(Circulation. 1996;94:340-345.)
© 1996 American Heart Association, Inc.
Articles |
Negative Chronotropic Effect of ß-Blockade Therapy Reduces Myocardial Oxygen Expenditure for Nonmechanical Work
the First Department of Internal Medicine, Kobe University School of Medicine, Kobe, Japan.
Correspondence to Motoshi Takeuchi, MD, First Department of Internal Medicine, Kobe University School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650, Japan.
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Abstract |
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Background The negative chronotropic effect of ß-blocking agents is likely to provide hemodynamic and energetic advantages. However, the negative chronotropic effect on cardiac energetics observed on the initiation of ß-blockade therapy has not been fully elucidated.
Methods and Results In 18 patients with heart failure, left ventricular pressure and volume, external work (EW), myocardial oxygen consumption per beat (total 
O2), mechanical efficiency (EW/total O2), and O2 for nonmechanical work (total O2-2·EW) were measured with the use of conductance catheter and Webster catheter at the following three states: under control conditions and after ß-blockade (0.15±0.07 mg/kg propranolol IV) with and without atrial pacing to keep the heart rate at control levels. Heart rate decreased after atrial pacing was stopped. EW decreased during ß-blockade with pacing and returned to the control level after pacing was stopped. Total O2 did not change during ß-blockade with or without pacing, whereas O2 for nonmechanical work increased with pacing and returned to the control level after pacing was stopped. As a result, mechanical efficiency decreased during ß-blockade with pacing and returned to the control level after pacing was stopped.
Conclusions The negative chronotropic effect of a ß-blocking agent may offset the mechanoenergetical deterioration resulting from its negative inotropic effect through a reduction in oxygen expenditure for nonmechanical work. These findings suggest that the negative chronotropic effect is an important aspect of ß-blockade therapy.
Key Words: heart failure • ß-adrenergic receptor blockade • heart rate • energetics
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Introduction |
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ß-Adrenoceptor blockade therapy, first described as a treatment for patients with heart failure in 1975,1 has been widely accepted because of its clinical, hemodynamic, and neurohormonal benefits.1 2 3 4 5 6 7 8 9 Many clinical trials have indicated that most patients with heart failure are able to tolerate ß-blockade therapy and show little clinical and hemodynamic deterioration.2 3 4 5 6 7 8 Several mechanisms have been postulated to account for the beneficial effects of ß-blockade therapy: attenuation in neurohormonal activation,9 10 11 upregulation of ß-adrenoceptor,3 12 reduction in
O2,9 13 14 prevention of catecholamine-induced cardiac necrosis,15 16 and reduction in heart rate.1 2 17 18 Among these postulated mechanisms, the negative chronotropic effect is likely to have hemodynamic and energetic advantages.2 17 18 19 However, the influences of negative chronotropic effect per se, especially on cardiac energetics during initiation of ß-blockade therapy, have not been fully elucidated. A previous investigation has shown that myocardial energy expenditure consists of a mechanical work component, related to cross-bridge cycling, and a nonmechanical work component, related to excitation-contraction coupling.20 Accordingly, to better understand the effects of ß-blockade on myocardial energetics, it is useful to discriminate between O2 for mechanical work and O2 for nonmechanical work.
In the present study, we focus on negative chronotropic effects on cardiac mechanoenergetics during acute ß-blockade. We compared the alterations in hemodynamics and energetics before and after intravenous administration of a ß-blocking agent, with and without right atrial pacing. The results suggest that the reduction in the component of O2 associated with nonmechanical work, which results from the negative chronotropic effect, is an important part of the therapeutic benefit of ß-blockade therapy in patients with heart failure.
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Methods |
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Patient Population
Eighteen patients (mean age, 57±10 years; 15 men and 3 women; 16 patients with previous myocardial infarction and 2 patients with dilated cardiomyopathy) undergoing cardiac catheterization for the evaluation of heart disease were enrolled in the study (Table 1
). Patients with acute myocardial infarction, unstable angina pectoris, valvular heart disease, or high-risk hemodynamic instability were excluded. Mean left ventricular ejection fraction was 39±11%. No patients had dyskinetic left ventricular wall motion. Complete informed, written consent was obtained from each patient before the study, and no unfavorable complications occurred as a result of this investigation. The study protocol was approved by the Institutional Committee on Human Research at Kobe University Hospital.
