Issue published January 1, 1968

E xperiments were done to test the hypothesis that alpha receptor blockers antagonize more effectively venous than arterial responses to norepinephrine in man.Systemic arterial blood pressure, venous pressure in the forearm, blood flow through the forearm, and the volume of the forearm at a venous pressure of 30 mm Hg were measured using pressure transducers and a mercury strain-gauge plethysmograph. Infusions of norepinephrine into the brachial artery reduced forearm blood flow and venous distensibility without changing arterial pressure. After intraarterial infusion of phentolamine the decrease in venous distensibility during administration of norepinephrine was blocked almost completely whereas the decrease in blood flow through the forearm was not altered.The results indicate that alpha adrenergic receptor blockade can antagonize constriction of capacitance vessels more effectively than constriction of resistance vessels.

T he effects of nerve stimulation and of intraarterial injections of norepinephrine on arterial and venous resistances were studied in the perfused forelimb of dog before and after administration of the alpha adrenergic receptor blocker phenoxybenzamine.Pressures were recorded from the perfused brachial artery and a small metacarpal vein in the forepaw. Blood flow to the whole forelimb was maintained constant. Changes in perfusion pressure in the brachial artery reflected primarily changes in arterial resistance and changes in small vein pressure reflected changes in resistance of venous segments downstream from the point of pressure measurement.Alpha receptor blockade reduced vasoconstrictor responses to both nerve stimulation and norepinephrine. Responses to angiotensin, used in these experiments as an internal control, were not blocked consistently in a dose-related manner indicating that the effects of phenoxybenzamine were specific to adrenergic stimuli.Increases in venous pressure in response to norepinephrine and to nerve stimulation were blocked almost completely whereas increases in arterial pressure were reduced only in part by the blocker. The more effective reduction of pressor responses in the small vein was not caused by a passive reduction in blood flow through the paw nor was it caused by a reduction in the concentration of norepinephrine in the venous effluent reaching the venous segments.This differential effect of alpha receptor blockade on increases in venous and arterial resistances may account for the beneficial effect of phenoxybenzamine in shock.

A bnormal estrogen metabolism has been found in cirrhosis after administration of intravenous tracers of estradiol-³H to 6 patients and 23 healthy controls. The major abnormalities observed involved estrogen metabolites other than the 3 “classic” ones, i.e., estrone (E1), estradiol (E2), and estriol (E3). Urinary recovery of radioactivity was regularly elevated in the patients, to an average of 71% of the dose compared to 51% in normals. This is considered to reflect the component of intrahepatic cholestasis in cirrhosis. The per cent dose recovered as urinary glucosiduronates (42%) was normal in cirrhotics in contrast to impaired glucuronidation of cortisol metabolites in this disease. E1 and E2 were present in normal amounts, and E3 was slightly elevated to 21% of the extract compared to 14% in controls. There were strikingly decreased excretion of 2-hydroxyestrone (3% compared with normal 20%) and 2-methoxyestrone (2% compared with 5%) and increased excretion of 16α-hydroxyestrone (12% compared with normal 6%). Thus cirrhosis, too, is characterized by the reciprocal relationship between decreased 2-hydroxylation and increased 16α-hydroxylation previously described in hypothyroidism and male breast cancer. However, unlike these latter, the increase of 16α-hydroxy metabolites was less than the decrease of 2-hydroxy metabolites. The data indicate clearcut impairment of 2-hydroxylation, suggestive impairment of 16α-hydroxylation, and a definite depression of the reaction 16α-hydroxyestrone→estriol, the latter finding so far unique to cirrhosis. Demonstration of abnormal peripheral metabolism of estrogen in cirrhosis provides a new approach to the origin of the hyperestrogenic syndrome in this disease.

A group of 13 normal subjects were evaluated for their extrathyroidal thyroxine distribution. The method employed the measurement of the acute plasma disappearance of a thyroxine-¹³¹I tracer and its concomitant uptake into the liver and forearm. The analysis of these parameters allowed the theoretical construction of a four compartmental mathematical model system comprised of the plasma, extracellular fluid, hepatic, and extrahepatic thyroxine pools. The results of this analysis revealed that the exchange of thyroxine from the plasma into the hepatic and extrahepatic cellular fluid spaces appeared, in general, to be rapid, while the uptake into the extrahepatic tissues was relatively slow. The calculated distribution of thyroxine at equilibrium was estimated to be 14% in liver, 34% in extrahepatic tissues, and 26% each in the plasma and extracellular fluid pools in this group of normal subjects.

