The Valsalva Maneuver Can Misdiagnose 'Normal' as 'Pseudonormal': A Word of Caution for an Echocardiographic Evaluation of Diastolic Function

Abstract

Objectives: To identify differences in cardiac hemodynamic changes between the Valsalva maneuver and nitroglycerin (NTG) administration. Methods: Fifty-three subjects (37 men, 43 +/- 12 years) with normal cardiac function [left ventricular ejection fraction >= 55%, early to late mitral inflow velocity ratio (E/A) >= 1, left atrial volume index <= 34 ml/m(2) and early diastolic mitral annulus velocity (E') >= 8 cm/s] were enrolled. Doppler parameters were determined at rest, during the Valsalva maneuver and after NTG administration. Results: Decreased E, A and E/A were observed both during the Valsa Iva maneuver and after NTG administration (p < 0.0001 for all). However, the reduction in E (Delta E-valsalva: -30 +/- 16 cm/s vs. Delta E-NTG: -17 +/- 17 cm/s) and E/A (Delta E/A(Valsalva): -0.37 +/- 0.28 vs. Delta E/A(NTG): -0.19 +/- 0.25) and the prolongation of the deceleration time (DT) of E (Delta DTvalsalva: 105 +/- 74 ms vs. Delta DTNTG: 83 +/- 63 ms) were more prominent during the Valsalva maneuver than with NTG administration (p < 0.0001 for all). Particularly, a greater decrease in E' was observed during the Valsalva maneuver (Delta E'(Valsalva): -3 +/- 2 cm/s vs. Delta E'(NTG): -2 +/- 2 cm/s, p < 0.0001). Eighteen subjects (34%) showed Iota E/A >= 0.5 during the Valsalva maneuver; thus, they were mislabeled as 'pseudonormal', while only 3 subjects (6%) showed Delta E/A >= 0.5 after NTG administration. Conclusions: The Valsalva maneuver not only decreases preload but also affects myocardial performance, thus, its use can result in the mislabeling of normal subjects as pseudonormal. (C) 2014 S. Karger AG, Basel