Reduced subendocardial coronary reserve. A potential mechanism for impaired diastolic function in the hypertrophied and failing heart.

The association between pressure overload, left ventricular (LV) hypertrophy and failure, and abnormalities in diastolic function has been described both clinically and experimentally. The mechanisms underlying this association, however, are complex and controversial. Factors that have been implicated include mechanical alterations due to hypertrophy alone, changes in collagen type and content, alterations in beta-adrenergic responsiveness, and chronic myocardial ischemia. Studies in our laboratory have identified limitations in subendocardial flow reserve in compensated LV hypertrophy and near exhaustion in subendocardial reserve in animals with decompensated LV hypertrophy and failure. These abnormalities in coronary reserve are associated with impaired diastolic function, particularly during periods of physiological stress. For example, with pacing-induced stress, impairment in diastolic function was observed in conscious dogs with compensated LV hypertrophy. In conscious dogs with LV hypertrophy and failure, isoproterenol also resulted in altered diastolic function. Thus, in the model of severe pressure-overload hypertrophy, which is characterized by limitations in coronary reserve, the mechanism of subendocardial ischemia might be responsible in part for the impairment in diastolic function observed in response to superimposed stress.