted immediately following sternotomy and release of the aortic cross-clamp (P < 0.05). Critical ST segment depression was significantly less in clonidine-treated patients for the period from sternotomy until application of the aortic cross-clamp (P < 0.01). Following CPB, absolute deviation of ST segments from isoelectric baseline was significantly less in the clonidine-treated group (P < 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Beta-adrenergic blockade improves uniformity of local contraction in the anterior wall of feline left ventricles

Uniformity of myocardial contraction has been put forward as an important regulatory mechanism of myocardial contraction, and we have previously demonstrated reduced uniformity of local myocardial contraction in the midwall of left ventricles during preload reduction combined with increased inotropy. The aim of the present study was to explore the isolated inotropic influence on uniformity of contraction, keeping loading conditions constant. Segment performance was measured by implanted piezo-electric crystals in ten open-chest, anaesthetized cats. One crystal pair, circumferential segment, aligned with midwall and epicardial fibres, whereas another perpendicular segment, longitudinal, ran close to endocardial fibre direction. Maximal systolic shortening of longitudinal segments remained unchanged following inotropic interventions, isoprenaline and timolol, whereas circumferential segments revealed reduced performance with timolol (8.4 +/- 1.0% compared with 14.0 +/- 1.3% during control; P < 0.001). In the control state the longitudinal-to-circumferential ratio (LONG/CIRC) a quantitative measure of uniformity, was 0.32 +/- 0.08. No change in uniformity occurred during isoprenaline infusion (0.32 +/- 0.11) but during beta-adrenergic blockade with timolol a clearly higher LONG/CIRC ratio was observed (0.56 +/- 0.06, P < 0.005). Myocardial tissue blood flow measurement by radioactive microspheres showed a shift in transmural distribution with interventions so that subepicardial blood flow was markedly reduced during beta-adrenergic blockade. The direction of subepicardial fibres approximates our circumferential segments. Thus, there may well exist a relationship between segmental shortening and perfusion. In conclusion, circumferential segments were most influenced by changes in inotropy in contrast to previous observations where pronounced changes in longitudinal segments with loading occur. Furthermore, this study demonstrates that reduced inotropy with timolol helped uniform local contraction as estimated by the increased LONG/CIRC ratio, a transition that could improve contraction efficacy.

Effects of exercise on myocardial catecholamine content and ischemic injury in dogs with gradual coronary occlusion

The effects of exercise on catecholamine content and the extent of myocardial damage in dogs with Ameroid constrictor occlusion of the left circumflex coronary artery were determined. Tissue samples from both the anterior and posterior walls of the left ventricle were obtained for determination of catecholamine content, and the rest of the ventricles were processed for histologic examination. When subjected to treadmill exercise for 40 days after surgery, obstructed animals performed significantly less exercise than sham-operated animals and showed significantly higher percentages of ischemia and necrosis in the left ventricle than sedentary, obstructed, sham-operated, or control dogs. Levels of norepinephrine and epinephrine in the posterior wall of the left ventricle were significantly lower than in the other groups. Our data show that exercise in this well-known model of chronic coronary artery stenosis produced deleterious effects on the myocardium and suggest a marked heterogeneity of catecholamine stores in the myocardium that may have important functional and electrophysiologic consequences.

Can new inodilators displace digitalis in the therapy of congestive heart failure?

New inodilators that possess both positive inotropic and vasodilator actions have many favorable effects in patients with congestive heart failure, even in those with refractory heart failure. These effects are expected to prevent myocardial injury, improve peripheral circulation, depress the excessive endogenous neurohumoral activation, and, finally, improve the quality of life, and increase lifespan. However, experience with new inodilators has only begun. Several questions remain to be answered before these drugs can be widely used with safety, including whether life-threatening adverse effects appear, mortality rate is lessened, and drug tolerance occurs. The therapeutic level of the dose and the relation between the effectiveness of the drug and the degree of the severity of heart failure should also be established. Therefore, long-term, randomized, double-blind, placebo-controlled clinical trials will be necessary before the new inodilators can take the place of digitalis and thus become the mainstay of the therapy of congestive heart failure.

The effects of nitroglycerin on regional myocardial contractile dysfunction produced by treadmill exercise or isoprenaline stimulation in dogs

