ACCURATE DETECTION OF ELEVATED LEFT-VENTRICULAR FILLING PRESSURE BY A SIMPLIFIED BEDSIDE APPLICATION OF THE VALSALVA MANEUVER

The hemodynamic effects induced by the Valsalva maneuver in both the normal and failing heart were initially described over 40 years ago by Hamilton et al.1 Since then, clinicians have attempted to exploit the Valsalva maneuver to help evaluate a variety of cardiac conditions. 2-12 The normal response of arterial pressure during the Valsalva maneuver is characterized by an initial increase followed by a rapid decline below the resting level (Figure 1A). With release of strain, systolic pressure transiently declines, then overshoots above the pre-Valsalva level and elicits an accompanying bradycardia. However, in congestive heart failure systolic pressure remains persistently elevated throughout strain and simply returns to baseline with termination, without an overshoot or bradycardia (square-wave response) (Figure 1B).1-4 The failure of arterial pressure to decrease during the Valsalva maneuver in congestive heart failure results primarily from an elevated central blood volume (reflected by an increased left ventricular [LV] filling pressure) acting as a reservoir to preserve LV filling despite a decrease in right-sided venous return during strain.13-14 We reasoned that by determining the fate of systolic pressure during strain, patients with elevated and normal LV filling pressures could be discerned at the bedside. This prospective study was designed to test the validity of this assumption using a simple bedside application of the Valsalva maneuver. © 1993.