M etabolic clearance rates and production rates of human luteinizing hormone (HLH) were determined in pre- and postmenopausal women by the constant infusion technique. Highly purified HLH-¹³¹I was infused into the fasting subjects at a constant rate. Serial plasma samples were obtained and the radioactive hormone was precipitated by a double antibody technique. Plasma HLH-¹³¹I levels reached equilibrium by 4 hr after the infusion started. Metabolic clearance rates were: 24.4 ± 1.8 (mean ± SE) ml/min in five normal premenopausal women; 23.3 ± 1.1 ml/min in five normal women taking norethinodrel and mestranol; and 25.6 ± 4.1 ml/min in four postmenopausal women. Endogenous plasma HLH levels measured in the same subjects by radioimmunoassay immediately before infusion were 32.0 ± 9.6 mU/ml in the normal women, 16.8 ± 3.2 mU/ml in the women on oral contraceptives, and 99.2 ± 23.2 mU/ml in the postmenopausal women. The corresponding HLH production rates were: 734 ± 170 mU/min in the normal women: 387 ± 86 mU/min in the women on norethinodrel and mestranol; and 2400 ± 410 mU/min in the postmenopausal women. The metabolic clearance rate did not change after ovariectomy in one women, but the production rate rose from 583 to 1420 mU/min. Based on previously reported bioassay values for pituitary content and urinary excretion of HLH, the estimated turnover of HLH in the pituitary is about once per day and less than 5% of the total HLH produced appears in the urine in a biologically active form.

T he effects of ingested and infused glucose upon circulating glucagon-like immunoreactivity (GLI) were compared in 14 triply catheterized conscious dogs. Within 60 min after the intraduodenal administration of 2 g/kg of glucose, the mean level of glucagon-like immunoreactivity in the vena caval plasma more than doubled, whereas after intravenous infusion of the same dose over a 90 min period no change in the mean vena caval level was observed; during glucose infusion mean glucagon-like immunoreactivity in the pancreatic venous effluent declined, suggesting that hyperglycemia suppresses rather than stimulates pancreatic glucagon secretion.To determine if the rise in glucagon-like immunoreactivity that occurs during glucose absorption was of pancreatic origin, the effect of pancreatectomy performed 1 hr after the intraduodenal administration of glucose was determined. Although circulating insulin disappeared after resection of the pancreas, the level of glucagon-like immunoreactivity continued to rise, establishing its extrapancreatic origin. In other experiments, measurements of Glucagon-like immunoreactivity in plasma obtained simultaneously from pancreaticoduodenal and mesenteric veins and from the vena cava revealed the increment after intraduodenal glucose loading to be greatest in the mesenteric vein in 8 of 12 experiments, favoring the gut as the likely source of the rise.To characterize gut glucagon-like immunoreactivity, acid-alcohol extracts of canine jejunum were compared with similar glucagon-containing extracts of canine pancreas with respect to certain physical and biological properties. On a G-25 Sephadex column the elution volume of the jejunal immunoreactivity was found to be smaller than that of glucagon, which suggested a molecular size at least twice that of pancreatic glucagon. Furthermore, the in vivo and in vitro biological activities of the eluates containing jejunal glucagon-like immunoreactivity appeared to differ from those of eluates containing pancreatic glucagon. The jejunal material lacked hyperglycemic activity when injected endoportally into dogs, was devoid of glycogenolytic activity in the isolated perfused rat liver, and did not increase hepatic 3′,5′ cyclic adenylate in the perfused liver; however, like glucagon it appeared to stimulate insulin release. It seems quite clear the material in intestinal extracts either is a different substance or a different form from that of true pancreatic glucagon, although it crossreacts in the radioimmunoassay with antibodies to glucagon.It is concluded, (a) that hyperglycemia does not stimulate and probably suppresses the secretion of pancreatic glucagon; (b) that during intestinal absorption of glucose, a rise in glucagon-like immunoreactivity occurs; (c) this immunoreactivity is derived from an extrapancreatic site, probably the gut; (d) that the glucagon-like immunoreactivity extractable from jejunum is not the same as pancreatic glucagon but is a larger molecule devoid of hyperglycemic and glycogenolytic activity, a cross-reactant in radioimmunoassay for glucagon; and (e) that the eluate in which jejunal immunoreactivity is contained can stimulate insulin release in conscious dogs.

