[Investigation on the identification and care of geriatric patients in regular hospitals for acute cases with respect to DRGs]. / Erhebung zur Identifizierung und Versorgung geriatrischer Patienten im Akutkrankenhaus unter DRG-Aspekten.

The aim of this pilot project, carried out over a period of 4 weeks, was to identify geriatric patients, hospitalised because of acute illness in the state of Baden-Wurttemberg, by means of a data entry form. A preliminary survey was expected to show the extent of medical care of acutely hospitalised geriatric patients in this state with special reference to the DRG system introduced recently. In addition, a questionnaire was used to check on acceptance and practicability of the evaluation process for adequate geriatric medical care. 985 patients hospitalised in 13 departments of 11 hospitals were included in the project. Of these, 352 were classified as "geriatric patients" according to the criteria "age usually > 65 years", "multimorbidity" and "disabilities in every day life". Without a major breach of protocol the data of 5 departments could be evaluated, representing 624 patients with 490 patients giving informed consent to participate in the project. Of these, 248 (39.7%) fulfilled the criteria for geriatric patients. Results show that approximately half of these patients require specific geriatric care, such as geriatric counselling, complex geriatric treatment and geriatric rehabilitation. In hospitals with specific geriatric competence, the need for geriatric care was higher than in those without. However, because of structural deficits, hospitals were unable to meet all these needs. The data entry form, in general, was accepted by the majority of the participants and proved to be practicable. Its use was more advantageous (optimisation of geriatric care) than disadvantageous (additional documentation). Data analysis suggests a reduction of the criteria for identification of geriatric patients to 2: "age" and "complex characteristics of geriatric multimorbidity".

[Speech therapy assessment: field study on psychometric properties, practicability, acceptance and process quality]. / Das logopädische Assessment: Feldversuch zu psychometrischen Eigenschaften, Praktikabilität, Akzeptanz und Prozessqualität.

OBJECTIVE: to investigate the internal consistency, responsiveness, discriminative validity, practicability, acceptance and process quality of a recently developed Speech Therapy Assessment (STA) under routine work conditions of speech and language therapists in German speaking countries. Since standardised, generic and ICF-oriented assessment tools for documentation and evaluation of speech therapy interventions for adult clients are missing in German speaking countries and existing tests cover only sub-areas, the STA has been developed in the years 1995 to 2002. By means of different domains, speech and language therapists assess client (1) communication, (2) aphasia, (3) speech apraxia, (4) dysarthria and (5) dysphagia as well as (6) her or his dealing with corresponding disabilities. METHODS: 17 therapists from 14 institutions applied the STA to 260 adult clients with language, speaking or swallowing disorders. The clients were included in the study consecutively over a period of 7 month. After this period, the therapists completed a questionnaire regarding the benefit and practicability of the STA. Cronbach alpha was calculated as indicator for internal consistency, effect sizes (standardised response means) for responsiveness and ROC values for discriminative validity. The answers of the questionnaire about the benefit of the STA were evaluated both, quantitatively and qualitatively. RESULTS: The internal consistency and discriminative validity were high (Cronbach alpha: 0.79 to 0.95; ROC-values: 0.84 to 0.98). Effect sizes regarding responsiveness were moderate (standardised response means: 0.46 to 0.78). On a 5-step Likert scale (1 = very good, 5 = inadequate), the therapists rated the average (standard deviation) benefit of the STA with: practicability 2.6 (1.2), acceptance 2.8 (1.3), impact on diagnostics 2.8 (1.3), impact on finding therapeutic goals 3.5 (1.2), impact on communication with other rehabilitation partners 2.7 (1.5) and overall judgement 2.6 (0.9). CONCLUSION: The STA fulfils essential quality criteria of the classical test theory. The involved therapists assessed the benefit of the STA as satisfactory. In addition, they pointed out concrete improvement potential for the implementation in practice. It is planed to investigate a refined version of the STA in a multi centre validation study.

[Controlled trials on the efficacy of occupational therapy with elderly. Part I: Research question, search strategy and methodological quality of trials]. / Kontrollierte Studien zur Wirksamkeit von Ergotherapie bei Alteren. Teil I: Fragestellung, Recherche-Strategie und methodische Qualität der Studien.

