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

 Moon J.  ;  Yoon J.H.  ;  Choi E.-Y.  ;  Chung W.-J.  ;  Kang W.C.  ;  Rim S.-J. 
 CARDIOLOGY, Vol.128(4) : 355-362, 2014 
Journal Title
Issue Date
Adult ; Diagnosis, Differential ; Diagnostic Errors* ; Diastole/physiology* ; Echocardiography, Doppler* ; Female ; Hemodynamics ; Humans ; Male ; Middle Aged ; Stroke Volume ; Valsalva Maneuver*
Diastolic function ; Doppler imaging ; Echocardiography ; Nitroglycerine ; Valsalva maneuver
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/m2 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 Valsalva maneuver and after NTG administration (p < 0.0001 for all). However, the reduction in E (ΔEValsalva: -30 ± 16 cm/s vs. ΔENTG: -17 ± 17 cm/s) and E/A (ΔE/AValsalva: -0.37 ± 0.28 vs. ΔE/ANTG: -0.19 ± 0.25) and the prolongation of the deceleration time (DT) of E (ΔDTValsalva: 105 ± 74 ms vs. ΔDTNTG: 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 (ΔE'Valsalva: -3 ± 2 cm/s vs. ΔE'NTG: -2 ± 2 cm/s, p < 0.0001). Eighteen subjects (34%) showed ΔE/A ≥0.5 during the Valsalva maneuver; thus, they were mislabeled as ‘pseudonormal', while only 3 subjects (6%) showed ΔE/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.
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1. College of Medicine (의과대학) > Dept. of Internal Medicine (내과학교실) > 1. Journal Papers
Yonsei Authors
Yoon, Ji Hyun(윤지현)
Rim, Se Joong(임세중) ORCID logo https://orcid.org/0000-0002-7631-5581
Choi, Eui Young(최의영) ORCID logo https://orcid.org/0000-0003-3732-0190
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