T he ability of reduced nicotinamide adenine dinucleotide (NADH), generated through the activity of lactic acid dehydrogenase, to support the reduction of endogenous oxidized glutathione in intact human erythrocytes and in hemolysates was investigated. Rapid initial oxidation of endogenous reduced glutathione was effected with methyl phenylazoformate. Freshly obtained normal erythrocytes and erythrocytes deficient in glucose-6-phosphate dehydrogenase activity were unable to regenerate reduced glutathione upon incubation with lactate. Only normal erythrocytes were capable of reducing oxidized glutathione after preincubation with glucose, inosine, or a medium which promoted the synthesis of increased amounts of intracellular NAD. This regeneration of reduced glutathione could be explained by the generation of reduced nicotinamide adenine dinucleotide phosphate through the metabolism of accumulated phosphorylated intermediates of glycolysis. Hemolysates prepared from both normal erythrocytes and from erythrocytes deficient in glucose-6-phosphate dehydrogenase activity were able to reduce oxidized glutathione in the presence of added lactate and NAD. The results obtained indicated either an inability of the intact erythrocyte to utilize the NAD at the concentrations attained or an altered behavior of the system for the regeneration of reduced glutathione after lysis of the cell.

U sing a coagulation assay specific for tissue factor, we found that removal of 95% of the tissue factor-phospholipid resulted in a loss of 98% of its biological activity. The activity could be restored, with yields in excess of 100% by combining the extracted tissue factor with either mixed brain phospholipids or highly purified phospholipids. Phosphatidylethanolamine was the most active, followed by phosphatidylcholine. Phosphatidylserine, phosphatidylinositol, and sphingomyelin had little or no activity. In addition, a requirement for unsaturation and the presence of two fatty acids was demonstrated. The activity of phosphatidylcholine was also dependent on the presence of the base. Furthermore, it was shown that activity was not a function of binding of phospholipids to tissue factor, as both active and inactive lipids were equally bound.

U sing radioactive xenon, we measured the regional distribution of pulmonary ventilation and blood flow in six normal men, whose ages ranged between 65 and 75 yr. The measurements were made in the standing position. The static volume-pressure relation of the lungs was also measured in five of the subjects. The results indicate that by comparison with normal young men: (a) Blood flow to the upper lung zones was increased, although it still remained predominant in the lower zones. (b) Ventilation distribution during a vital capacity inspiration was similar to that seen in young subjects. (c) In five of the six elderly subjects, however, the distribution of ventilation in the resting tidal volume range was not preferential to the lower zones as it was in young men. This was probably caused by airway closure in the lower lung zones. The elderly subjects thus exhibit during normal tidal volume breathing a ventilation distribution pattern similar to that observed in young subjects when breathing at low lung volumes, i.e., near residual volume. This difference is probably due to the combined effect of the loss in elastic recoil of the lungs observed in the elderly subjects and of a decreased resistance to collapse of the aged airways. These findings suggest that in the elderly subjects there is a significant regional ventilation-perfusion impairment during quiet breathing, which may explain in part the reported increase in alveolar-arterial oxygen difference with advancing age.

T he continuous infusion of ³H-6,7-estrone and ³H-6,7-estradiol has been used to study the metabolic clearance rate (MCR), the interconversions, and the red cell uptake of these steroids in normal males and females. The whole blood MCR of estrone is 1,990 ± 120 liters per day/m² (SE) in males and 1,910 ± 100 liters per day/m² in females. The whole blood MCR of estradiol is 1,600 ± 80 liters per day/m² in males and 1,360 ± 40 liters per day/m² in females. The values in females do not vary significantly when studied in the follicular or luteal phase of the cycle. At least 35% of the total estrone metabolism in both sexes is extrasplanchnic and at least 25% of the total estradiol metabolism in males, and 15% in females is extrasplanchnic. The [ρ]_BB^2,1 [transfer constant of estradiol to estrone, which is equivalent to the fraction of the precursor (estradiol) converted to the product (estrone) when both the infusion of the precursor and the measurement of the product are in peripheral blood] is 15%; and the [ρ]_BB^1,2 [transfer constant of estrone to estradiol, which is equivalent to the fraction of the precursor (estrone) converted to product (estradiol) when both the infusion of the precusor and the measurement of the product are in peripheral blood] is 5% in both males and females. Our findings concerning the radioactivity in whole blood, as measured by our procedure, were the following: 15-20% of estrone in both sexes and 15% of estradiol in males is associated with red cells. Only 2% of the whole blood radioactivity of estradiol in females is associated with red cells. Changes in the distribution of radioactivity between plasma and red cells will influence the MCR as calculated from plasma, but not as calculated from whole blood.