OBJECTIVE: To investigate how far controlled trials give evidence for the assumption that occupational therapy treatment improves or stabilises the competence, autonomy or satisfaction of elderly while performing every day activities. METHOD: Clinical trials with randomised, quasi-experimental or crossover control group design and "occupational therapy" as the main subject were identified by an electronic search of the medline database. The criteria for the analysis were derived from the CONSORT-Statement and adapted for occupational therapy. They relate to the quality of sample, intervention, measurement and data analysis. RESULTS: The 31 identified studies (RCT, n=23; quasi-experimental, n=2; crossover, n=6) were mainly conducted in Great Britain, USA and Canada, but not in Germany. They are heterogeneous regarding the characteristics and size of samples, the outcome variables and treatment approaches. They give evidence for a significant efficacy of occupational therapy with elderly, but also show some methodological shortcomings. CONCLUSION: While on an international level the positive potential of occupational therapy for the elderly is evident, there is a strong need for further studies in Germany. Therefore a methodological harmonization and a co-operation with occupational therapy research and occupational science emerging currently in Europe are recommended.

[Controlled trials on the efficacy of occupational therapy with elderly. Part II: Evidence for prioritized diseases and disabilities]. / Kontrollierte Studien zur Wirksamkeit von Ergotherapie bei Alteren. Teil II: Evidenz bei priorisierten Krankheiten und Behinderungen.

OBJECTIVE: To identify the evidence for the efficacy of occupational therapy on prioritized diseases and disabilities of the elderly. METHOD: Reviews, meta-analyses and clinical trials with control group design regarding "occupational therapy" were identified by an electronic search of pubmed and reviewed based on the CONSORT-Statement. The study results were summarised in regard to diseases and commented considering further literature. RESULTS: A total of 31 studies were identified: 10 on stroke, 6 on dementia, 5 on prevention of falls, growing loneliness or inactivity, 4 on need of nursing care, and 6 on other diseases or disabilities. There is evidence for a positive efficacy of occupational therapy on the level of several controlled trials or reviews. CONCLUSION: Especially in Germany, further research specific to occupational therapy is needed in the fields of depression, diabetes mellitus and nursing care in the community.

[Effects of physical training and age-induced structural and functional changes in cardiovascular system and skeletal muscles]. / Trainingseinflüsse auf altersbedingte strukturelle und funktionelle Veränderungen am Herzkreislaufsystem und an der Skelettmuskulatur.

Age-related morphological changes in the cardiovascular system refer to a thickening of the arterial wall as well as a diffuse increase in the wall thickness of the myocardium. In terms of function, this leads to a decrease of the myocardial contractility in systole and to a delay of the diastolic myocardial relaxation. At the arterial wall, an impairment of wall elasticity as well as a decrease of the vasoreagibility can be observed. The systolic blood pressure and the blood pressure amplitude rise; the blood flow-dependent vasodilatation mediated by endothelial cells decreases. The loss of cardiac pacemaker cells by approximately 90% from the 2nd to the 8th decade leads to a reduction of the heart rate variability and to a decrease of the maximum heart rate during exhaustive physical exercise. Hemodynamically these changes resulted in a continuous decline of the maximum cardiac output as well as the maximum oxygen transport capacity. Between the 3rd and 8th decade the peripheral skeletal muscle mass decreases as a result of a reduction of the size and the number of muscle fibers with an overproportional loss of 30-40% regarding the highly glycolytic type IIb fibers. Furthermore, the intramuscular capillarization declines so that, with a concomitant decrease in the number and size of the mitochondria, the supply with oxygen and energy sources and consecutively the aerobic muscular energy metabolism decreases by 8-10% per decade beginning with the 4th to 5th decade. Additionally, the maximum and explosive muscular strength decreases by 30-35% from the 4th decade onwards. In older, healthy men who perform a regular aerobic muscular training in endurance sport disciplines (e.g., walking, jogging or cycling), a decrease of the resting heart rate, a restoration of the primarily lowered heart rate variability, an improvement of the early diastolic left-ventricular filling as well as a significant increase in the VO2max could be proven. Other studies showed that regular endurance training on a cycle-ergometer resulted in a significant increase in capillarization within the exercising muscle groups. In older, trained individuals a reduced stiffness of the arterial vessel walls and an improved maximum exercise-induced muscular blood supply occurs. In other training studies performed with older subjects, a positive influence of regular endurance training on the carbohydrate metabolism along with an improvement of the primarily reduced insulin sensitivity could be demonstrated. In older men and women who regularly underwent muscular strength training, a significant increase in maximum strength with a significant increase in the proportion of type II muscle fibers was found.

[Psychometric analyses of occupational therapy assessment]. / Psychometrische Testung des Ergotherapeutischen Assessments.

