Perfusion of the left coronary artery of open chest dogs at fixed control and ischemic flow rates demonstrated that ST alterations in the electrocardiogram were always associated with significant hemodynamic and metabolic changes. Decreased pressure time per minute, atrial hypertension, increased myocardial oxygen extraction, and the presence of excess lactate accompanied ischemia. In three dogs, hemodynamic changes, the presence of "excess lactate," or both, preceded significant electrocardiographic changes.
Whenever coronary flow was insufficient to meet myocardial oxygen demands, a series of metabolic shifts occurred. The most significant of these was inadequate aerobic energy production and stimulation of anaerobic glycolysis. This acceleration of anaerobic myocardial metabolism may be present without notably altering the surface electrocardiogram. The absence of ST shifts does not rule out the presence of concomitant and potentially severe myocardial ischemia.