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Eighty years ago Tennant and Wiggers1 made the seminal observation that coronary artery occlusion lead to systolic left ventricular (LV) dysfunction laying the foundation for the current well-accepted physiological paradigm of tight coupling between myocardial blood flow (MBF) and systolic function.  link between MBF and function is oxygen, which serves as the final electron acceptor in oxidative phosphorylation, the primary process for generating cellular ATP. Consequently, myocardial health and thus normal LV function is dependent on a balance between oxygen supply and demand. In contrast to other vascular beds, the resting myocardial extraction of oxygen is high, ≈75% of the arterial oxygen content. Thus, the ability of the myocardium to further increase oxygen extraction is limited. As a consequence, the demands for increased myocardial oxygen are met via increases in oxygen delivery, which is determined by MBF and arterial oxygen content.  major determinants of the myocardial oxygen demand or consumption are heart rate, wall stress, and LV contractility with wall stress being directly related to systolic blood pressure and LV diameter and inversely related to wall thickness. Thus, under normal conditions where oxygen supply and demand are balanced, oxygen extraction will not change, whereas during ischemia where oxygen supply is inadequate to meet demand, oxygen extraction will increase, albeit modestly.Article see p 1088 The LV dysfunction of idiopathic dilated cardiomyopathy (DCM) is characterized by abnormalities in resting MBF, vasodilator function as evidenced by impaired MBF reserve (peak MBF/rest MBF in response to vasodilator stress) and impaired energetics.2–4 On the basis of the aforementioned discussion on the tight linkage of MBF and LV function, it would be reasonable to surmise that in DCM myocardial oxygenation must be inadequate resulting in tissue hypoxia. Indeed, the induction hypoxia-inducible factor 1α, which functions as a master regulator …

Myocardial Hypoxia in Dilated Cardiomyopathy: Is it Just a Matter of Supply and Demand?