PURPOSE: In German-speaking countries standardised assessments measuring the specific aspects of occupational therapy in adults are missing. The Occupational Therapy Assessment (OTA) was introduced by the authors during 2000 in the context of a field study regarding acceptance, practicability and the influence of the instrument on process quality. The purpose of this study was to test the psychometric properties of the OTA. METHODS: : OTA was applied by 76 occupational therapists from 44 institutions to 833 consecutive patients. Additionally, the Mini Mental State Examination (MMSE) was applied. Patients completed established German instruments measuring functional capacity (Funktionsfragebogen Hannover - polyartikuläre Erkrankungen; FFbH-P), body complaints (Beschwerdenliste; BL) and general health (Indikatoren des Reha-Status; IRES). 59 randomly selected patients were assessed independently by two therapists. 42 randomly selected patients were assesses twice for test-retest reliability. RESULTS: : For the domains 'activities of physical self-supply', 'activities of independent living', and the three domains 'consequences of sensomotor/neuropsychological/psychosocial functioning on everyday life' internal consistency (Cronbach alpha: 0.90-0.97), test-retest reliability (intraclass correlation coefficient: 0.93-0.99) and interrater reliability (kappa: 0.72-0.82) were high. Overall, the concurrent validity of the domains with corresponding scales or subscales of the MMSE, FFbH-P and IRES is satisfactory. In addition, the domains are sensitive to change. CONCLUSION: : The OTA is a standardised assessment measuring the specific aspects of occupational therapy reliably, valid, sensitive to change and sufficiently comprehensive.

[Ergotherapy assessment: field study of acceptance, practicability and process quality]. / Das Ergotherapeutische Assessment: Feldstudie zu Akzeptanz, Praktikabilität und Prozessqualität.

There is need for comprehensive assessment of patients suitable for occupational therapy. The "Ergotherapeutische Assessment" (EA) occupational therapy assessment instrument has been developed recently by a group of experts in the field. Its main purpose is to significantly support occupational therapists in diagnostics, planning, communication and evaluation of therapeutic outcome. In a first step, EA was tested in a field study with regard to practicability, acceptance, and its effects on process quality. The EA was applied in 329 patients by 22 occupational therapists (office, institution) who had been specially trained (handbook, instruction session) prior to the study. In addition, participants had to answer standardized evaluation forms with respect to the general therapeutic success, relevant functional changes possibly not covered by the EA, and professional benefit in the areas under investigation. In summary, the value for practicability as described using a 10-point scale was 5.8, and 7.6 for acceptance. With regard to process quality, the ratings were 7.3 for diagnostic effect, 6.0 for definition of therapeutic aims, and 6.8 for improvement of communication between members of the rehabilitation team. The internal consistency of the five individual modules of the instrument as calculated by Cronbachs alpha was between 0.72 and 0.95. Changes considered relevant by the participants and not reflected by the instrument accounted for 9% only. The correlation coefficient for the evaluated general success of the patients and category changes found on the basis of EA severity ratings was 0.48.

[Geriatric assessment]. / Das Geriatrische Assessment.

The emerging procedures for geriatric assessments in various medical and therapeutical areas in Germany are still in an early phase. Tests for assessing elderly patients must be adopted mostly from the English literature; specific items and problem-orientated assessment contents have to be developed. This requires tremendous efforts and may require a long time because of its empirical and scientific complexities. This does not surprise because geriatric assessment is considered a basic geriatric instrument which has to take into account general and problem-oriented aspects of impairments, disabilities and handicaps. In addition, large cohorts are required to test validity and reliability of these procedures as well as efficiency and benefit of therapeutic interventions related to the assessment processes. In addition, rules of informed consent as well as legal requirements must be observed. Regarding results of assessment procedures, it is not sufficient to express them in a mere figure. Instead, it is necessary to make individual test results visible in a feasible visual presentation. The geriatric assessment serves as a major instrument to improve quality of life of geriatric patients, to support their autonomy and stimulate their social contacts.

The effect of the partial beta-1-adrenoceptor agonist xamoterol on hemodynamics and myocardial energetics in patients with idiopathic dilated cardiomyopathy.