1. To compare different methods of cardiac stress testing that are clinically applied in the management of coronary heart disease, 2 groups of dogs each were chronically instrumented and subjected to treadmill exercise or isoprenaline infusion in the presence of coronary stenosis. 2. It was of interest to determine differences in haemodynamic and regional myocardial contractile parameters, the response to antianginal therapy (nitroglycerin 15 micrograms kg-1 15 min-1, i.v.), and, in particular, whether this response differed according to the mode of cardiac stimulation, i.e. treadmill exercise or isoprenaline infusion. 3. After stenosis of the circumflex branch of the left coronary artery which affected resting myocardial function only minimally, treadmill exercise or isoprenaline infusion induced transient regional contractile dysfunction. Heart rate, arterial blood pressure, left ventricular end-diastolic pressure and left ventricular dp/dtmax were registered and myocardial oxygen demand was calculated. Regional contractile performance was assessed by ultrasonic distance measurement in the underperfused and in a normally perfused area. 4. Treadmill exercise led to an increase in systolic arterial and left ventricular end-diastolic pressure. In contrast, isoprenaline-induced stimulation led to a decrease in diastolic arterial and left ventricular end-diastolic pressure. Regional contractile function in the critically underperfused area showed a deterioration during both modes of stress. Nitroglycerin completely abolished stress-induced contractile dysfunction only in the group where treadmill exercise was employed for stimulation. 5. The inability of nitroglycerin to prevent myocardial dysfunction in the isoprenaline group may be due to exhaustion of the arterial and/or venous vasodilator potency of nitroglycerin in the presence of adrenoceptor vasodilatation induced by isoprenaline. 6. These findings indicate that clinical antianginal drug testing and the evaluation of the course of disease in patients with coronary heart disease may be highly dependent on the test method chosen.

The effect of different mechanisms of myocardial ischemia on left ventricular function

Myocardial ischemia may be produced by limitation of blood flow as in abrupt coronary occlusion, termed supply-type ischemia, or by increasing myocardial oxygen demand in the setting of restricted flow, termed demand-type ischemia. To examine the comparative extent and severity of the dysfunction related to both forms of ischemia, we studied anesthetized, open-chest dogs by means of two-dimensional echocardiography and tracer microspheres. Supply-type ischemia was produced by total occlusion of the LCx (n = 7); demand-type ischemia was induced by infusion of dobutamine after creation of a critical LCx stenosis (n = 6). At the time of the production of ischemia, the group with demand-type ischemia had significant increases in both heart rate (p less than 0.05) and mean arterial pressure (p less than 0.05), whereas the group with supply-type ischemia had a decrease in mean arterial pressure (p less than 0.05). Subendocardial blood flow in the LCx region was severely depressed in supply-type ischemia (0.09 +/- 0.04 ml/min/gm) compared to demand-type ischemia (1.04 +/- 0.07 ml/min/gm; p less than 0.01). Although both groups of animals had an abnormality of left ventricular function during ischemia, as determined by two-dimensional echocardiography, the extent of the dysfunction in the group with supply-type ischemia was greater (146 +/- 12 degrees) compared to the group with demand-type ischemia (99 +/- 9 degrees; p less than 0.01). Similarly, the degree of left ventricular dysfunction in the group with supply-type ischemia was greater than that for the group with demand-type ischemia (p less than 0.05). Thus these data suggest that supply-type ischemia produced by coronary occlusion results in a greater extent and degree of left ventricular functional abnormality than pharmacologically induced demand-type ischemia.

Stimulation of myocardium during reperfusion injury by a new inotrope-vasodilator agent, MCI-154

The systemic and coronary hemodynamic actions of a newly synthesized inotropic agent structurally related to milrinone and amrinone, MCI-154 (0.5-4.0 micrograms/kg/min IV), were studied in 2 groups of conscious, chronically instrumented dogs with normal or depressed postischemic, reperfused myocardium after a 15-min coronary artery occlusion. In an additional group of control experiments, the time course of recovery of postischemic, reperfused myocardium was studied to verify the constancy of regional segment shortening in the previously ischemic zone during the time corresponding to drug infusion. Similar inotropic actions of MCI-154 were observed in both normal and postischemic, reperfused hearts, indicating significant contractile reserve to be present in 'stunned' myocardium. Global contractility as measured by peak positive dP/dt was significantly increased in both groups. In postischemic, reperfused myocardium 90 min after initiation of reflow, regional segment function remained depressed at 44% of control but improved to 93% of control after administration of MCI-154. In addition, MCI-154 produced significant dose-related decreases in mean arterial pressure, left ventricular end-diastolic pressure, end-diastolic segment length, and diastolic coronary vascular resistance. The data demonstrate that in addition to producing beneficial hemodynamic changes, MCI-154, a new non-sympathomimetic inotropic agent, markedly enhances regional contractility of postischemic, reperfused myocardium.