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Catheterization Procedure
All diuretics and vasodilators were withheld for at least 24 hours before the study. Patients underwent routine catheterization, including coronary angiography and left ventriculography. After completion of routine catheterization, a thermodilution Swan-Ganz catheter (Goodtech) was advanced into the pulmonary artery, a conductance (volume) catheter (CardioDynamics) was advanced into the left ventricle, and a Webster catheter (Wilton Webster Manufacturing Co) was advanced into the coronary sinus as confirmed by injection of contrast medium, as previously described.21 22 23
Left ventricular pressure-volume relations were determined with the use of a conductance catheter attached to a stimulator/processor (Sigma-5, CardioDynamics), with a Millar catheter (Millar Instruments) advanced into the left ventricle through the lumen of the conductance catheter. This technique has been described previously.22 23 24 25
Measurements of Pressure-Volume Parameters
After completion of calibrations, a balloon catheter (Baxter) was advanced to the right atrium just above the inferior vena cava to occlude venous return. After caval occlusion, pressure-volume loops were recorded over 8 to 10 beats to obtain the end-systolic pressure-volume relation (Fig 1A). Left ventricular pressure-volume data during the decrease in left ventricular pressure were fitted with the use of the linear least-squares technique to determine the following:
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Ea incorporates the principal elements of vascular load, including peripheral resistance, vascular compliance, characteristic impedance, and systolic and diastolic time intervals. This variable can be approximated by the steady state ratio ESP/SV, as shown schematically in Fig 1B
. The ratio Ea/Emax represents ventriculoarterial coupling. EW was calculated as the area that is bounded by the pressure-volume trajectory of one beat, PVA was calculated as the area that is bounded by the end-systolic pressure-volume relation, the end-diastolic pressure-volume relation, and the systolic pressure-volume trajectory of each beat.23 PE was calculated by subtracting EW from PVA.23
Measurements of Cardiac Energetics
The coronary sinus catheter was advanced percutaneously through a left jugular vein to the great cardiac vein. In each instance, the catheter tip was angiographically verified to be beyond the origin of any visible intermediate or lateral branches and in proximity to the anterior cardiac vein. Coronary sinus blood flow was measured at least twice with a Webster catheter.26 27 Coronary venous blood samples were taken from the distal lumen of the Webster catheter for oximetry. O2 per minute was calculated as the product of coronary sinus flow (mL/min) and the arterial-coronary sinus oxygen-content difference (vol%) and was divided by heart rate to yield O2 per beat (mL O2/beat).21 27 28 We calculated mechanical efficiency as the ratio of EW (J/beat) to O2 per beat (J/beat), where 1 mm Hg·mL of EW and 1 mL O2 of O2 correspond to 1.33x10-4 and 20 J, respectively. The converting efficiency from metabolic energy to mechanical energy has been found to be 
40% to 50%.20 21 29 Therefore, O2 for EW was calculated as 2xEW. O2 for nonmechanical work (O2,non) was calculated as the following:
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O2,non consists of O2 for PE (O2,PE) and PVA-independent O2,20 O2,non was also calculated as the following:
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Study Protocol
Patients were divided into the two groups (with different order of protocol) to allow us to determine the possible influences of the study design. The study protocol for 10 patients was as follows. (1) In the control study, routine heart catheterization and calibrations were carried out; hemodynamic variables, pressure-volume loops, and coronary sinus blood flow were measured; and blood gas samples were collected from the coronary sinus and femoral artery during spontaneous sinus rhythm. Inferior vena cava occlusions were performed several times to obtain the end-systolic pressure-volume relation. (2) For the ß-blockade–with–pacing study, after control measurements were made, right atrial pacing was started to maintain heart rate at the control rate. An intravenous bolus of propranolol was injected carefully to decrease peak positive dP/dt by 
10%. The mean dose of propranolol administered was 0.15±0.07 mg/kg. We repeated the same measurements as in the control study. (3) In the ß-blockade–without–pacing study, after all measurements with atrial pacing during acute ß-blockade were completed, atrial pacing was stopped. Five minutes later, we repeated the same measurements as performed previously at the slowed heart rate.
The study protocol for an additional eight patients was as follows: (1) control study, (2) ß-blockade–without–pacing study, and (3) ß-blockade–with–pacing study.