Xamoterol, a new partial beta 1-adrenoceptor agonist, was evaluated in respect to its hemodynamic and energetic effects when given acutely i.v. (0.2 mg/kg body weight) to 10 patients with idiopathic dilated cardiomyopathy. Hemodynamically, a small drop in left ventricular end-systolic volume index (from 105 +/- 38 to 91 +/- 48 ml/m2; p less than 0.05) and end-diastolic volume index (from 168 +/- 44 to 152 +/- 41 ml/m2; p less than 0.05) and an increase in maximum rate of left ventricular pressure rise (from 1,003 +/- 358 to 1,283 +/- 398 mm Hg/s; p less than 0.001) was observed. The systolic stress-time integral was only slightly reduced after injection of xamoterol, from 107 +/- 28 to 94 +/- 35 x 10(3) dyn.s/cm2 (NS). Other conventional hemodynamic variables did not change significantly. Myocardial oxygen consumption per beat increased from 125 +/- 39 microliters/beat/100 g to 153 +/- 62 microliters/beat/100 g (p less than 0.05). The ratio of myocardial oxygen consumption per beat and stress-time integral--as an inverse measure of left ventricular contraction economy--increased significantly, from 132 +/- 62 to 192 +/- 115 microliters/beat/10(3) dyn.s/cm2 (p less than 0.02) after injection of xamoterol, whereas left ventricular efficiency decreased from 17.6 +/- 7.8 to 13.8 +/- 6.5% (p less than 0.05). Thus, in idiopathic dilated cardiomyopathy, xamoterol exhibited only minor hemodynamic effects whereas myocardial contraction economy and efficiency were significantly reduced.

[Vasodilatation and positive inotropic effect of the phosphodiesterase inhibitor enoximone]. / Vasodilatation und positive Inotropie des Phosphodiesterasehemmers Enoximon.

The comparison of two invasive studies using intravenous application of the phosphodiesterase enoximone demonstrated unchanged cardiac output in patients with dilated cardiomyopathy NYHA II-III, and increased cardiac output (from 3.22 +/- 1.15 to 5.04 +/- 2.05 l/min; p less than 0.01) in acute heart failure. This comparison of hemodynamic parameters in addition to studies on myocardial oxygen consumption support the use of intravenous enoximone in acute heart failure, whereas the long-term application of enoximone in chronic heart failure is judged to be critical.

Reocclusion prophylaxis with dipyridamole combined with acetylsalicylic acid following PTA.

After primary successful PTA, 199 patients were randomized into one of three treatment groups, namely, placebo or a combination of 75 mg dipyridamole with either 330 mg (high dose) or 100 mg (low dose) acetylsalicylic acid (ASA) tid. The duration of treatment was six months. Of the 199 patients admitted to the study, 156 completed the six-month trial period. Not all patients had a second angiogram, and in these cases clinical findings were used in the evaluation. Evaluation of the combined angiographic and clinical results showed improvement or no deterioration in 37% of patients in the placebo group compared with 49% in the low-dose and 61% in the high-dose ASA groups respectively. The only statistically significant difference observed was between the placebo group and the group treated with dipyridamole and high-dose ASA (p = 0.01). This difference remained statistically significant at p = 0.039 if only the angiographic findings were considered for group comparison. It cannot, however, be concluded from this study that 75 mg dipyridamole in combination with 100 mg ASA tid is more effective in preventing reocclusion after PTA than in combination with 330 mg ASA tid.

Repeat determination of left ventricular wall thickness from mass and volume during one cardiac cycle for the calculation of left ventricular wall stress parameters.

Left ventricular end-diastolic wall stress, end-systolic wall stress, and systolic stress-time integral are important parameters to characterize left ventricular load and function. To obtain these parameters, left ventricular pressure, volume, and wall thickness data must be determined at short time intervals throughout one cardiac cycle. However, the measurement of wall thickness at short intervals (i.e., 20 ms) throughout a cardiac cycle is tedious. Furthermore, measurements of wall thickness are less accurate at end-systole compared with end-diastole. For these reasons we developed a computer program for calculating wall thickness at short intervals (20 ms) throughout the cardiac cycle from one single determination of left ventricular wall mass and repetitive measurements of left ventricular (LV) volume.

Influence of UDCG-115 on hemodynamics and myocardial energetics in patients with idiopathic dilated cardiomyopathy.

