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Abnormal Valsalva Maneuver Is Not Always a Sign of Congestive Heart Failure
The American Journal of Medicine (2007) 120, e15-e16
LETTER Abnormal Valsalva Maneuver Is Not Always a Sign of Congestive Heart Failure To the Editor: Felker and colleagues1 are to be commended for highlighting the clinical utility of the Valsalva maneuver. This is a classic physical examination tool that is easily performed Supported in part by grants K23 RR020783 and P01 HL56993 from the National Institutes of Health.
in the office or at the bedside. Unfortunately, this simple test is increasingly being forgotten in clinical medicine. We commonly perform the Valsalva maneuver in our clinic, because it provides an integrated assessment of autonomic nervous system function. On the basis of our experience, we would like to add a couple of caveats to the authors’ excellent review of the Valsalva maneuver. First, the authors refer to the “absent overshoot” of systolic blood pressure after the release of Valsalva as representing mild heart failure. They show a nice example in
Figure 1 Absent sympathetically mediated vasoconstriction in autonomic nervous system failure. The heart rate, blood pressure, and generated Valsalva pressure are shown top to bottom. The blood pressure decreases throughout the Valsalva maneuver without late recovery, and blood pressure after release of Valsalva does not recover back to the baseline blood pressure, let alone “overshoot” the baseline blood pressure. 0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
e16
The American Journal of Medicine, Vol 120, No 6, June 2007
Figure 2 Square wave pattern Valsalva response in a healthy volunteer. The blood pressure paradoxically increases with Valsalva and stays elevated until the release of Valsalva.
their Figure 1B. We often see this pattern in patients with sympathetic nervous system failure in the absence of heart failure (Figure 1).2 This presumably results from the lack of sympathetically mediated vasoconstriction that, if present, would lead to the increased peripheral resistance to which Felker et al1 allude. Second, the authors refer to the “square wave” pattern of blood pressure in response to the Valsalva maneuver (Figure 1C in Felker et al1) as being a sign of severe heart failure. This is certainly a common cause of this abnormal pattern. We also see this pattern, however, in young, healthy individuals without congestive heart failure (Figure 2). Although the physiology of this square wave pattern in such patients is not fully understood, it is important for clinicians to know that this abnormal pattern can be a “normal variant.”3 The “exceptions to the rule” outlined here should be taken as an adjunct to this excellent review of the clinical utility of the Valsalva maneuver.
Satish R. Raj, MD, MSCI David Robertson, MD Italo Biaggioni, MD André Diedrich, MD, PhD Autonomic Dysfunction Center Division of Clinical Pharmacology Departments of Medicine and Pharmacology Vanderbilt University Nashville, Tenn
doi:10.1016/j.amjmed.2006.03.022
References 1. Felker GM, Cuculich PS, Gheorghiade M. The Valsalva maneuver: a bedside “biomarker” for heart failure. Am J Med. 2006;119:117-122. 2. Mosqueda-Garcia R. Evaluation of autonomic failure. In: Robertson D, Biaggioni I, eds. Disorders of the Autonomic Nervous System. Luxembourg: Harwood Academic Publishers GmbH; 1995. 3. Sandroni P, Benarroch EE, Low PA. Pharmacological dissection of components of the Valsalva maneuver in adrenergic failure. J Appl Physiol. 1991;71:1563-1567.
LETTER Abnormal Valsalva Maneuver Is Not Always a Sign of Congestive Heart Failure To the Editor: Felker and colleagues1 are to be commended for highlighting the clinical utility of the Valsalva maneuver. This is a classic physical examination tool that is easily performed Supported in part by grants K23 RR020783 and P01 HL56993 from the National Institutes of Health.
in the office or at the bedside. Unfortunately, this simple test is increasingly being forgotten in clinical medicine. We commonly perform the Valsalva maneuver in our clinic, because it provides an integrated assessment of autonomic nervous system function. On the basis of our experience, we would like to add a couple of caveats to the authors’ excellent review of the Valsalva maneuver. First, the authors refer to the “absent overshoot” of systolic blood pressure after the release of Valsalva as representing mild heart failure. They show a nice example in
Figure 1 Absent sympathetically mediated vasoconstriction in autonomic nervous system failure. The heart rate, blood pressure, and generated Valsalva pressure are shown top to bottom. The blood pressure decreases throughout the Valsalva maneuver without late recovery, and blood pressure after release of Valsalva does not recover back to the baseline blood pressure, let alone “overshoot” the baseline blood pressure. 0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
e16
The American Journal of Medicine, Vol 120, No 6, June 2007
Figure 2 Square wave pattern Valsalva response in a healthy volunteer. The blood pressure paradoxically increases with Valsalva and stays elevated until the release of Valsalva.
their Figure 1B. We often see this pattern in patients with sympathetic nervous system failure in the absence of heart failure (Figure 1).2 This presumably results from the lack of sympathetically mediated vasoconstriction that, if present, would lead to the increased peripheral resistance to which Felker et al1 allude. Second, the authors refer to the “square wave” pattern of blood pressure in response to the Valsalva maneuver (Figure 1C in Felker et al1) as being a sign of severe heart failure. This is certainly a common cause of this abnormal pattern. We also see this pattern, however, in young, healthy individuals without congestive heart failure (Figure 2). Although the physiology of this square wave pattern in such patients is not fully understood, it is important for clinicians to know that this abnormal pattern can be a “normal variant.”3 The “exceptions to the rule” outlined here should be taken as an adjunct to this excellent review of the clinical utility of the Valsalva maneuver.
Satish R. Raj, MD, MSCI David Robertson, MD Italo Biaggioni, MD André Diedrich, MD, PhD Autonomic Dysfunction Center Division of Clinical Pharmacology Departments of Medicine and Pharmacology Vanderbilt University Nashville, Tenn
doi:10.1016/j.amjmed.2006.03.022
References 1. Felker GM, Cuculich PS, Gheorghiade M. The Valsalva maneuver: a bedside “biomarker” for heart failure. Am J Med. 2006;119:117-122. 2. Mosqueda-Garcia R. Evaluation of autonomic failure. In: Robertson D, Biaggioni I, eds. Disorders of the Autonomic Nervous System. Luxembourg: Harwood Academic Publishers GmbH; 1995. 3. Sandroni P, Benarroch EE, Low PA. Pharmacological dissection of components of the Valsalva maneuver in adrenergic failure. J Appl Physiol. 1991;71:1563-1567.