- Email: [email protected]
Tachycardia during the valsalva maneuver: a sign of normal diastolic filling pressures
Tachycardia During the Valsalva Maneuver: A Sign of Normal Diastolic Filling Pressures Calin V. Maniu, MD, Rick A. Nishimura, MD, and A. Jamil Tajik, MD, Rochester, Minnesota
Alteration of the loading conditions during the Valsalva maneuver is a helpful ancillary method in the noninvasive assessment of diastolic filling of the heart by Doppler echocardiography. When tachycardia is induced by the maneuver, mitral inflow velocity curves may become uninterpretable because of E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and A velocity (the velocity at atrial contraction on the transmitral flow velocity curve) wave fusion. To determine the clinical significance of the E velocity and A velocity wave fusion, our study assessed the relation between the heart rate response induced by the Valsalva maneuver and the left ventricular filling
Evaluation
of diastolic filling of the heart has become an important part of the Doppler echocardiographic examination. The transmitral flow velocity curves reflect the relative driving pressure between left atrium and left ventricle (LV) and are routinely used for the determination of the diastolic filling characteristics of the LV. In patients with LV systolic dysfunction, there is progression of disease that occurs in parallel with changes in the mitral flow velocity curves, with a higher initial E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and shorter deceleration time indicating higher filling pressures and decreased effective operative compliance.1 However, for patients with normal systolic function, the transmitral flow velocity curves alone cannot be used for determination of diastolic filling properties of the LV. This is a result of the contribution of LV “suction” in normal hearts, which results in higher initial E velocities and shorter deceleration times. Thus, it becomes difficult to separate the normal from the pseudonormal transmitral flow velocity curve for patients with normal systolic function. This differentiation has required adjunctive analyses such as color M-mode, Doppler
From the Division of Cardiovascular Diseases, Mayo Clinic and Foundation. Reprint requests: Rick A. Nishimura, MD, Mayo Clinic and Foundation, 200 First St SW, Rochester, MN 55905. (E-mail: [email protected]). 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.02.004
634
pressures measured during cardiac catheterization. In all, 77 patients performed the maneuver during continuous hemodynamic and electrocardiographic monitoring. The ratio between the baseline R-R interval and the shortest R-R interval during the maneuver was calculated. A ratio value higher than 1.1 was predictive of a pre-A pressure of less than 18 mm Hg (94% positive predictive value). Reflex tachycardia during the Valsalva maneuver and subsequent fusion of the E velocity and A velocity waves on the mitral velocity curves is a sign of normal left ventricular filling pressures. (J Am Soc Echocardiogr 2004;17:634-7.)
tissue imaging, and pulmonary vein flow velocities. The response of the mitral flow velocity curve to lowering of preload during the Valsalva maneuver has also been used, examining the contour of the mitral flow velocity curve during preload reduction.2 However, in some patients, the mitral flow velocity curve cannot be analyzed when there is tachycardia and subsequent E/A fusion (Figure 1). We hypothesized that the occurrence of tachycardia during the strain phase of the Valsalva maneuver had diagnostic value in itself. Thus, the purpose of this study was to determine the clinical significance of tachycardia produced during the strain phase of the Valsalva maneuver. We, thus, assessed the heart rate response during the Valsalva maneuver and related this response to the LV filling pressure obtained during cardiac catheterization.