Relation between graded, subcritical impairments of coronary flow reserve and regional myocardial dysfunction induced by isoproterenol infusion in dogs

Isoproterenol has been used experimentally and clinically to elicit ischemia. The usefulness of this approach, however, in eliciting regional dysfunction in the presence of mild to moderate single-vessel coronary disease quantitated on the basis of coronary flow reserve measurements has not been previously defined. Open-chest, anesthetized dogs were instrumented with an electromagnetic flow probe, high-fidelity micromanometers, and subendocardial ultrasonic crystals. A rigid, screw occluder was used to produce five subcritical coronary stenoses in each dog associated with varying impairment of postocclusion reactive hyperemia at rest but no impairment of resting coronary blood flow. Regional function at rest and in response to the isoproterenol challenge (0.25 micrograms/kg/min) in nonstenotic and stenotic conditions was assessed. Relative regional function was maintained during the infusion until nearly total loss of coronary flow reserve. With this near-critical stenosis, function was lower than in the nonstenotic state but remained greater than resting control values. Moderate impairments of coronary flow reserve were not associated with isoproterenol-induced deterioration of regional function. In conclusion, detection of impaired coronary flow reserve at rest is a more sensitive index of the severity of a coronary stenosis than is detection of regional dysfunction during isoproterenol challenge. Failure to maintain the expected isoproterenol-induced increase in regional function is manifested only when stenoses are associated with nearly total loss of resting coronary flow reserve. This suggests that the clinical use of isoproterenol challenge is not effective in eliciting regional dysfunction when mild coronary disease is present.

Is inotropic therapy appropriate for patients with chronic congestive heart failure? Or is the digitalis leaf withering?

The appropriateness of inotropic therapy in chronic heart failure was examined by critically reviewing five assumptions upon which this form of therapy has been justified. Only the first, that cardiac performance can be acutely improved by inotropic therapy, has been empirically proven. That such acute improvement is sustained appears to be true with non-catecholamine agents whereas the chronic haemodynamic efficacy of oral catecholamines remains in doubt. That any inotropic agent can improve exercise tolerance, make the patient feel better, or effect a change without deleteriously affecting the myocyte is very much in doubt. Thus, although the prospect of using powerful inotropic therapy in the patient with heart failure is theoretically appealing, its utility remains to be proven.

Exercise-induced regional dysfunction with subcritical coronary stenosis

The hypothesis was tested that regional myocardial contractile dysfunction can detect subtle regional coronary blood flow maldistribution induced by exercise. In seven dogs, left ventricular pressure (micromanometer), regional systolic wall thickening (WTh, sonomicrometry), and myocardial blood flow (MBF, microspheres) were measured when mild degrees of coronary artery stenosis were produced during treadmill exercise. During exercise without coronary stenosis, WTh increased by 21 +/- 12% (SD), and transmural MBF increased uniformly. In each dog, two levels of coronary stenosis were produced during exercise by adjusting the coronary hydraulic cuff: (1) St-Ex I, where WTh during exercise failed to increase significantly (average change 0 +/- 7%), and (2) St-Ex II, where WTh during exercise decreased moderately from the resting control value (average -20 +/- 8%). In the potentially ischemic zone coronary hyperemia occurred with each run: resting subendocardial MBF was 1.09 +/- 0.30 mg/g/min, and it was 3.04 +/- 0.83 during control exercise, 2.48 +/- 0.75 during St-Ex I, and 1.55 +/- 0.59 ml/g/min during St-Ex II (p less than .01 compared with control exercise and control area). The subendocardial-subepicardial blood flow ratio fell from 1.32 +/- 0.27 during control exercise to 1.07 +/- 0.20 (p less than .05) during St-Ex I, and to 0.64 +/- 0.15 (p less than .01) with St-Ex II. Changes in the subendocardial electrogram and reactive hyperemia occurred more consistently during St-Ex II than St-Ex I. Thus, failure of regional function to increase during exercise detected slight maldistribution of regional MBF, whereas reduction of regional function during exercise of 10% or more below the resting value was a reliable marker of a regional flow defect and was always associated with other evidence of ischemia. Therefore, regional dysfunction during exercise can detect subcritical but functionally significant coronary stenosis, which may allow regional wall motion to be used for detecting coronary artery disease at a relatively early stage.

Reversal of rest myocardial asynergy during exercise: a radionuclide scintigraphic study

While exercise-induced segmental left ventricular wall motion abnormalities are well described, the phenomenon of improvement in certain asynergic segments during exercise in some patients remains a curiosity. To assess this unexpected finding, results were analyzed in 85 patients with wall motion abnormalities at rest who underwent two view (45 degrees left anterior oblique and anterior) exercise radionuclide ventriculography and exercise thallium-201 myocardial perfusion imaging. Wall motion was scored with a 5 point system (from 3 [normal] to - 1 [dyskinesia]); normalization or increase of 2 or more points with exercise signified improvement. Forty-eight patients (56%) had no change or further deterioration of wall motion at peak exercise, 15 (18%) showed both improvement of wall motion and deterioration and 22 (26%) showed only improvement of wall motion. Wall motion improvement during exercise was found in 57 (20%) of 279 segments with asynergy at rest. Of these 57 segments improving with exercise, 45 (79%) showed mild and 12 (21%) showed severe asynergy at rest. Only seven segments (12%) were associated with pathologic Q waves. Thallium-201 perfusion was normal in 44 segments (77%) while only 6 segments (11%) had reversible and only 7 (12%) had nonreversible thallium-201 defects.

