title: The Valsalva maneuver can misdiagnose 'normal' as 'pseudonormal': a word of caution for an echocardiographic evaluation of diastolic function.
abstract: OBJECTIVE
  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 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.
authors: Division of Cardiology, Department of Internal Medicine, Gachon University of Medicine and Science, Incheon, Republic of Korea.
authors: Jeonggeun
authors: J
authors: Moon
authors: Ji Hyun
authors: JH
authors: Yoon
authors: Eui-Young
authors: EY
authors: Choi
authors: Wook-Jin
authors: WJ
authors: Chung
authors: Woong Chol
authors: WC
authors: Kang
authors: Se-Joong
authors: SJ
authors: Rim
mesh_terms: D000328:Adult; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D003971:Diastole / Q000502:physiology*; D015150:Echocardiography, Doppler; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D013318:Stroke Volume; D014636:Valsalva Maneuver