METHODS The protocol was approved by the Mayo Medical Center institutional review board, Rochester, Minn. In all, 100 consecutive patients who were referred to a single operator in the catheterization laboratory for a clinically recommended left heart catheterization were evaluated for this study. Patients were excluded if they were not in sinus rhythm, were unable to perform a Valsalva maneuver, or refused to participate in the study. A left heart catheterization was performed using standard techniques, and the hemodynamic measurements were obtained before injection of contrast dye. A pigtail catheter was introduced in the retrograde manner in the LV, and the LV pressures were recorded. The pigtail catheter was then
Journal of the American Society of Echocardiography Volume 17 Number 6
Maniu, Nishimura, Tajik 635
Figure 1 Pulsed Doppler mitral inflow velocity curves at baseline and during Valsalva maneuver. There is fusion of E velocity and A velocity waves as result of tachycardia during Valsalva maneuver. withdrawn in the ascending aorta and the patients performed the Valsalva maneuver3 during continuous hemodynamic and electrocardiographic monitoring. An increase in diastolic pressure of greater than 10 mm Hg during the strain phase of the Valsalva maneuver was required to assure that adequate positive intrathoracic pressure was being generated. The pre-A pressure was measured by a blinded observer who was unaware of the heart rate response. The pre-A pressure is defined as the LV diastolic pressure immediately before the A velocity wave. It has been shown to be a more accurate estimation of the mean left atrial pressure than LV end-diastolic pressure.4 The R-R intervals were measured off the electrocardiographic tracing. The baseline R-R interval was measured before the onset of the maneuver. The shortest R-R interval occurred during the peak of the strain phase (phase 2) or immediately after the release of the strain phase (phase 3). The ratio of the baseline R-R interval over the shortest R-R interval during the peak strain phase (phase 2 or 3) was calculated and was named the R-R ratio (Figure 2).
RESULTS In all, 77 consecutive patients were included in the study and their clinical characteristics are summarized in Table 1. The majority of the patients were referred to the catheterization laboratory for evaluation of known or presumed coronary artery disease. Their cardiac medications were not withheld before the invasive assessment. The overall mean pre-A pressure was 15 ⫾ 5.7 mm Hg. The mean heart rate at the time of the shortest R-R interval during phase 2/3 was 74 ⫾ 13
Figure 2 Aortic pressure and electrocardiographic (ECG) recordings during Valsalva maneuver performed by patient with normal (11 mm Hg) (A) and elevated (21 mm Hg) (B) left ventricular filling pressure. Table 1 Clinical characteristics of the study patients Age (ys) Males (%) Referral for chest pain (%) Hypertension (%) Diabetes mellitus (%) Neuropathy (%) Ejection fraction ⬍50% (%) -blockers (%) Diuretics (%)
64.8 ⫾ 10.6 62 72 59 30 10 21 54 36
bpm and the mean heart rate at the time of the measurement of the baseline R-R interval was 67 ⫾ 12 bpm. In all, 58 patients had pre-A pressure ⱕ 18 mm Hg and 19 patients had a pre-A pressure ⬎ 18 mm Hg. The relationship of the R-R ratio to the pre-A pressure is illustrated on Figure 3. A R-R ratio of ⬎ 1.1 had a positive predictive value of 94% for a pre-A ⱕ 18 mm Hg. Table 2 shows the positive predictive value of a R-R ratio of ⬎ 1.1 for individual subsets of patients. These subsets included those patients taking and not taking a -blocker, the presence or absence of diabetes (treated with either insulin or oral hypoglycemic medications), a normal or abnormal ejection fraction (abnormal defined as ⬍50%), and age (cutoff value of 60 years). There was a positive predictive value for the R-R ratio of ⬎1.1 of 90% or more in all subsets except for the patients with diabetes
Journal of the American Society of Echocardiography June 2004
636 Maniu, Nishimura, Tajik
Figure 3 Relationship of R-R ratio to left ventricular pre-A pressure. Table 2 Positive predictive value of the R-R ratio greater than 1.1 for a pre-A left ventricular diastolic pressure less than or equal 18 mm Hg Subgroup
No. patients in each group
Positive predictive value (%)
Age ⬍ 60 y Age ⱖ 60 y EF ⬍ 50%* EF ⬎ 50%* DM-yes DM-no Beta-blocker-yes Beta-blocker-no
23 54 16 55 28 49 42 35
92 100 100 100 75 100 100 90
DM, Diabetes mellitus; EF, ejection fraction. *EF not measured in 6 patients.
(positive predictive value of 75%, but there were only 4 patients in this subgroup).