IN CONCLUSION

1) wall motion that is abnormal at rest can sometimes improve with exercise; 2) this phenomenon generally occurs in zones without a Q wave or nonreversible thallium-201 defect. Hence, segments with abnormal wall motion at rest that show improvement with exercise appear to represent viable nonischemic segments.

Does prostacyclin (PGI2) cardioplegic infusion improve myocardial protection after ischemic arrest?

To determine whether prostacyclin (PGI2) plays a beneficial role in the blood-perfused heart undergoing global ischemia, 20 isolated canine hearts were studied after sustaining one hour of cardioplegic arrest under moderate hypothermia (27 degrees to 28 degrees C). Left ventricular function (peak systolic pressure, rate of rise of left ventricular pressure [dP/dt], and compliance change in left ventricular volume), myocardial edema, coronary blood flow, and oxygen content were measured during the preischemic period and at 15 and 30 minutes during reperfusion. Results showed an improved hemodynamic recovery (peak systolic pressure, p = 0.018 at 30 minutes; dP/dt, p = 0.020 at 15 minutes) in the group of hearts treated with PGI2 infusion compared with controls. There was no difference in ventricular compliance or myocardial edema between the two groups. This benefit was attributed to a significant increase in myocardial blood flow (p = 0.028 at 15 minutes) and oxygen delivery (p = 0.021 at 15 minutes) during the reperfusion period with PGI2. These data suggest a potential clinical role for PGI2 when applied to the globally ischemic heart in the improvement of myocardial resuscitation during the early reperfusion period.

Dopamine: its potential for inducing ischemic left ventricular dysfunction

As an agent potentially capable of inducing ischemia in patients with coronary artery disease, dopamine administered intravenously was evaluated as a pharmacologic stress agent by supine radionuclide angiography, and the results were compared with ergometer exercise. In a preliminary group of 11 subjects (4 normal subjects and 7 patients with coronary disease), dopamine alone was administered in increments of 2.5 micrograms/kg per min to a maximum of 15 micrograms/kg per min. There were significant differences between exercise and dopamine in maximal stress heart rates, 129.3 +/- 30.0 versus 88.0 +/- 35.8 beats/min (p less than 0.05) in normal subjects and 118.9 +/- 21.1 versus 87.6 +/- 22.6 beats/min (p less than 0.05) in patients with coronary disease, as well as in maximal stress rate-pressure products, 213.3 +/- 51.4 versus 155.0 +/- 52.5 mm Hg/min X 10(2) (p less than 0.02) in normal subjects and 216.0 +/- 45.6 versus 161.0 +/- 48.6 mm Hg/min X 10(2) (p less than 0.003) in patients with coronary disease. As a result, in these patients the ejection fraction response was significantly different: -3.3 +/- 4.5% with exercise versus + 6.3 +/- 4.6% with dopamine (p less than 0.05). In a second group of 41 subjects (9 normal subjects and 32 patients with coronary disease), atropine (0.6 mg) was administered intravenously before and after every second dopamine dose increment. This produced statistically similar maximal stress heart rates as compared with exercise in all subjects, rate-pressure products in normal subjects and slightly higher values with dopamine in patients with coronary disease: 200.3 +/- 47.2 versus 183.1 +/- 43.0 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Relation of coronary blood flow and reactive hyperemia to regional dysfunction induced by dopamine infusion in dogs: limitations in detecting subcritical coronary stenoses

Sympathomimetic agents have been used clinically to elicit regional dysfunction or heterogeneity of coronary blood flow to detect coronary artery lesions. However, the usefulness of this procedure in detecting mild to moderate coronary stenoses has not been defined previously. This was investigated in 10 open chest anesthetized dogs using subendocardial ultrasonic crystals to measure segment lengths. An electromagnetic flow probe was placed on the proximal left anterior descending artery, and graded coronary stenoses were created using a cuff occluder. In the first phase of the study, subcritical coronary stenoses were created which impaired maximal postocclusion reactive hyperemia, but not coronary blood flow at rest. A constant infusion of dopamine (average 15 micrograms/kg per min) was then administered. Regional dysfunction during dopamine infusion was not consistently observed despite production of coronary stenoses resulting in total loss of reactive hyperemia at rest. Regional function during dopamine treatment was, however, critically related to the actual changes in coronary blood flow during the infusion. In the second phase of the study, regional function during dopamine challenge was investigated during progressive impairments of coronary blood flow. Regional function was maintained until coronary blood flow during the infusion was reduced to near rest levels below which regional function deteriorated rapidly.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of ICI 118,587 on left ventricular function during graded treadmill exercise in conscious dogs

