he heart is able to adjust its pump function to immediately meet the demand of vital organs in the body by increasing cardiac output several fold by means of increases in cardiac contractility and heart rate. Cardiac myocytes constitute a pseudo-syncytium, follow the all-ornone law, and all of them contribute to the maintenance of stroke volume. Therefore, under physiological conditions, alteration of the contractility of individual cardiac myocytes is directly reflected in cardiac pump function.Two of the most important intrinsic characteristics of the contractile regulation of cardiac myocytes are the FrankStarling mechanism and the positive force -frequency relationship. The Frank-Starling mechanism represents the basic cardiac contractility as a length -tension relationship ex vivo and left ventricular (LV) function curve in vivo, in which stretching of myocytes to an optimal length immediately increases the contractile force with little alteration of [Ca 2+ ]i, preceding to a stretch-induced slowly developing increase in contractile force associated with an increase in [Ca 2+ ]i mobilization. The positive force -frequency relationship induced by elevated heart rate increases ventricular contractility by a marked facilitation of [Ca 2+ ]i mobilization, resulting in an increase in stroke volume. 1 In addition to the intrinsic regulatory mechanisms characteristic of cardiac myocytes, numerous external regulatory mechanisms, including receptor activation induced by
Circulation Journal Vol.72, December 2008neurotransmitters released by autonomic nerve stimulation, hormones, autacoids and cytokines, contribute to the adaptation of the cardiac pump. 2 In the operation of all of these multiple mechanisms, cardiac Ca 2+ signaling plays a key role in contractile regulation.In 1978, Allen and Blinks developed an experimental procedure for detecting [Ca 2+ ]i simultaneously with contractile activity by applying the Ca 2+ -sensitive bioluminescent protein aequorin to intact cardiac muscle. 3 Since then, it has been directly demonstrated by the use of aequorin and other fluorescent dyes such as fura-2, indo-1, and fluo-3 that Ca 2+ ions play a central role in the regulation of cardiac excitation -contraction (E-C) coupling in the intact myocardium or single cardiac myocytes.Although cardiac contractile regulation is essentially achieved by dynamic modulation of [Ca 2+ ]i mobilization (upstream mechanism), it has been proved that the process subsequent to elevation of [Ca 2+ ]i (central and downstream mechanism) is also an important target of cardiotonic agents and the contractile modulation induced by physiological and pathological interventions on the heart. In the early 1980s there was a strong movement toward the development of cardiotonic agents that act by novel mechanisms to replace the conventional cardiotonic agents, such as digitalis and catecholamines, that were used to treat the cardiac contractile dysfunction in congestive heart failure (CHF). 1,2 Those agents elicit a positive inotropic effect (PIE) by i...