DISCUSSION A normal-appearing mitral flow velocity curve in the baseline state may represent either normal diastolic filling with normal filling pressures or a pseudonormal pattern with high filling pressures. The response of the mitral flow velocity curve to a reduction in preload has been shown to differentiate these 2 states. For patients with normal flow velocity curves, there will be a hypovolemic pattern during preload reduction with a lowering of both the E and A waves. For patients with a pseudonormal pattern, an abnormal relaxation pattern will emerge during preload reduction. The findings in this study support the hypothesis that tachycardia elicited during the strain phase of a Valsalva maneuver is a specific
marker for normal LV filling pressures. Thus, if E/A fusion occurs on the transmitral flow velocity curve during the Valsalva maneuver, the resting transmitral flow velocity curve can be interpreted as a normal curve and not a pseudonormal curve. The pathophysiology of the heart rate response to the Valsalva maneuver can be explained in terms of the effect of lowering preload to the LV.3 In patients with normal filling pressures, the lowering of preload during the strain phase of the Valsalva maneuver will result in a decrease in stroke volume and a subsequent activation of the baroreceptor reflex. Sympathetic stimulation of the cardiac 1-receptors results in a tachycardic response. There will also be an increase in peripheral resistance from activation of ␣-receptors. During the release phase, there will be an increase in stroke volume as the preload is gradually increased in the LV. This will result in an “overshoot” of the blood pressure as peripheral resistance is still increased and a secondary bradycardia. Conversely, in patients with high filling pressures, a reduction in preload during the strain phase of the Valsalva maneuver will not change the stroke volume, as the relationship between myocardial performance and preload is on a relatively flat portion of the Starling curve. Hence, the heart rate remains relatively constant. These findings of the heart rate response to the Valsalva maneuver to predict cardiac function and circulatory integrity have been shown by others.5–7 The heart rate response to the different phases of the Valsalva maneuver can be influenced by other physiologic or pathologic conditions. Kalbfleisch et al8 have shown that age has an effect on the circulatory response to the Valsalva maneuver. Increasing age was associated with lesser heart rate changes in the different phases of the Valsalva tests. Airaksinen et al9 have shown that the Valsalva ratio (longest R-R interval after the strain divided by the shortest R-R interval during the maneuver) was significantly blunted by -blockers. Autonomic dysfunction, which is common in older patients or patients with diabetes, may also blunt the heart rate response to the Valsalva maneuver. These confounding factors may explain the finding that a lack of change in heart rate response was not predictive of filling pressures in the study herein. Thus, although a tachycardia response during the strain phase of the Valsalva maneuver is a specific finding in patients with normal filling pressures, the lack of tachycardia is not of diagnostic benefit. There are multiple reasons for a lack of tachycardia aside from the presence of high LV filling pressure, including autonomic dysfunction, concomitant -blockade, and an inadequate effort in performing the Valsalva maneuver. The initial mitral E velocity can be used to determine whether there is an effective maneuver resulting in a lowering of the LV
Journal of the American Society of Echocardiography Volume 17 Number 6
preload, as there will be a drop in the initial E velocity of greater than 0.2 m/s.2 If this decrease in the initial E velocity occurs during the strain phase of the maneuver in the absence of a tachycardia, then the filling pressure can be evaluated by the change in the E:A velocity ratio, as previously described.2 Study Limitations The Valsalva maneuver was not standardized and, therefore, it is possible that some patients might not have performed an adequate straining phase. We did not exclude patients on -blocker therapy or patients with diabetes mellitus and neuropathy. All of these factors may affect the heart rate response to the strain phase of the Valsalva maneuver. Nevertheless, our goal was to provide insight into the use of the Valsalva maneuver in a real-world situation. In our unselected population, the prevalence of diabetes mellitus was 36% and the use of -blockers was 54%. Conclusions The heart rate response to the Valsalva maneuver can be a useful adjunct for the noninvasive Doppler assessment of LV filling pressure. A R-R ratio ⬎ 1.1 (resulting in fusion of the E velocity and A velocity waves on the mitral flow velocity curve during the Valsalva maneuver) is a reliable marker of normal LV filling pressures. All other patients who do not have the tachycardia response should undergo a detailed
Maniu, Nishimura, Tajik 637