Because the results for the two groups of the other order of study protocol did not differ from each other, the combined data for 18 patients have been given ("Results").
Statistical Analysis
We obtained end-systolic pressure-volume relations with the use of linear regression analysis. ANOVA was applied to compare the alterations in hemodynamics and energetics during the three studies. When ANOVA demonstrated statistical significance, the Wilcoxon method with Bonferroni's correction was applied to compare the paired variables among the three studies. Differences were considered significant at a value of P<.05.
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Results |
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The changes in cardiac hemodynamics are summarized in Table 2
. During ß-blockade with pacing, heart rate and ESP remained unchanged, and EDP increased. After atrial pacing was stopped, heart rate decreased (-15.2±5.0%, P<.001), and ESP and EDP remained unchanged. Peak positive dP/dt decreased during ß-blockade with pacing and declined considerably after pacing was stopped. During ß-blockade with pacing, EDVI and ESVI did not change significantly, but SVI decreased. After atrial pacing was stopped, EDVI and ESVI increased, and SVI returned to the control level. Ejection fraction decreased during ß-blockade with pacing but remained unchanged after pacing was stopped.
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Changes in pressure-volume parameters are shown in Table 3. Emax decreased and Ea increased during ß-blockade with pacing, resulting in deterioration of ventriculoarterial coupling. After pacing was stopped, Emax declined more, and Ea returned to the control level, resulting in improvement of ventriculoarterial coupling. EW decreased during ß-blockade with pacing and returned to the control level after pacing was stopped. PE increased during ß-blockade with pacing and tended to decline after pacing was stopped. As a result, PVA did not change during ß-blockade with pacing and increased after pacing was stopped.
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Fig 2 demonstrates the influence of acute ß-blockade with and without atrial pacing on pressure-volume relations. After pacing was stopped, pressure-volume loop shifted rightward: SV, V0, EW, and PVA increased, and Emax, Ea, and ventriculoarterial coupling decreased.
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Changes in cardiac energetics are given in Table 3. O2 per minute remained unchanged during acute ß-blockade with pacing and decreased after pacing was stopped. O2 per beat remained unchanged with and without pacing during acute ß-blockade. As a result, the decrease in EW without a net change in O2 per beat resulted in decreased mechanical efficiency during ß-blockade with pacing, which was associated with the increase in O2 for nonmechanical work. After atrial pacing was stopped, mechanical efficiency returned to the control level; O2 for nonmechanical work was reduced because of the recovery in EW without a net change in O2 per beat (Fig 3).
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Fractional changes in O2 are demonstrated in Fig 4. Oxygen expenditure for nonmechanical work increased during ß-blockade with pacing and returned to the control level after pacing was stopped. Moreover, O2 for PE as well as PVA-independent O2, two components of O2 for nonmechanical work, tended to decrease after atrial pacing was stopped.
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Discussion |
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In the present study, we hypothesized that the negative chronotropic effect of ß-blocking agents is an advantageous aspect of ß-blockade therapy in terms of cardiac mechanoenergetics. To test this hypothesis, a ß-blocking agent was administrated, and cardiac mechanoenergetics, with and without right atrial pacing, were compared. When control heart rate was maintained through atrial pacing during acute ß-blockade, EW decreased with no net change in
O2 per beat, indicating a reduction in mechanical efficiency. When heart rate slowed after atrial pacing was stopped, EW increased with no net change in O2 per beat, indicating that mechanical efficiency had returned to the control level. O2 for nonmechanical work increased during ß-blockade with pacing and decreased to the control level after pacing was stopped. That is, the negative chronotropic effect of the ß-blocking agent reduced oxygen expenditure for nonmechanical work and, therefore, offset the deterioration in mechanical efficiency caused by its negative inotropic action.
