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Original Research: Pulmonary Vascular Disease |

Valsalva Maneuver in Pulmonary Arterial Hypertension: Susceptibility to Syncope and Autonomic Dysfunction

Philip L. Mar, MD, PharmD; Victor Nwazue, MD; Bonnie K. Black, RN, CNP; Italo Biaggioni, MD; André Diedrich, MD, PhD; Sachin Y. Paranjape, BS; James E. Loyd, MD; Anna R. Hemnes, MD; Ivan M. Robbins, MD; David Robertson, MD; Satish R. Raj, MD; Eric D. Austin, MD
Author and Funding Information

FUNDING/SUPPORT: This study was funded by the National Institutes of Health [Grants P01 HL 108800 and K23 HL 098743].

CORRESPONDENCE TO: Eric D. Austin, MD, Vanderbilt University MCN, Room DD-2211, Nashville, TN 37232-2578


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(5):1252-1260. doi:10.1016/j.chest.2015.11.015
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Background  Patients with pulmonary arterial hypertension (PAH) are routinely instructed to avoid performing the Valsalva maneuver for fear of syncope or sudden cardiac death. The mechanism of this action has not been elucidated. We conducted a case-control trial of nine patients with PAH and 15 healthy control subjects to determine if systemic hemodynamic changes during the Valsalva maneuver in these patients invoke greater susceptibility to syncope than healthy control subjects. Metrics commonly employed in autonomic testing were used to assess the degree of autonomic failure.

Methods  Common Valsalva parameters, including adrenergic baroreflex sensitivity, pressure recovery time, systolic BP (SBP) recovery, diastolic BP (DBP) recovery, mean arterial pressure recovery, and the Valsalva ratio, were calculated. Mann-Whitney U tests were used to compare continuous variables. The primary end point was adrenergic baroreflex sensitivity.

Results  Patients with PAH had lower adrenergic baroreflex sensitivity (9.7 ± 4.6 mm Hg/s vs 18.8 ± 9.2 mm Hg/s; P = .005), longer pressure recovery time (3.6 ± 2.5 s vs 1.7 ± 0.8 s; P = .008), similar SBP recovery (–13 ± 11 mm Hg vs –12 ± 23 mm Hg; P = .640), less DBP recovery (–1 ± 12 mm Hg vs 13 ± 14 mmHg; P = .025), less mean arterial pressure recovery (–5 ± 11 mm Hg vs 5 ± 17 mm Hg; P = .048), and a decreased Valsalva ratio (1.25 ± 0.11 vs 1.60 ± 0.22; P < .001) compared with healthy control subjects.

Conclusions  Compared with healthy control subjects, patients with PAH are more susceptible to syncope during the Valsalva maneuver because of autonomic dysfunction causing cerebral hypoperfusion. These study patients with PAH exhibited a degree of susceptibility to syncope similar to a spectrum of patients with intermediate autonomic failure who typically experience a SBP drop of 10 to 30 mm Hg with standing.

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