analysis of the change in the mitral flow velocity curve during the Valsalva maneuver. REFERENCES 1. Nishimura RA, Tajik AJ. Evaluation of diastolic filling of left ventricle in health and disease: Doppler echocardiography is the clinician’s Rosetta Stone. J Am Coll Cardiol 1997;30:8-18. 2. Hurrell DG, Nishimura RA, Ilstrup DM, Appleton CP. Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol 1997;30:459-67. 3. Nishimura RA, Tajik AJ. The Valsalva maneuver and response revisited. Mayo Clin Proc 1986;61:211-7. 4. Yamamoto K, Nishimura RA, Redfield MM. Assessment of mean left atrial pressure from the left ventricular pressure tracing in patients with cardiomyopathies. Am J Cardiol 1996;78: 107-10. 5. Levin AB. A simple test of cardiac function based upon the heart rate changes induced by the Valsalva maneuver. Am J Cardiol 1966;18:90-9. 6. Elisberg EI. Heart rate response to the Valsalva maneuver as a test of circulatory integrity. JAMA 1963;186:120-5. 7. Kalbfleisch JH, Stowe DF, Smith JJ. Evaluation of the heart rate response to the Valsalva maneuver. Am Heart J 1978;95:70715. 8. Kalbfleisch JH, Reinke JA, Porth CJ, Ebert TJ, Smith JJ. Effect of age on circulatory response to postural and valsalva tests (39884). Proc Soc Exp Biol Med 1977;156:100-3. 9. Airaksinen KE, Niemela MJ, Huikuri HV. Effect of betablockade on baroreflex sensitivity and cardiovascular autonomic function tests in patients with coronary artery disease. Eur Heart J 1994;15:1482-5.
ELECTRONIC MANUSCRIPT SUBMISSION
Journal of the American Society of Echocardiography uses an online, electronic submission system. By accessing the Web site http://ees.elsevier.com/jase authors will be guided stepwise through the creation and uploading of the various files. When submitting a manuscript to Elsevier Editorial System, authors need to provide an electronic version of their manuscript. For this purpose original source files, not PDF files, are preferred. The author should specify a category designation for the manuscript (original investigation, review article, brief communication, etc) and choose a set of classifications from the prescribed list provided online. Authors may send queries concerning the submission process, manuscript status, or journal procedures to the Editorial Office ([email protected]). Once the submission files are uploaded, the system automatically generates an electronic (PDF) proof, which is then used for reviewing. All correspondence, including the Editor’s decision and request for revisions, will be by e-mail.
Alteration of the loading conditions during the Valsalva maneuver is a helpful ancillary method in the noninvasive assessment of diastolic filling of the heart by Doppler echocardiography. When tachycardia is induced by the maneuver, mitral inflow velocity curves may become uninterpretable because of E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and A velocity (the velocity at atrial contraction on the transmitral flow velocity curve) wave fusion. To determine the clinical significance of the E velocity and A velocity wave fusion, our study assessed the relation between the heart rate response induced by the Valsalva maneuver and the left ventricular filling
Evaluation
of diastolic filling of the heart has become an important part of the Doppler echocardiographic examination. The transmitral flow velocity curves reflect the relative driving pressure between left atrium and left ventricle (LV) and are routinely used for the determination of the diastolic filling characteristics of the LV. In patients with LV systolic dysfunction, there is progression of disease that occurs in parallel with changes in the mitral flow velocity curves, with a higher initial E velocity (the initial early diastolic velocity on the transmitral flow velocity curve) and shorter deceleration time indicating higher filling pressures and decreased effective operative compliance.1 However, for patients with normal systolic function, the transmitral flow velocity curves alone cannot be used for determination of diastolic filling properties of the LV. This is a result of the contribution of LV “suction” in normal hearts, which results in higher initial E velocities and shorter deceleration times. Thus, it becomes difficult to separate the normal from the pseudonormal transmitral flow velocity curve for patients with normal systolic function. This differentiation has required adjunctive analyses such as color M-mode, Doppler
From the Division of Cardiovascular Diseases, Mayo Clinic and Foundation. Reprint requests: Rick A. Nishimura, MD, Mayo Clinic and Foundation, 200 First St SW, Rochester, MN 55905. (E-mail: [email protected]). 0894-7317/$30.00 Copyright 2004 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.02.004
634
pressures measured during cardiac catheterization. In all, 77 patients performed the maneuver during continuous hemodynamic and electrocardiographic monitoring. The ratio between the baseline R-R interval and the shortest R-R interval during the maneuver was calculated. A ratio value higher than 1.1 was predictive of a pre-A pressure of less than 18 mm Hg (94% positive predictive value). Reflex tachycardia during the Valsalva maneuver and subsequent fusion of the E velocity and A velocity waves on the mitral velocity curves is a sign of normal left ventricular filling pressures. (J Am Soc Echocardiogr 2004;17:634-7.)