Effect of ICI 118,587 (corwin, ICI), a new cardioselective beta-partial agonist, on left ventricular (LV) function was studied and compared with that of isoproterenol and propranolol in 10 conscious normal dogs, instrumented with a micromanometer and pairs of ultrasonic crystals for analysis of LV wall motion. Heart rate, LV dP/dt and mean circumferential shortening velocity were measured at rest and during 3 levels of treadmill exercise (Ex). Before drug administration (control), the heart rate, dP/dt, percent shortening and mean circumferential shortening velocity were enhanced linearly along with the graded Ex. The Ex response curve shifted upward during isoproterenol infusion and downward after the administration of propranolol. With ICI, hemodynamic and contractile indexes were enhanced at rest as with isoproterenol, while these indexes were depressed during maximal Ex as after propranolol. The Ex response curve after ICI crossed the control response curve at a moderate level of Ex. Thus ICI exerts positive inotropic and chronotropic effects at rest when basal sympathetic tone is low, whereas it exerts negative inotropic and chronotropic properties at maximal Ex when sympathetic tone is high. The inherent dual action of this drug is expected to open a new field of treatment for ischemic heart disease with or without heart failure.

Systolic and diastolic time intervals during spontaneous angina

In 5 patients who suffered spontaneous angina during cardiac catheterization, aortic pressure and electrocardiographic lead (V5) were recorded at rest, at the onset of anginal pain, 5 and 10 min after 0.6 mg sublingual nitroglycerin (NTG). Heart rate, systemic arterial pressure, systolic, and diastolic time intervals were measured. Heart rate and systemic arterial pressure rose significantly immediately after the onset of angina and declined progressively within 10 min from NTG administration. Preejection period did not change during angina, while left ventricular ejection time and electromechanical systole lengthened. As a consequence, diastolic time, expressed as percent of cardiac cycle, shortened sharply. All parameters considered went back to basal values within 10 min from NTG administration, and were preceded by relief or reduction of anginal pain. We concluded that a fall in diastolic time, secondary to a prolongation of electromechanical systole occurring during angina, may further increase the degree of ischemia resulting in a vicious cycle than can be interrupted by NTG administration.

Effects of a calcium-entry blocker (diltiazem) on regional myocardial flow and function during exercise in conscious dogs

We examined the effects of diltiazem, a calcium-entry blocker, on exercise-induced myocardial ischemia in nine conscious dogs with chronic coronary stenoses. An ameroid constrictor, Doppler flow probe, and hydraulic occluder were placed around the left circumflex coronary artery, and left ventricular pressure was measured (Konigsberg micromanometer). Pairs of ultrasonic crystals were implanted for measuring left ventricular systolic wall thickening (% delta WTh) in control (left ventricular anterior wall) and ischemic (left ventricular posterior wall) regions, and regional myocardial blood flow was measured with the microsphere method. Eighteen days (average) after surgery mean coronary blood flow velocity had decreased and reactive hyperemic flow velocity after 10 sec of coronary occlusion was markedly reduced, but % delta WTh at rest remained normal, indicating collateral development. Control treadmill exercise was performed for 3.7 min (average), and 2 hr later administration of 0.3 mg/kg diltiazem was followed by an identical exercise bout. Control exercise increased % delta WTh in the normal region, while in the ischemic region % delta WTh decreased markedly and ischemia was evident (subendocardial flow, 0.29 +/- 0.12[SD] ml/min/g). After diltiazem hemodynamic and % delta WTh values at rest were not changed; during exercise the heart rate was significantly lower (204 +/- 24 vs 227 +/- 33 beats/min, p less than .01), but values for other hemodynamic measures were similar to those during the control run. % delta WTh in the control region was not changed during exercise after diltiazem, but compared with control exercise in the ischemic zone there was less dysfunction and subendocardial flow was greater. Recovery from exercise-induced dysfunction in the ischemic region occurred within 5 min, compared with over 30 min after control exercise. Thus, in a preparation of chronic coronary stenosis, the calcium-entry blocker improved the relationship between regional myocardial flow and function during exercise and led to more rapid recovery of regional myocardial dysfunction.

Elevated catecholamines during cardiac surgery: consequences of reperfusion of the postarrested heart