W hen a serum-buffer solution of etiocholanolone is incubated with human blood leukocytes in vitro, a pyrogen is released. Like endogenous pyrogen of leukocyte origin, this pyrogen produces prompt monophasic fevers in rabbits, does not induce fever tolerance when given daily, and is inactivated by trypsin. In many respects, the characteristics of the in vitro reaction resemble experimental steroid-induced fever. For example, release of pyrogen varies directly with the concentration of steroid. 4-8 hr of contact between steroid and leukocyte is required for activation of the cell. Rabbit leukocytes are not activated by etiocholanolone. Finally, androsterone, the 5α-isomer of etiocholanolone, does not induce pyrogen release in vitro. These studies suggest that experimental steroid fever in man may be mediated by an endogenous pyrogen released from leukocytes.

M agnesium-deficient rats develop significant hypercalcemia, hypophosphatemia, and hyperphosphaturia. These changes suggest a state of hyperparathyroidism. This study examines the regulation of parathyroid gland activity in magnesium-deficient rats. Magnesium deficiency was induced in intact and chronically parathyroidectomized animals by feeding them a diet free of this cation. Control animals were pair fed and treated identically except for the inclusion of magnesium in their gavage solution.Magnesium-deficient rats with intact parathyroid glands developed significant hypercalcemia and hypophosphatemia. In addition, the concentration of ionic calcium in plasma was significantly elevated. In contrast, magnesium-deficient parathyroidectomized animals did not have a higher level of calcium in plasma than their nondeficient controls; they developed a decreased concentration of ionic calcium in the absence of a difference in the concentration of phosphate in plasma when compared with appropriate controls. The increased urinary excretion of phosphate was independent of the parathyriod status of the animals.It can be concluded that the hypercalcemia and hypophosphatemia of magnesium deficiency demands parathyroid gland activity and that the regulation of this activity is modified in the magnesium-deficient state to permit the maintenance of an elevated concentration of ionic calcium in plasma. Additional explanations must be found for the hyperphosphaturia.

I n 35 patients maintained solely on liquid formula diets, chromic oxide has been evaluated as an internal standard for balance studies that require stool collections. In 28 patients the excretion of chromic oxide was ideal: steady states were attained in which mean daily output was 90% (or more) of mean daily intake. In these patients corrections for fecal flow could validly be applied.In patients who excreted the marker ideally, the availability of chromic oxide balance data made possible the calculation of pool sizes and turnover rates of unexcreted intestinal content. These indexes bore little relationship to the usual clinical descriptions of bowel habits. In some patient who had daily bowel movements, pool sizes were very large and daily turnover was small, i.e., a large proportion of the colonic contents was not excreted for surprisingly long periods. It is critically important for investigators to recognize this possibility when carrying out balance studies for fecal constituents that may be altered by bacterial action within the gut lumen: for instance, in 6 patients a significant inverse correlation was found between daily fecal turnover and degradative losses of large amounts of dietary β-sitosterol.7 of 35 patients failed to attain the ideal steady state of chromic oxide excretion. These patients would not have been singled out if an internal standard had not been used. In such patients balance studies that require analysis of fecal constituents must be interpreted with great caution, since the constituents in question may be handled in the same nonideal fashion as the internal standard.