tissue imaging, and pulmonary vein flow velocities. The response of the mitral flow velocity curve to lowering of preload during the Valsalva maneuver has also been used, examining the contour of the mitral flow velocity curve during preload reduction.2 However, in some patients, the mitral flow velocity curve cannot be analyzed when there is tachycardia and subsequent E/A fusion (Figure 1). We hypothesized that the occurrence of tachycardia during the strain phase of the Valsalva maneuver had diagnostic value in itself. Thus, the purpose of this study was to determine the clinical significance of tachycardia produced during the strain phase of the Valsalva maneuver. We, thus, assessed the heart rate response during the Valsalva maneuver and related this response to the LV filling pressure obtained during cardiac catheterization.
METHODS The protocol was approved by the Mayo Medical Center institutional review board, Rochester, Minn. In all, 100 consecutive patients who were referred to a single operator in the catheterization laboratory for a clinically recommended left heart catheterization were evaluated for this study. Patients were excluded if they were not in sinus rhythm, were unable to perform a Valsalva maneuver, or refused to participate in the study. A left heart catheterization was performed using standard techniques, and the hemodynamic measurements were obtained before injection of contrast dye. A pigtail catheter was introduced in the retrograde manner in the LV, and the LV pressures were recorded. The pigtail catheter was then
Journal of the American Society of Echocardiography Volume 17 Number 6
Maniu, Nishimura, Tajik 635
Figure 1 Pulsed Doppler mitral inflow velocity curves at baseline and during Valsalva maneuver. There is fusion of E velocity and A velocity waves as result of tachycardia during Valsalva maneuver. withdrawn in the ascending aorta and the patients performed the Valsalva maneuver3 during continuous hemodynamic and electrocardiographic monitoring. An increase in diastolic pressure of greater than 10 mm Hg during the strain phase of the Valsalva maneuver was required to assure that adequate positive intrathoracic pressure was being generated. The pre-A pressure was measured by a blinded observer who was unaware of the heart rate response. The pre-A pressure is defined as the LV diastolic pressure immediately before the A velocity wave. It has been shown to be a more accurate estimation of the mean left atrial pressure than LV end-diastolic pressure.4 The R-R intervals were measured off the electrocardiographic tracing. The baseline R-R interval was measured before the onset of the maneuver. The shortest R-R interval occurred during the peak of the strain phase (phase 2) or immediately after the release of the strain phase (phase 3). The ratio of the baseline R-R interval over the shortest R-R interval during the peak strain phase (phase 2 or 3) was calculated and was named the R-R ratio (Figure 2).
