This study examined the impairment in systolic and diastolic performance of both ventricles during pacing-induced myocardial ischemia in 12 men with coronary artery disease. Simultaneous hemodynamic, ECG, and radionuclide angiographic assessments were made: pre pacing (pre-P); intermediate pacing (P-1); maximum pacing (P-2); and immediately after pacing (post pacing (P-P). The prepacing measurements were made with the patient in the supine position and during leg elevation. Pacing produced a leftward and upward shift in the diastolic pressure-volume relation, a progressive decrease in left ventricular (LV) end-diastolic volume (p less than 0.003) and right ventricular (RV) end-diastolic volume (p less than 0.01), concomitant with an increase in the pulmonary artery wedge pressure (p less than 0.004) and the right atrial pressure (p less than 0.04). The shift in the LV pressure-volume relation was associated with an initial increase (P-1), followed by a decrease (P-2) in the peak filling rate (p less than 0.001). Pacing also resulted in systolic dysfunction: abnormal LV ejection fraction responses in eight patients, LV regional wall motion abnormalities in eight patients, and abnormal RV ejection fraction responses in seven patients. Leg elevation resulted in a 7% increase in cardiac output, a 20% increase in RV end-diastolic volume, a 28% increase in right atrial pressure, a 29% increase in pulmonary artery wedge pressure, and a 10% increase in LV end-diastolic volume (p less than 0.05). Thus, the ischemic response to pacing results in systolic and diastolic LV and RV dysfunction, with the diastolic impairment being more frequent than the systolic impairment.