The influence of the new inotropic and vasodilating agent UDCG-115 on hemodynamics and myocardial oxygen metabolism was investigated in 11 patients with idiopathic dilated cardiomyopathy (New York Heart Association class II to III). After intravenous administration of UDCG-115, cardiac index increased from 3.03 +/- 0.68 to 3.76 +/- 1.07 L/min/m2 (p less than 0.01), left ventricular ejection fraction increased from 31 +/- 13 to 39 +/- 16% (p less than 0.01), and maximum rate of left ventricular pressure rise increased from 935 +/- 248 to 1056 +/- 284 mm Hg/sec (p less than 0.05). Left ventricular end-diastolic wall stress (index of preload) and left ventricular end-systolic wall stress (index of afterload) decreased by 41% (p less than 0.01) and 34% (p less than 0.001), respectively. Heart rate did not change significantly. With UDCG-115 myocardial oxygen consumption decreased from 14.3 +/- 5.1 to 10.6 +/- 3.8 ml/min/100 gm (p less than 0.05), and the ratio of myocardial oxygen supply to myocardial oxygen demand increased from 1.40 +/- 0.08 to 1.53 +/- 0.17 (p less than 0.05). Thus intravenous UDCG-115 improves left ventricular function by increasing inotropism and reducing preload and afterload in patients with idiopathic dilated cardiomyopathy and moderate congestive heart failure. The systemic hemodynamic actions are associated with favorable effects on myocardial energetics.

Myocardial energetics in patients with dilated cardiomyopathy. Influence of nitroprusside and enoximone.

Cardiotonic agents influence myocardial energy consumption by vasodilation, which may reduce energy demand, and by inotropism, which may increase it. To distinguish between the two effects, myocardial oxygen consumption must be analyzed in relation to its hemodynamic determinants. The coupling of myocardial oxygen consumption with its determinants was investigated in 22 patients with idiopathic dilated cardiomyopathy (NYHA Class II and III). Predicted myocardial oxygen consumption by the pressure-work index, the Bretschneider index, and the pressure-volume area correlated moderately with measured myocardial oxygen consumption (r = 0.57, p less than 0.001; r = 0.52, p less than 0.005; and r = 0.63, p less than 0.001). Multiple regression analysis, including left ventricular peak systolic wall stress, systolic stress-time integral, pressure-volume work, maximum rate of left ventricular pressure rise, and mean velocity of circumferential fiber shortening indicated that systolic stress-time integral is the major determinant of myocardial oxygen consumption (r = 0.75, p less than 0.001) in these patients. Enoximone, a phosphodiesterase inhibitor, has an inotropic and a vasodilating effect. To investigate the inotropic portion of the energy cost of this phosphodiesterase inhibitor, the influence of enoximone on myocardial oxygen consumption and systolic stress-time integral was compared with the effects of nitroprusside, which is a vasodilator only. Nitroprusside (10 patients) and enoximone (12 patients) reduced left ventricular systolic stress-time integral from 109 +/- 22 to 71 +/- 21 (p less than 0.005) and from 104 +/- 23 to 42 +/- 10 (p less than 0.001) 10(3) dynes.sec/cm2, respectively. Myocardial oxygen consumption decreased from 159 +/- 44 to 112 +/- 23 (p less than 0.005) and from 134 +/- 28 to 109 +/- 21 (p less than 0.001) microliters/beat/100 g, respectively. In both groups, there was a significant correlation between the decrease in myocardial oxygen consumption and the decrease in systolic stress-time integral. The slopes of the respective linear regression lines were significantly different (1.27 for nitroprusside and 0.51 nl.cm2/100 g.dynes.sec for enoximone, p less than 0.05), indicating a smaller decrease of myocardial oxygen consumption for a given decrease of stress-time integral with enoximone. Applying the pressure-work index or the pressure-volume area instead of systolic stress-time integral yielded comparable results. Thus, vasodilation reduces myocardial oxygen consumption in proportion to the reduction of stress-time integral. With enoximone, the energy-saving effect of vasodilation is counteracted in part by the increased energy d

Influence of the calcium-sensitizer UDCG-115 on hemodynamics and myocardial energetics in patients with idiopathic dilated cardiomyopathy. Comparison with nitroprusside.