RESULTS In all, 77 consecutive patients were included in the study and their clinical characteristics are summarized in Table 1. The majority of the patients were referred to the catheterization laboratory for evaluation of known or presumed coronary artery disease. Their cardiac medications were not withheld before the invasive assessment. The overall mean pre-A pressure was 15 ⫾ 5.7 mm Hg. The mean heart rate at the time of the shortest R-R interval during phase 2/3 was 74 ⫾ 13
Figure 2 Aortic pressure and electrocardiographic (ECG) recordings during Valsalva maneuver performed by patient with normal (11 mm Hg) (A) and elevated (21 mm Hg) (B) left ventricular filling pressure. Table 1 Clinical characteristics of the study patients Age (ys) Males (%) Referral for chest pain (%) Hypertension (%) Diabetes mellitus (%) Neuropathy (%) Ejection fraction ⬍50% (%) -blockers (%) Diuretics (%)
64.8 ⫾ 10.6 62 72 59 30 10 21 54 36
bpm and the mean heart rate at the time of the measurement of the baseline R-R interval was 67 ⫾ 12 bpm. In all, 58 patients had pre-A pressure ⱕ 18 mm Hg and 19 patients had a pre-A pressure ⬎ 18 mm Hg. The relationship of the R-R ratio to the pre-A pressure is illustrated on Figure 3. A R-R ratio of ⬎ 1.1 had a positive predictive value of 94% for a pre-A ⱕ 18 mm Hg. Table 2 shows the positive predictive value of a R-R ratio of ⬎ 1.1 for individual subsets of patients. These subsets included those patients taking and not taking a -blocker, the presence or absence of diabetes (treated with either insulin or oral hypoglycemic medications), a normal or abnormal ejection fraction (abnormal defined as ⬍50%), and age (cutoff value of 60 years). There was a positive predictive value for the R-R ratio of ⬎1.1 of 90% or more in all subsets except for the patients with diabetes
Journal of the American Society of Echocardiography June 2004
636 Maniu, Nishimura, Tajik
Figure 3 Relationship of R-R ratio to left ventricular pre-A pressure. Table 2 Positive predictive value of the R-R ratio greater than 1.1 for a pre-A left ventricular diastolic pressure less than or equal 18 mm Hg Subgroup
No. patients in each group
Positive predictive value (%)
Age ⬍ 60 y Age ⱖ 60 y EF ⬍ 50%* EF ⬎ 50%* DM-yes DM-no Beta-blocker-yes Beta-blocker-no
23 54 16 55 28 49 42 35
92 100 100 100 75 100 100 90
DM, Diabetes mellitus; EF, ejection fraction. *EF not measured in 6 patients.
(positive predictive value of 75%, but there were only 4 patients in this subgroup).
DISCUSSION A normal-appearing mitral flow velocity curve in the baseline state may represent either normal diastolic filling with normal filling pressures or a pseudonormal pattern with high filling pressures. The response of the mitral flow velocity curve to a reduction in preload has been shown to differentiate these 2 states. For patients with normal flow velocity curves, there will be a hypovolemic pattern during preload reduction with a lowering of both the E and A waves. For patients with a pseudonormal pattern, an abnormal relaxation pattern will emerge during preload reduction. The findings in this study support the hypothesis that tachycardia elicited during the strain phase of a Valsalva maneuver is a specific
marker for normal LV filling pressures. Thus, if E/A fusion occurs on the transmitral flow velocity curve during the Valsalva maneuver, the resting transmitral flow velocity curve can be interpreted as a normal curve and not a pseudonormal curve. The pathophysiology of the heart rate response to the Valsalva maneuver can be explained in terms of the effect of lowering preload to the LV.3 In patients with normal filling pressures, the lowering of preload during the strain phase of the Valsalva maneuver will result in a decrease in stroke volume and a subsequent activation of the baroreceptor reflex. Sympathetic stimulation of the cardiac 1-receptors results in a tachycardic response. There will also be an increase in peripheral resistance from activation of ␣-receptors. During the release phase, there will be an increase in stroke volume as the preload is gradually increased in the LV. This will result in an “overshoot” of the blood pressure as peripheral resistance is still increased and a secondary bradycardia. Conversely, in patients with high filling pressures, a reduction in preload during the strain phase of the Valsalva maneuver will not change the stroke volume, as the relationship between myocardial performance and preload is on a relatively flat portion of the Starling curve. Hence, the heart rate remains relatively constant. These findings of the heart rate response to the Valsalva maneuver to predict cardiac function and circulatory integrity have been shown by others.5–7 The heart rate response to the different phases of the Valsalva maneuver can be influenced by other physiologic or pathologic conditions. Kalbfleisch et al8 have shown that age has an effect on the circulatory response to the Valsalva maneuver. Increasing age was associated with lesser heart rate changes in the different