title: Value of Plethysmographic Pulse Amplitude Ratio With Valsalva Maneuver in Identifying Left Ventricular Dysfunction During COPD Exacerbation.
abstract: BACKGROUND
  Left-ventricular dysfunction associated with COPD exacerbation is frequently underestimated. We tested whether finger plethysmography waveform change during the Valsalva maneuver could aid in the distinction between patients with COPD exacerbation with and without left-ventricular dysfunction.
  
  
  METHODS
  We included 102 subjects with COPD exacerbation and 51 subjects with acute heart failure admitted to the emergency department for acute dyspnea. Measurements of the plethysmographic pulse amplitude ratio under the Valsalva maneuver were obtained. The value of the plethysmographic pulse amplitude ratio in diagnosing left-ventricular dysfunction in COPD exacerbation subjects was quantified using the area under the receiver operating characteristic curves. Diagnostic performance of the plethysmographic pulse amplitude ratio was compared with the Boston score, and the net reclassification improvement was calculated to determine the incremental value in detecting left-ventricular dysfunction.
  
  
  RESULTS
  Values of the plethysmographic pulse amplitude ratio were higher in COPD exacerbation subjects with left-ventricular dysfunction compared with those without left-ventricular dysfunction (0.78 vs. 0.38, P = .01) but not significantly different from those of the acute heart failure group (0.78). There was a significant correlation between plethysmographic pulse amplitude ratio values and brain natriuretic peptide serum levels. The area under the receiver operating characteristic curve for the plethysmographic pulse amplitude ratio to detect left-ventricular dysfunction among subjects with COPD exacerbation was significantly higher compared with that of the Boston score (0.92 vs. 0.76, P = .02). Exposure to plethysmographic pulse amplitude ratio values increased the overall accuracy from Boston score-based predictions of left-ventricular dysfunction and provided a net reclassification improvement of 17.3%.
  
  
  CONCLUSIONS
  An increased plethysmographic pulse amplitude ratio associated with COPD exacerbation is a good predictor of left-ventricular dysfunction. This simple and noninvasive index could help emergency department physicians to detect or rule out left-ventricular dysfunction in patients with COPD exacerbation who are able to perform the Valsalva maneuver. (ClinicalTrials.gov registration NCT01619540.).
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Hamdi
authors.initials: H
authors.lastname: Boubaker
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Mohamed Habib
authors.initials: MH
authors.lastname: Grissa
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Haithem
authors.initials: H
authors.lastname: Debbabi
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Kaouthar
authors.initials: K
authors.lastname: Beltaief
authors.affiliation: Cardiology Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.
authors.forename: Zohra
authors.initials: Z
authors.lastname: Dridi
authors.affiliation: Biochemistry Department, Fattouma Bourguiba University Hospital, Monastir, Tunisia.
authors.forename: Mohamed Fadhel
authors.initials: MF
authors.lastname: Najjar
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Wahid
authors.initials: W
authors.lastname: Bouida
authors.affiliation: Emergency Department, Sahloul University Hospital, Sousse, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Riadh
authors.initials: R
authors.lastname: Boukef
authors.affiliation: Emergency Department, Tahar Sfar University Hospital, Mahdia, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia.
authors.forename: Soudani
authors.initials: S
authors.lastname: Marghli
authors.affiliation: Emergency Department, Fattouma Bourguiba University Hospital Monastir, Tunisia and the Research Laboratory (LR12SP18), University of Monastir, Monastir, Tunisia. Semir.nouira@rns.tn.
authors.forename: Semir
authors.initials: S
authors.lastname: Nouira
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D018450:Disease Progression; D005260:Female; D006333:Heart Failure / Q000150:complications / Q000503:physiopathology; D006339:Heart Rate; D006801:Humans; D008297:Male; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010991:Plethysmography / Q000379:methods*; D011237:Predictive Value of Tests; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications* / Q000473:pathology / Q000503:physiopathology; D014636:Valsalva Maneuver; D018487:Ventricular Dysfunction, Left / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology
chemical_list: D020097:Natriuretic Peptide, Brain
keywords: COPD; Valsalva maneuver; heart failure; left ventricular dysfunction; plethysmography