Usefulness and limitations of the rate of rise of intraventricular pressure (dp/dt) in the evaluation of myocardial contractility in man∗

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Studies on the first derivative of the ventricular pressure pulse in man

To determine the sensitivity of several isovolumic and ejection phase indices of myocardial contractility to loading, inotropic stimulation and heart rate in man, 14 patients (pts) were studied during cardiac catheterization with simultaneous recordings of left ventricular (LV) pressures and ultrasound dimensions. Measurements were made of instantaneous and mean circumferential fiber shortening velocity (VCF), maximal (max) rate of LV pressure rise (dP/dt), dPHdt divided by end-diastolic circumference [(dP/dt)/C], (DP/dt)/C divided by aortic valve opening pressure [(dP/dt/CP], PEAK CONTRACTILe element velocity (VCE) using total LV pressure, VCE extrapolated to zero total pressure (Vmax), VCE at a developed pressure of 10 mm Hg (VCEDP10) and dP/dt at a common isovolumic developed pressure of 40 mm Hg [(dP/dt)/DP40]. Resulta are expressed in per cent change of the mean for the group. Acute preload increase (8.6% increase in end-diastolic circumference) with volume expansion at constant heart rate in 7 pts produced insignificant changes in VSF, an 8.3% increase in max dP/dt, no change in (dP/dt)/C, a variable response in (dP/dt)/CP, 18% reduction in peak VCE, 16% reduction in Vmax, 14% increase in VCEDP10, and a 10% increase in (dP/dt)/DP40. An acute increase in afterload produced by angiotensin in 8 pts (44% increase in peak stress) led to a 38% decrease in VCF, a 2.5% increase in max dP/dt, no significant change in (dP/dt)/C, a 26% reduction in (dP/dt)/CP, variable responses in peak VCE and Vmax, an 11% increase in VCEDP10 and minor changes in (dP/dt)/DP40. All of the contractility indices were augmented significantly by isoproterenol and atrial pacing. In a given patient, max, dP/dt appears to be useful in the assessment of acute changes in inotropic state since the magnitude of its response to abrupt changes in preload is small and to afterload insignificant. Normalizing max dP/dt for end-diastolic circumference assures better stability during loading with good sensitivity to inotropic stimulation. VCF may be used whenever changes in afterload are minimal. The isovolumic measurements of VCE (regardless of whether total or developed pressure is used) lack sufficient stability during acute changes in loading conditions to warrant their use in the quantitative assessment of acute changes in inotropic state.

Influence of acute changes in preload, afterload, contractile state and heart rate on ejection and isovolumic indices of myocardial contractility in man.

I investigated the relation of the maximum rate of left ventricular pressure rise to the end-diastolic volume and the comparison of the maximum rate of left ventricular pressure rise-end-diastolic volume relation to the end-systolic pressure-volume relation, using the time-varying elastance model. These studies were performed in 11 dogs chronically instrumented to measure left ventricular pressure and determine left ventricular volume from three orthogonal dimensions. During vena caval occlusions, the relations between the maximum rate of left ventricular pressure rise and end-diastolic volume were described by straight lines (r = 0.97 +/- 0.01, mean +/- SD). Dobutamine increased the slope of the maximum rate of left ventricular pressure rise-end-diastolic volume relation to 358 +/- 94% of control. This increase was greater than the 244 +/- 61% increase in the slope of the end-systolic pressure-volume relation (P less than 0.005). The volume intercepts of the maximum rate of left ventricular pressure rise-end-diastolic volume relation and end-systolic pressure-volume relation were similar and were not significantly altered by dobutamine. The ratio of the slope of the maximum rate of left ventricular pressure rise-end-diastolic volume relation to the slope of the end-systolic pressure-volume relation divided by the time from end-diastole to end-systole was similar before (2.2 +/- 0.7) and after dobutamine (2.3 +/- 0.7, P = NS). Angiotensin II did not significantly alter the maximum rate of left ventricular pressure rise-end-diastolic volume relation generated by caval occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

The left ventricular dP/dtmax-end-diastolic volume relation in closed-chest dogs.

We have investigated the possibility that alterations in the duration of the systolic preejection period can be used to estimate adrenergic influences on the human left ventricle. The preejection period was determined from high speed, simultaneous recordings of the phonocardiogram, carotid pulse tracing, and electrocardiogram. The preejection period was shortened by isoproterenol, epinephrine, and moderate doses of norepinephrine-all of which activate beta adrenergic receptors-and by cedilanid-D. It was unaltered by changes in heart rate induced by atropine and right atrial electrical pacing. Beta adrenergic receptor blockade by propranolol abolished the shortening effects of the three catecholamines but did not inhibit that due to cedilanid-D. Vasoconstriction, both alpha adrenergic (epinephrine and norepinephrine after propranolol) and nonadrenergic (angiotensin), prolonged the preejection period. Most of the shortening of the preejection period by beta adrenergic receptor activating agents and cedilanid-D and all of the prolongation accompanying pharmacologic vasoconstriction occurred after the onset of the first heart sound, thereby excluding changes in electrical-mechanical delay as a major factor in the observed preejection period responses. Shortening of the preejection period by beta adrenergic activity induced with isoproterenol was dose-related. Increasing doses of propranolol produced parallel shifts to the right in the isoproterenol dose-response curve. In 37 normal resting subjects intravenous propranolol (10 mg) prolonged the preejection period an average of 10 (SE +/- 1) msec. In six patients with psychogenic sinus tachycardia and a patient with a pheochromocytoma the presence of excessive beta adrenergic influences on the left ventricle was demonstrated by the finding of an initially short preejection period which responded with an abnormally great prolongation to beta adrenergic receptor blockade.

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Effects of Adrenergic Receptor Activation and Blockade on the Systolic Preejection Period, Heart Rate, and Arterial Pressure in Man

The hemodynamic determinants of the rate of change in pressure in the left ventricle during isometric contraction.

The ballistocardiograms of young normal subjects as recorded with a wide frequency range technic are described. These records contain high frequency forces not previously described. An analysis of these components in terms of known cardiovascular events strongly suggests that they have definite dynamic significance. In addition, these correlations offer evidence as to the genesis of some forces in the ballistocardiogram.

Wide frequency range force ballistocardiogram; its correlation with cardiovascular dynamics.

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Velocity of blood flow and stroke volume obtained from the pressure pulse.

Circulatory and ventilatory responses to postprandial exercise.

Direct anastomosis of the end of the internal mammary artery to the side of the distal left anterior descending coronary artery with microsurgical technique produces an immediate increase in myocardial perfusion rather than a delayed increase as after mammary artery implantation. The distal left coronary artery is usually soft and widely patent even in patients with diffuse disease of this vessel. Seven consecutive patients have undergone this procedure; five had a simultaneous aorto-right coronary artery bypass with the saphenous vein. All but one survived and were markedly improved.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=352142&pdfFileName=jama_211_7_015.pdf

William B. Jones

Papers

The hemodynamic determinants of the rate of change in pressure in the left ventricle during isometric contraction.

Wide frequency range force ballistocardiogram; its correlation with cardiovascular dynamics.

Velocity of blood flow and stroke volume obtained from the pressure pulse.

Circulatory and ventilatory responses to postprandial exercise.

Direct surgery for coronary artery disease. Technique for left anterior descending coronary artery bypass.