This study determines whether reperfusion of the heart with elevated blood levels of epinephrine (E) and norepinephrine (NE) during cardiac surgery produces deleterious effects. The study was conducted in 60 patients undergoing coronary artery bypass surgery. Arterial catecholamine values increased significantly (p less than 0.05), from prebypass control levels of 152 +/- 29 and 327 +/- 30 pg/ml of E and NE, respectively, to 415 +/- 78 and 554 +/- 49 pg/ml, at initiation of perfusion of the heart after the aortic cross-clamp was removed. Serial measurement of arterial (A) and coronary sinus (CS) E, NE, potassium, lactate, PO2 and CK-MB revealed that during 10 minutes of reperfusion the heart extracted E (positive A-CS difference, p less than 0.05), but that the NE A-CS difference was 0. The CS effluent contained significantly (p less than 0.05) higher concentrations of potassium, lactate and CK-MB during reperfusion than before aortic occlusion. There was no significant correlation of arterial E and NE, CS E and NE or A-CS differences in E and NE with myocardial release of lactate, potassium or CK-MB. There was a weak association (r = 0.4, p less than 0.01) between coronary sinus CK-MB and aortic occlusion time. Maximal arterial E and NE values did not correlate with 10-hour postoperative (maximal) CK-MB values. These results indicate that reperfusion of the postarrested ischemic heart with high levels of endogenously released catecholamines does not worsen ischemia or contribute significantly to myocardial damage.

The effect of dobutamine on exercise performance in patients with symptomatic ischemic heart disease

The effect of dobutamine on exercise performance was assessed in 20 patients with ischemic heart disease (CAD) and a positive stress test. These patients had a wide range of resting left ventricular ejection fraction (range 22% to 69%, mean 42%). Each patient entered a double-blind crossover study in which two identical exercise radionuclide ventriculograms were performed in patients on dobutamine, 5 micrograms/kg/min intravenously, or placebo. Dobutamine increased resting left ventricular ejection fraction. Although ejection fraction fell with dobutamine during submaximal exercise, it remained higher than with placebo. At peak exercise, ejection fraction fell to the same level on dobutamine as with placebo. Dobutamine diminished exercise time and time to ischemia while peak pressure-rate product was unchanged. Four of 20 patients developed complex ventricular premature beats, all while on dobutamine. Although useful when administered to resting patients with acute left ventricular failure, dobutamine's effects may be deleterious in exercising patients with chronic ischemic heart disease.

Salvage of myocardial function by coronary artery reperfusion 1, 2, and 3 hours after occlusion in conscious dogs

The effects of coronary artery occlusion and reperfusion at 1 hour (1-hr group), 2 hours (2-hr group), and 3 hours (3-hr group) were compared with a permanently occluded group (P group) on measurements of overall left ventricular and regional endocardial function over a 4-week period. The studies were conducted in conscious dogs 1-2 weeks after recovery from instrumentation with solid state left ventricular pressure gauges, aortic, and left atrial catheters, hydraulic occluders, and Doppler flow transducers on the left anterior descending or left circumflex coronary arteries, and multiple pairs of ultrasonic transducers implanted in the endocardial third of the left ventricular free wall to measure endocardial segment shortening. During coronary artery occlusion, similar effects were observed in the four groups. At 1 hour after coronary artery occlusion, three classes of ischemia-induced dysfunction were observed; dyskinetic (systolic shortening completely lost and replaced by paradoxical bulging), severely hypokinetic (systolic shortening depressed by 65-95%), and moderately hypokinetic (systolic shortening depressed by 40-65%). Compared with the P group, significant (P less than 0.05) return of systolic shortening and velocity of shortening gradually occurred over the 4-week period following reperfusion in all classes of segments in the 1-hour group. In the 2-hour group, systolic shortening returned in the moderately and severely hypokinetic segments, but was slight and not significant in the dyskinetic segments. In the 3-hour group, significant systolic shortening returned only in the moderately hypokinetic segments. The effects of isoproterenol, 0.04 micrograms/kg per min, and exercise were compared on "salvaged" dyskinetic segments prior to and at 1, 2, 3, and 4 weeks after coronary artery occlusion and reperfusion. The responses to isoproterenol were significantly depressed at 1 week after reperfusion and gradually recovered over the 4-week period. At 3-4 weeks after reperfusion, severe exercise also increased shortening and velocity of shortening in "salvaged" segments. Thus, in the conscious dog, coronary artery reperfusion at 1 hour after coronary artery occlusion results in substantial return of endocardial function even in the most severely ischemic myocardium. The "salvaged" myocardium responds adequately to myocardial stress with increases in the extent and velocity of systolic shortening, as long as 3-4 weeks after reperfusion are allowed for recovery. However, after 3 hours of coronary artery occlusion, little salvage of regional myocardial function can be induced by acute reperfusion in this model.

Left ventricular performance during exercise: response of ear densitogram derivative

The peak derivative of the ear densitogram (PD) has been shown to track left ventricular (LV) function during exercise. Measured as percent change in amplitude from resting control, PD in normal subjects slowly and consistently increased throughout exercise and to 2 minutes of recovery, followed by return to control level. In contrast, PD in patients with coronary artery disease rapidly increased only to 1 minute of exercise, with no significant subsequent increase. Expressed as a percent change from control, the response of normal subjects differs significantly from that of patients with coronary artery disease at 1 and 4 minutes of exercise, and 2 minutes of recovery. The PD increase in normal subjects from end-exercise to 2 minutes of recovery may be attributable to the heart rate decreasing faster than venous return, associated with LV ejection time, which is significantly shorter than heart rate-predicted values 2 minutes after exercise.

