Usefulness of Noninvasively Measured Pulse Amplitude Changes During the Valsalva Maneuver to Identify Hospitalized Heart Failure Patients at Risk of 30-Day Heart Failure Events (from the PRESSURE-HF Study)

• Published in: The American journal of cardiology 2020-03, Vol.125 (6), p.916-923
• Main Authors: Gilotra, Nisha A., Wanamaker, Brett L., Rahim, Hussein, Kunkel, Katherine, Yenokyan, Gayane, Schulman, Steven P., Tedford, Ryan J., Russell, Stuart D., Silber, Harry A.
• Format: Article
• Language: English
• Subjects: Blood pressure; Cardiovascular disease; Clinical trials; Confidence intervals; Congestive heart failure; Diastolic pressure; Diuresis; Diuretics; Ejection fraction; Heart failure; Intravenous administration; Medical records; Mercury; Patients; Pressure transducers; Pulse amplitude; Ultrasonic imaging; Valsalva exercise; Variables; Ventricle; Waveforms
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/j.amjcard.2019.12.027

The pulse amplitude ratio (PAR), the ratio of pulse pressure at the end of the Valsalva maneuver to before the onset, correlates with cardiac filling pressure. We have developed a handheld device that uses finger photoplethysmography to measure PAR and estimate left ventricular end diastolic pressure (LVEDP). Patients hospitalized with heart failure (HF) performed three 10-second trials of a standardized Valsalva maneuver (at 20 mm Hg measured via pressure transducer), while photoplethysmography waveforms were recorded, at admission and discharge. Combined primary outcome was 30-day HF hospitalization, intravenous diuresis, or death. Fifty-two subjects had discharge PAR testing; 12 met the primary outcome. Median PAR on admission was 0.55 (interquartile range: 0.40 to 0.70, n = 48) and on discharge was 0.50 (interquartile range: 0.36 to 0.69). Mean PAR-estimated LVEDP was significantly higher in subjects that had an event (20.2 vs 16.9 mm Hg, p = 0.043). Subjects with PAR-estimated LVEDP >19.5 mm Hg had an event rate hazard ratio of 4.57 (95% confidence interval 1.37, 15.19, p = 0.013) compared with patients with LVEDP 19.5 mm Hg or below, with significantly lower 30-day event-free survival (log-rank p = 0.006). In conclusion, noninvasively estimated LVEDP using the pulse amplitude response to a Valsalva maneuver in patients hospitalized for HF changes with diuresis and identifies patients at high risk for 30-day HF events. Detection of elevated filling pressures before hospital discharge may be useful in guiding HF management to reduce HF events.