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

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.