A lthough baroreceptor stimulation produced by marked alterations in arterial pressure has been shown to produce reflex changes in venous tone in animals, the effects on venous tone in man of altering arterial pressure within the physiologic range have not been clear. In six subjects, venous tone did not change when mean arterial pressure was raised by 25-40 mm Hg, although heart rate fell reflexly by 40%. Venous tone remained constant in 10 subjects when arterial pressure was lowered. This contrasted to the sustained rise in forearm vascular resistance and the persistent tachycardia that occurred. However, 12 subjects continued to respond to these interventions by transient venoconstriction. To eliminate possible emotional influences on venous tone due to the experimental intervention, venous responses were studied before and during general anesthesia in five of these subjects. In contrast to the response before anesthesia, an equivalent fall in arterial pressure during anesthesia no longer evoked a venoconstrictor response. Venous reactivity and the baroreceptor reflex arc remained intact during anesthesia, since venous tone always rose after a deep inspiration, and tachycardia always accompanied the fall in arterial pressure. It is concluded that changes in arterial pressure in the physiologic range in man do not induce measurable reflex alterations in venous tone, and that the increases sometimes seen with decreases in arterial pressure appear to be due to extraneous psychic factors.

G lucose metabolism and insulin sensitivity of isolated human adipose tissue was studied as a function of adipose cell size and number. Glucose metabolism by these tissues was closely related to the number of cells in the fragment, irrespective of cell size. Adipose cells of obese individuals metabolized glucose to carbon dioxide and triglyceride at rates similar to adipose cells of nonobese subjects. In contrast, insulin responsiveness of adipose tissue was dependent upon adipose cell size. The larger its adipose cells the less insulin sensitive was the tissue. Thus, adipose tissue of obese subjects, with enlarged cells, showed a diminished response to insulin. After weight loss and reduction in adipose cell size, insulin sensitivity of the adipose tissue of obese patients was restored to normal. When adipose tissue of obese individuals showed impaired responsiveness to insulin, their plasma insulin levels, after oral glucose, were elevated. Weight loss and reduction in adipose cell size restored plasma insulin concentration to normal, concomitant with the return of normal tissue insulin sensitivity.

C holesterol synthesis has been extensively investigated in various tissues of lower mammals; however, there is little specific information concerning cholesterologenesis in the primate. Furthermore, experiments in whole animals suggest that important differences may exist in the features of cholesterologenesis in the dog and rat versus the monkey and man. Using the new world squirrel monkey, therefore, we performed the present studies to determine the rates of cholesterologenesis in various tissues per unit weight, to define the relative rates of whole organ synthesis, and to evaluate the operation of control mechanisms in these tissues.In control animals fed a low cholesterol chow diet, the liver and ileum were the two most active sites for cholesterologenesis followed, in order, by the colon, esophagus, and proximal small bowel. Rates of synthesis in 10 other tissues tested were considerably lower than these found in the gastrointestinal tract. When rates of whole organ synthesis were calculated, three tissues, i.e., liver, bowel, and skin, accounted for 92% of the total demonstrable synthetic activity.Following cholesterol feeding utilizing either a solid chow or liquid formula diet, marked suppression of hepatic cholesterologenesis occurred while synthesis in other organs remained essentially unaltered. Similarly, fasting animals for periods up to 96 hr resulted in suppression of synthesis in the liver, but not in various levels of the intestine. Finally, biliary diversion for 48 hr caused a twofold increase in hepatic cholesterologenesis and a six- to eightfold increase in sterol synthesis in the small but not the large intestine.

T he possibility that the intestinal wall serves as a biosynthetic site for serum cholesterol has been examined in two types of studies in the squirrel monkey. First, animals were fed cholesterol in order to inhibit cholesterol synthesis in the liver, and the intestinal lymph ducts were cannulated. After the administration of acetate-2-¹⁴C it was possible to demonstrate that cholesterol synthesized by the intestinal wall enters intestinal lymph and thereby in the intact animal enters the circulating pool. Second, an attempt to quantitate the significance of this intestinal contribution has been made in animals fed cholesterol-3-³H and injected with cholesterol-4-¹⁴C for long periods. By an application of the technique of analysis utilizing the isotopic steady state we estimated as a minimal value that in the squirrel monkey 1.5-2.0 mg of cholesterol synthesized in the intestinal wall reaches the circulation each day.