phases of the Valsalva tests. Airaksinen et al9 have shown that the Valsalva ratio (longest R-R interval after the strain divided by the shortest R-R interval during the maneuver) was significantly blunted by -blockers. Autonomic dysfunction, which is common in older patients or patients with diabetes, may also blunt the heart rate response to the Valsalva maneuver. These confounding factors may explain the finding that a lack of change in heart rate response was not predictive of filling pressures in the study herein. Thus, although a tachycardia response during the strain phase of the Valsalva maneuver is a specific finding in patients with normal filling pressures, the lack of tachycardia is not of diagnostic benefit. There are multiple reasons for a lack of tachycardia aside from the presence of high LV filling pressure, including autonomic dysfunction, concomitant -blockade, and an inadequate effort in performing the Valsalva maneuver. The initial mitral E velocity can be used to determine whether there is an effective maneuver resulting in a lowering of the LV
Journal of the American Society of Echocardiography Volume 17 Number 6
preload, as there will be a drop in the initial E velocity of greater than 0.2 m/s.2 If this decrease in the initial E velocity occurs during the strain phase of the maneuver in the absence of a tachycardia, then the filling pressure can be evaluated by the change in the E:A velocity ratio, as previously described.2 Study Limitations The Valsalva maneuver was not standardized and, therefore, it is possible that some patients might not have performed an adequate straining phase. We did not exclude patients on -blocker therapy or patients with diabetes mellitus and neuropathy. All of these factors may affect the heart rate response to the strain phase of the Valsalva maneuver. Nevertheless, our goal was to provide insight into the use of the Valsalva maneuver in a real-world situation. In our unselected population, the prevalence of diabetes mellitus was 36% and the use of -blockers was 54%. Conclusions The heart rate response to the Valsalva maneuver can be a useful adjunct for the noninvasive Doppler assessment of LV filling pressure. A R-R ratio ⬎ 1.1 (resulting in fusion of the E velocity and A velocity waves on the mitral flow velocity curve during the Valsalva maneuver) is a reliable marker of normal LV filling pressures. All other patients who do not have the tachycardia response should undergo a detailed
Maniu, Nishimura, Tajik 637
analysis of the change in the mitral flow velocity curve during the Valsalva maneuver. REFERENCES 1. Nishimura RA, Tajik AJ. Evaluation of diastolic filling of left ventricle in health and disease: Doppler echocardiography is the clinician’s Rosetta Stone. J Am Coll Cardiol 1997;30:8-18. 2. Hurrell DG, Nishimura RA, Ilstrup DM, Appleton CP. Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol 1997;30:459-67. 3. Nishimura RA, Tajik AJ. The Valsalva maneuver and response revisited. Mayo Clin Proc 1986;61:211-7. 4. Yamamoto K, Nishimura RA, Redfield MM. Assessment of mean left atrial pressure from the left ventricular pressure tracing in patients with cardiomyopathies. Am J Cardiol 1996;78: 107-10. 5. Levin AB. A simple test of cardiac function based upon the heart rate changes induced by the Valsalva maneuver. Am J Cardiol 1966;18:90-9. 6. Elisberg EI. Heart rate response to the Valsalva maneuver as a test of circulatory integrity. JAMA 1963;186:120-5. 7. Kalbfleisch JH, Stowe DF, Smith JJ. Evaluation of the heart rate response to the Valsalva maneuver. Am Heart J 1978;95:70715. 8. Kalbfleisch JH, Reinke JA, Porth CJ, Ebert TJ, Smith JJ. Effect of age on circulatory response to postural and valsalva tests (39884). Proc Soc Exp Biol Med 1977;156:100-3. 9. Airaksinen KE, Niemela MJ, Huikuri HV. Effect of betablockade on baroreflex sensitivity and cardiovascular autonomic function tests in patients with coronary artery disease. Eur Heart J 1994;15:1482-5.
ELECTRONIC MANUSCRIPT SUBMISSION
Journal of the American Society of Echocardiography uses an online, electronic submission system. By accessing the Web site http://ees.elsevier.com/jase authors will be guided stepwise through the creation and uploading of the various files. When submitting a manuscript to Elsevier Editorial System, authors need to provide an electronic version of their manuscript. For this purpose original source files, not PDF files, are preferred. The author should specify a category designation for the manuscript (original investigation, review article, brief communication, etc) and choose a set of classifications from the prescribed list provided online. Authors may send queries concerning the submission process, manuscript status, or journal procedures to the Editorial Office ([email protected]). Once the submission files are uploaded, the system automatically generates an electronic (PDF) proof, which is then used for reviewing. All correspondence, including the Editor’s decision and request for revisions, will be by e-mail.