Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea: Discussion (Part 3)

The Valsalva maneuver was first described in 1704 in order to expel pus from the middle ear; it has since found widespread use in the bedside evaluation of heart murmurs as well as left ventricular and autonomic function. The response to this maneuver has been found to correlate well with left ventricular ejection fraction in a population of dyspneic patients with chronic obstructive pulmonary disease. In this study, 20 of 37 patients had a normal, sinusoidal response to Valsalva (mean LVEF 0.64 ±0.13), eight had an absent overshoot response (mean LVEF 0.42 ±0.20), and nine had a square wave response (mean LVEF 0.19 ±0.05). Our data confirm that an abnormal response to the Valsalva maneuver is a valid indicator of congestive heart failure in dyspneic patients; howev er, of 17 abnormal responses in our study, only two had the square wave response. This may reflect differences in technique and interpretation, inability of acutely ill patients to perform an optimal maneuver, or a lower prevalence of severely impaired ventricular function. buy flovent inhaler
A more recent study compared physical signs with hemodynamic data in patients with chronic heart failure.9 The subjects were 50 patients undergoing elective hemodynamic measurements with LVEF < 0.30 (mean 0.18),  of these performed during an evaluation for cardiac transplantation. The major finding in this study was that a PPP <0.25 strongly predicted a depressed cardiac index. Our study population was quite different and generally less severely impaired. Only two (4 percent) of our subjects had a PPP of 0.25, compared with 32 (54 percent) in the previous report. Further, we compared PPP not with hemodynamics but with the diagnosis of congestive heart failure by criteria. Despite these substantial differences, a statistically significant relation between PPP and congestive heart failure was observed in the current study. However, the mean PPP was very close in both groups, and the range observed had significant overlap (Fig 1); we doubt that measurement of PPP will be clinically useful in this setting.

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