T his study examined the ventilatory adjustment to chronic metabolic alkalosis induced under controlled conditions in normal human volunteers. Metabolic alkalosis induced by buffers (sodium bicarbonate, trishydroxymethylamine methane) or ethacrynic acid was associated with alveolar hypoventilation, as evidenced by a rise in arterial Pco₂, a fall in arterial Po₂, a reduced resting tidal volume, and a diminished ventilatory response to CO₂ inhalation. Alveolar hypoventilation did not occur when metabolic alkalosis was induced in the same subjects by thiazide diuretics or aldosterone despite comparable elevations of the arterial blood pH and bicarbonate concentration.The different ventilatory responses of the two groups could not be ascribed to differences among individuals comprising each group, pharmacological effects of the alkalinizing agents, differences in the composition of the lumber spinal fluid, changes in extracellular fluid volume, or sodium and chloride balance.The differences in ventilatory adjustments were associated with differences in the patterns of hydrogen and potassium ion balance during the induction of alkalosis. Alveolar hypoventilation occurred when hydrogen ions were buffered (sodium bicarbonate, trishydroxymethylamine methane) or when renal hydrogen ion excretion was increased (ethacrynic acid). Alveolar hypoventilation did not occur when induction of similar degrees of extracellular alkalosis was accompanied by marked potassium loss and no demonstrable increase in external hydrogen loss (thiazides and aldosterone).These observations suggest that respiratory depression does not necessarily accompany extracellular alkalosis but depends on the effect of the mode of induction of the alkalosis on the tissues involved in the control of ventilation.

T he function of the proximal and distal tubule was studied in the rhesus monkey during antidiuresis and during the diuresis after furosemide administration (during which extracellular fluid volume was maintained).In the proximal tubule, fluid to plasma ratios for sodium, potassium, and osmolality approximated unity. During antidiuresis, about 30% of the filtered water remained at the end of the accessible portion of this segment (92% of length). Fluid was hypotonic to plasma throughout the distal tubule. 25% of the filtered water was present in the early distal tubule. Small but significant water reabsorption (about 8% of filtered) occurred in remainder of this segment. Tubule fluid to plasma potassium concentration ratios tended to increase along the distal tubule, and the amount of potassium, relative to the amount filtered, increased from 13% in the early portion of this segment to 26% in the late portion.After furosemide was administered animals excreted about one-third of the filtered sodium and water. Despite this diuresis, electrolyte and water reabsorption along the proximal tubule did not differ from values obtained in control animals. Osmolality and sodium concentration of fluid from the distal tubule approached those of plasma. 22% of the filtered sodium (twice the control values) reached the distal tubule, whereas the fraction of filtered water remaining was only slightly increased. These findings indicate that, after the administration of this drug, inhibition of sodium reabsorption occurred in the water-impermeable segment of the nephron, rather than in the proximal tubule. After furosemide administration, all tubule fluid to plasma potassium concentration ratios in the distal tubule were equal to or greater than one, suggesting inhibition of active potassium reabsorption at or prior to this site.Fluid to plasma bicarbonate concentration ratios from the midportion of the proximal tubule were consistently less than one in normal monkeys. After acetazolamide was administered, the bicarbonate concentration of samples of tubule fluid recollected from these same sites was the same as, or higher than in plasma. This fact demonstrates the inhibition of bicarbonate reabsorption in this portion of the tubule.

T he effect of steady-state increases in systemic arterial pressure on the duration of left ventricular ejection time was studied in 11 normal male subjects. Methoxamine, a pressor amine of predominantly vasoconstrictor activity but lacking significant inotropic effect, was administered intravenously resulting in an average increase in mean arterial pressure of 27 mm Hg. Heart rate was held constant by high right atrial pacing, and there was no significant change in cardiac output. During methoxamine infusion, when stroke volume, heart rate, and inotropic state were held constant, left ventricular ejection time increased as mean arterial pressure increased. There was a highly significant correlation between the increase in mean systolic blood pressure and the prolongation of left ventricular ejection time (r = 0.870). In one subject, an increase in mean systolic pressure of 75 mm Hg prolonged left ventricular ejection time 55 msec, producing paradoxical splitting of the second heart sound. The prolongation of left ventricular ejection time during infusion was not blocked by the prior intravenous administration of atropine sulfate or propranolol hydrochloride, thus ruling out both vagal inhibition of the left ventricle and reflex withdrawal of sympathetic tone as its cause. In three subjects, left ventricular end diastolic pressure was measured and found to be significantly increased. This finding suggests that the normal left ventricle maintains a constant stroke volume in the presence of an increased pressure load by the Frank Starling mechanism. This study concludes that arterial pressure must be included as a prime determinant of left ventricular ejection time along with stroke volume, heart rate, and inotropic state in intact man.