No subject had a PPP of less than 0.25; however, two subjects had a PPP = 0.25, which would just meet the cutoff for abnormal PPP previously established. Both of these subjects had congestive heart failure by criteria. Further, we noted a statistically significant association between PPP and the diagnosis of congestive heart failure: those who met criteria had a mean PPP of 0.3725 ±0.063 (range 0.25 to 0.46), vs 0.4225 ±0.094 (range 0.27 to 0.67) in those who did not meet criteria (p = 0.044 by Student’s Mest). However, the range of values observed both with and without congestive heart failure was extensive (Fig 1); setting a cutoff of 0.40 yielded an association short of statistical significance (p = 0.059 by Fisher’s exact test).
Despite the correlation noted between these maneuvers and the diagnosis of congestive heart failure, their routine use would rarely have changed the clinical diagnosis in the emergency room. For instance, there were two patients with hepatojugular reflux who did not have an emergency room diagnosis of congestive heart failure, and both met criteria; however, one had a secondary diagnosis of congestive heart failure by the emergency room physician. Thus, adding the hepatojugular reflux maneuver to the routine clinical assessment would have led to the appropriate diagnosis of congestive heart failure in only one additional patient. The Valsalva maneuver was abnormal in ten subjects who did not have an emergency room diagnosis of congestive heart failure; only five of these met our criteria, one of w hom had a secondary diagnosis. birth control pills
Figure 1. Proportional pulse pressure in relation to the diagnosis of congestive heart failure by predetermined criteria. Number of subjects within proportional pulse pressure range.