The Frank-Starling relationship between left ventricular stroke work and end-diastolic minor-axis cross-sectional area was evaluated as a load-insensitive measure of inotropic state by two-dimensional echocardiography in 10 conscious dogs. Stroke work was calculated as the product of systolic change in cross-sectional area and either (1) beat-to-beat mean arterial pressure or (2) initial systolic blood pressure. Both Frank-Starling relationships were highly linear during preload variation (mean r = 0.96), sensitive to the inotropic state (slope increase with calcium 51% +/- 43% and 62% +/- 53%, respectively), and insensitive to afterload (r < 0.4, slope or x intercept versus afterload). Thus the Frank-Starling relationships derived from two-dimensional echocardiographic images and peripheral arterial pressure may be a useful and practical means of assessing inotropic state with minimally invasive measurements.