Improvement in mechanical efficiency caused by a negative chronotropic effect occurred due to an increase in EW with no change in O2 per beat. In the present study, ESP remained unchanged, and SV index was increased. Therefore, the increase in EW can probably be attributed to an increase in SV due to improvement in diastolic filling. Although a mechanism by which the negative chronotropic effect can improve diastolic filling has not been fully explained, prolongation of the diastolic period and a decrease in wall stiffness may contribute to this improvement.2
The constancy of O2 per beat seen with the negative chronotropic effect, despite an increase in EW, may be related to a decrease in contractility and a reduction in afterload. A decrease in contractility is known to reduce O2 for nonmechanical work.20 30 Suga20 reported that a negative inotropic agent reduced O2 for nonmechanical work in the isolated canine heart; this decrease was due to a reduction in O2 for excitation-contraction coupling.20 30 In the present study, the peak positive dP/dt and Emax decreased significantly, and the V0 increased significantly after pacing was stopped (data not shown). Thus, left ventricular contractility was further reduced by the negative chronotropic effect. Accordingly, O2 for nonmechanical work may be decreased by the negative chronotropic effect of a ß-blocking agent.
Hata et al31 reported that appropriate afterload reduction increased EW and decreased PE without changing left ventricular contractility and O2. Thus, afterload reduction can improve mechanical efficiency. Previous investigations with ventriculoarterial coupling also demonstrated that reduction in afterload rather than in preload plays an important role in restoring optimal ventricular load coupling.32 33 Afterload reduction would decrease PE by improving ventriculoarterial coupling. In the present study, the negative chronotropic effect of a ß-blocking agent decreased Ea and optimized ventriculoarterial coupling, thereby decreasing PE, an element of O2 for nonmechanical work. Unlike our result, Haber et al34 demonstrated that ventriculoarterial coupling was preserved during acute ß-blockade; in their study, the changes in Emax were similar but Ea decreased. The difference may be in part accounted for by the influences of ß-blocking agent on ESP, which remained unchanged in our study but decreased in their study. Ventriculoarterial coupling deteriorated by 20% in their study, which is consistent with our result (Ea/Emax increased by 21%). Thus, the difference in the acute response of ventriculoarterial coupling to ß-blockade does not appear to be crucial, and the alteration in ventriculoarterial coupling appears to be similar in the two studies.
These two beneficial effects of the negative chronotropic effect on cardiac energetics offset the increase in O2 for EW, resulting in the preservation of the net O2.
It is noteworthy that the negative chronotropic effect provided a reduction in oxygen expenditure for nonmechanical work per beat. Many studies have demonstrated that the patients with heart failure are already in a critical stage of cardiac energetics.35 36 37 Any further energy expenditure may be disastrous to the failing heart. Therefore, it is likely that the reduction in oxygen expenditure for nonmechanical work resulting from the negative chronotropic effect would be an important mechanism to account for the salutary effect of ß-blockade therapy.
There have been several studies of the effects of long-term ß-blockade on cardiac energetics.4 5 9 38 The results have been conflicting. Andersson et al38 reported that long-term metoprolol treatment improved hemodynamic status in patients with dilated cardiomyopathy at rest and had a more pronounced effect during exercise, with improved or stable myocardial metabolic data. Mechanical efficiency was shown to be preserved with long-term bucindolol therapy4 or improved with long-term metoprolol treatment.5 O2 per minute increased with bucindolol4 but did not change with metoprolol,5 whereas EW increased in both studies. Further investigation is required to clarify the effects of long-term as well as short-term ß-blockade therapy on cardiac energetics.
Study Limitations
There are several limitations in the present study. First, we used a nonselective ß-blocking agent, propranolol. If we had used a cardioselective ß-blocking agent, the results might have been somewhat different. However, we wanted to demonstrate the benefits and importance of the negative chronotropic effect of propranolol on cardiac mechanoenergetics. Second, the hearts of the patients studied were markedly but not severely depressed. The results might be different in patients with severe heart failure because the adrenergic drive would be greater.10 11 Therefore, these findings can be applied to patients with mild-to-moderate heart failure. Finally, we focused on the short-term effects of a ß-blocking agent, not on its long-term effects. We speculate that the negative chronotropic effect may also play an important role in long-term ß-blockade therapy, but further investigation is required.
Conclusions
We evaluated the influences of the negative chronotropic effect on left-ventricular hemodynamics and energetics in patients with heart failure during acute ß-blockade. Our results have demonstrated that by reducing the oxygen expenditure for nonmechanical work, the negative chronotropic effect of a ß-blocking agent may offset mechanoenergetic deterioration caused by its negative inotropic action. These findings suggest that the negative chronotropic effect is an important advantageous aspect of ß-blockade therapy.
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Selected Abbreviations and Acronyms |
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Received November 16, 1995; revision received January 23, 1996; accepted January 29, 1996.
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