UDCG-115 is a new cardiotonic agent which in vitro increases the sensitivity of the contractile proteins to calcium ions, inhibits the activity of phosphodiesterase, and prolongs the duration of the action potential. The influence of UDCG-115 (i.v.) on hemodynamics and myocardial energetics was investigated in patients with idiopathic dilated cardiomyopathy (NYHA II-III) and compared to the effects of the pure vasodilator nitroprusside. UDCG-115 increased cardiac index from 3.2 +/- 0.4 to 4.2 +/- 0.8 l/min/m2 (p less than 0.01) and decreased left ventricular end-diastolic wall stress (preload) from 52 +/- 21 to 28 +/- 18 10(3) dyn/cm2 (p less than 0.01) and end-systolic wall stress (afterload) from 201 +/- 61 to 129 +/- 43 10(3) dyn/cm2 (p less than 0.01) compared to control conditions. Compared to nitroprusside, for a similar decrease in preload and afterload. UDCG-115 increased cardiac index by 40% (p less than 0.01), stroke volume index by 37% (p less than 0.01) and maximum rate of left ventricular pressure rise by 23% (p less than 0.05). Heart rate did not significantly change with either drug. Myocardial oxygen consumption per beat decreased by 33% (p less than 0.05) with UDCG-115 and by 30% (p less than 0.01) with nitroprusside. With both drugs, the decrease of myocardial oxygen consumption correlated significantly with the decrease of left ventricular systolic stress-time integral. The slopes of the respective linear regression lines were not significantly different. Thus, UDCG-115 given intravenously in patients with idiopathic dilated cardiomyopathy and moderate congestive heart failure exhibits significant inotropic and vasodilating properties. The systemic hemodynamic actions are associated with favorable effects on myocardial energetics.

Effects of pimobendan on hemodynamics and myocardial energetics in patients with idiopathic dilated cardiomyopathy: comparison with nitroprusside.

The influence of pimobendan and nitroprusside on hemodynamics was investigated in nine patients with idiopathic dilated cardiomyopathy (NYHA class II-III). Pimobendan and nitroprusside resulted in a comparable decrease of left ventricular end-diastolic wall stress (preload) by 46% (p less than 0.01) and 52% (p less than 0.01), respectively, and of end-systolic wall stress (afterload) by 36% (p less than 0.01) and 34% (p less than 0.01), respectively. Cardiac index increased from 3.2 +/- 0.4 to 4.2 +/- 0.8 L/min/m2 with pimobendan (p less than 0.01) and did not significantly change with nitroprusside (3.0 +/- 0.6 L/min/m2). Compared to nitroprusside, pimobendan resulted in a significant increase in stroke volume index by 37% (p less than 0.01) and maximum rate of left ventricular pressure rise by 23% (p less than 0.05). Heart rate did not significantly change with either drug. Following the application of pimobendan, there was a decrease in myocardial oxygen consumption from 14.3 +/- 5.1 to 10.6 +/- 3.8 ml/min/100 g (p less than 0.05). The ratio of myocardial oxygen consumption and systolic stress-time integral did not significantly change. Thus, in comparison with nitroprusside, pimobendan exhibits significant inotropic and vasodilating properties. The hemodynamic actions of pimobendan are associated with favorable effects on myocardial energetics.

Influence of enoximone on myocardial energetics in patients with idiopathic dilated cardiomyopathy: comparison with nitroprusside.

Enoximone may influence myocardial energetics by vasodilation, which may reduce and by inotropism which may increase myocardial energy demand. To separate both pharmacological properties, the influence of enoximone on myocardial oxygen consumption and its hemodynamic determinants was analyzed and compared to the effects of the pure vasodilator nitroprusside. The relationship between myocardial oxygen consumption and left ventricular hemodynamics was evaluated in 22 patients with idiopathic dilated cardiomyopathy (NYHA stages II-III). During control, myocardial oxygen consumption per beat [MVO2 (beat)] correlated closely with left ventricular systolic stress-time integral (STI) (r = 0.74; p less than 0.001). The ratio of MVO2 (beat) and STI was used as an inverse measure of the economy of myocardial contraction. Following nitroprusside (10 patients) the STI decreased by 35% (p less than 0.005) and MVO2 (beat) by 30% (p less than 0.005). MVO2 (beat)/STI did not significantly change. Following enoximone (12 patients), STI decreased by 60% (p less than 0.001), MVO2 (beat) by 19% (p less than 0.001), and MVO2 (beat)/STI increased from 1.31 +/- 0.16 to 2.72 +/- 0.78 nl.cm2/100 g.dyn.s (p less than 0.001). In summary, vasodilation by nitroprusside decreased MVO2 (beat) in proportion to its major determinant, STI; the economy of myocardial contraction remained unchanged. Compared to nitroprusside, enoximone reduced the economy of contraction. Thus, with enoximone, the energy-saving effect of vasodilation is counteracted by increased energy demand due to the inotropic stimulation of the myocardium. Global myocardial oxygen consumption depends on the balance of both pharmacological properties.