Effect of exercise on the relationship between myocardial blood flow and systolic wall thickening in dogs with acute coronary stenosis

Relationships between regional myocardial perfusion and transmural function, both during treadmill exercise and at rest, were examined in conscious dogs with varying degrees of coronary stenosis produced by a hydraulic occluder. In 13 dogs we measured myocardial blood flow with microspheres (10-12 microns in diameter) and regional systolic wall thickening (%). During exercise with coronary stenosis, myocardial blood flow was characterized by nonuniform distribution, and associated with regional dysfunction. The relationships between normalized myocardial blood flow and normalized %wall thickening during exercise with coronary stenosis were linear, with significantly different slopes (mean myocardial blood flow: y = 1.23x - 0.16, r = 0.93; subendocardial myocardial blood flow: y = 1.50x - 0.02, r = 0.86; subepicardial myocardial blood flow: y = 0.83x - 0.18, r = 0.87). To fill the gap between available subendocardial and subepicardial data during exercise with coronary stenosis and control points, however, would require nonlinear components. In 10 of the dogs, coronary stenosis at rest was also produced to compare regional myocardial blood flow - %wall thickening relations at rest with those during steady state exercise. The absolute mean myocardial blood flow - %wall thickening relation during exercise with coronary stenosis (y = 11.6x - 1.9, r = 0.90) was significantly shifted rightward from the resting relation (y = 25.3x -2.1, r = 0.80). However, when changes in %wall thickening were plotted vs. myocardial blood flow per beat, the relationships at rest and exercise were nearly superimposable. Likewise, relations between normalized myocardial blood flow and changes in %wall thickening at rest and exercise were not significantly different. We conclude: %wall thickening during exercise is directly related to changes in mean myocardial blood flow but is related in nonlinear fashion to changes in subepicardial and subendocardial myocardial blood flow; %wall thickening may provide a reliable index of the relative transmural flow distribution during exercise as well as at rest; during brief bouts (5-8 minutes) of exercise with coronary stenosis, the relationship between stabilized regional contractile dysfunction and level of myocardial blood flow per beat is the same as that during coronary stenosis at rest.

Improvement of resting myocardial asynergy with cessation of upright bicycle exercise

Exercise generally aggravates ischemic myocardial dysfunction, presumably by increasing tissue oxygen demand out of proportion to the increase in supply. Nevertheless, resting left ventricular (LV) wall motion abnormalities can improve dramatically after upright exercise. To investigate this "paradoxical" phenomenon, we performed upright bicycle exercise equilibrium radionuclide ventriculography in 93 patients with angiographic coronary artery disease. Immediately after exercise, LV end-diastolic volume was similar to the resting level (1 +/- 22% of rest value), but end-systolic volume (ESV) was significantly below (p less than 0.05) that at rest (-11 +/- 32%) and LV ejection fraction increased significantly compared with rest (0.57 +/- 0.16 vs 0.51 +/- 0.13, p less than 0.05). Improvement in resting myocardial asynergy was frequent (115 of 330 abnormal segments), and was observed more commonly in patients without pathologic Q waves and in segments manifesting mild rather than severe asynergy. In 60 additional patients with resting asynergy who were also studied after nitroglycerin (NTG), there was 89% concordance of wall motion response in asynergic segments after exercise and NTG: 71 of 85 segments manifesting improvement with NTG also improved after exercise, and 157 of 172 segments without improvement with NTG also failed to improve after exercise. Despite the similar wall motion response, the mechanism of improvement is probably different from that produced by NTG. With NTG, preload (end-diastolic volume) and afterload (systolic blood pressure) were significantly lower than their resting control levels (p less than 0.05). These changes did not occur after exercise. Instead, an isolated, significant reduction in ESV was noted. These data support the hypothesis that catecholamine stimulation is responsible for paradoxical wall motion improvement after upright exercise.

Relative inotropic and chronotropic activity of beta-adrenoceptor stimulants in anaesthetised, areflexic dogs

The use of different methods of measuring contractility and the effects of cardiovascular reflexes are among the factors which complicate the assessment of selective inotropic activity of beta-adrenoceptor agonists. The effects of dobutamine, prenalterol, noradrenaline and isoprenaline on heart rate, iliac blood flow, left ventricular pressure, max dP/dt and (dP/dt) divided by IIT (integrated isometric tension) were evaluated in anaesthetised dogs in which the hearts were denervated and blood pressure held constant. All the drugs caused dose-dependent increases in heart rate and contractility. The relative chronotropic and inotropic activity of each agonist was evaluated. At most doses studied the agonists exerted similar chronotropic and inotropic activity when compared to the non-selective agonist isoprenaline. It is likely that the inotropic selectivity observed with prenalterol and dobutamine in previous studies depends on factors other than direct drug action.

Hemodynamic effects of salbutamol, an oral long-acting beta-stimulant, in patients with congestive heart failure

As the efficacy of oral long-acting sympathomimetic drugs is not yet well established, we investigated the hemodynamic effects of orally administered salbutamol in eight heart failure patients. Cardiac index, heart rate, blood pressure, and left ventricular filling pressure were monitored for 6 hours after a single oral administration of 4 to 8 mg salbutamol and placebo. In patients who had received salbutamol, a 40% increase in the cardiac index (+0.75 L/min/m2, p less than 0.01) was noted 1 hour post administration; a 44% increase (peak effect) occurred at 2 hours (+0.84 L/min/m2, p less than 0.05); and a significant increase persisted for 6 hours. Changes in heart rate showed a similar time course; however, the increase was less pronounced (+27% at 2 hours). The changes in blood pressure were slight and none of the eight patients developed ventricular arrhythmia or other complications. After placebo administration, no consistent changes in the hemodynamic parameters were noted. The present study suggests that, due to its sustained positive action on cardiac output, the oral administration of salbutamol may be efficacious in ambulatory patients with low cardiac output due to heart failure.

Cardiac effects of prolonged and intense exercise training in patients with coronary artery disease

The effects of intense and prolonged exercise training on the heart were studied with echocardiography in eight men with coronary artery disease with a mean age (+/- standard error of the mean) of 52 +/- 3 years. Training consisted of endurance exercise 3 times/week at 50 to 60 percent of the measured maximal oxygen uptake for 3 months followed by exercise 4 to 5 days/week at 70 to 80 percent of maximal oxygen uptake for 9 months. Maximal oxygen uptake capacity increased by 42 percent (26 +/- 1 versus 37 +/- 2 ml/kg per min; p less than 0.001). Heart rate at rest and submaximal heart rate and systolic blood pressure at a given work rate were significantly lower after training. Systolic blood pressure at the time of maximal exercise increased (145 +/- 9 before versus 166 +/- 8 mm Hg after training; probability [p] less than 0.01). Left ventricular end-diastolic diameter was increased after 12 months of training (from 47 +/- 1 to 51 +/- 1 mm; p less than 0.01). Left ventricular fractional shortening and mean velocity of circumferential shortening decreased progressively in response to graded isometric handgrip exercise before training but not after training. At comparable levels of blood pressure during static exercise, mean velocity of circumferential shortening was significantly higher after training (0.76 +/- 0.04 versus 0.98 +/- 0.07 diameter/sec, p less than 0.01). No improvement in echocardiographic or exercise variables was observed over a 12 month period in another group of five patients who did not exercise. Thus the data suggest that prolonged and vigorous exercise training in selected patients with coronary artery disease can elicit cardiac adaptations.

Preoperative prediction of reversible myocardial asynergy by postexercise radionuclide ventriculography

Myocardial asynergy is sometimes reversed by coronary bypass, and a noninvasive method of predicting which assess are reversible would be desirable. To assess whether changes in myocardial wall motion observed immediately after exercise can differentiate reversible from nonreversible myocardial asynergy, we evaluated 53 patients by radionuclide ventriculography before and after exercise and again at rest after coronary bypass surgery. Preoperative improvement in wall motion immediately after exercise was highly predictive of the surgical outcome (average chance-corrected agreement, 91 per cent). At surgery the asynergic segments that had improved after exercise were free of grossly apparent epicardial scarring. The accuracy of these predictions for postoperative improvement was significantly greater (P less than 0.01) than that of analysis of Q waves on resting electrocardiography (average chance-corrected agreement, 40 per cent). In contrast, preoperative changes in left ventricular ejection fraction after exercise were not predictive of postoperative resting ejection fraction. We conclude that postexercise radionuclide ventriculography can be used to identify reversible resting myocardial asynergy. This test should prove effective in predicting which patients with myocardial asynergy are most likely to benefit from aortocoronary revascularization.

The influence of inosine on the size of myocardial ischaemia and myocardial metabolism in the pig

In acute experiments on open chest pigs 15 min occlusions of the left anterior descending coronary artery were performed, each occlusion followed by 45 min reperfusion. Myocardial ischaemia was defined by epicardial electrogram recorded from the border of the ischaemic area. Myocardial extraction of lactate and glucose as well as the extraction of FFA were measured before and at the 15th min of occlusion. Inosine (5 mg/kg/min) or 0.9% NaCl infusion was administered i.v. throughout the occlusion period. Inosine significantly diminished the number of ischaemic points and reduced an increase in R-wave voltage induced by coronary occlusion. Myocardial extraction of measured substrates was not significantly influenced by inosine administration. In conclusion, inosine decreases the area of ischaemic injury induced by acute coronary occlusion in the pig.