van Kraaij D J, Schuurmans M M, Jansen R W, Hoefnagels W H, Go R I
Department of Geriatric Medicine, University Hospital Nijmegen, The Netherlands.
Nephrol Dial Transplant. 1998 Jun;13(6):1518-23. doi: 10.1093/ndt/13.6.1518.
In the presence of elevated cardiac filling pressures, the decline of blood pressure (BP) during the straining phase of a Valsalva manoeuvre is blunted or absent. We compared the use of non-invasively measured BP response to a Valsalva manoeuvre with clinical assessment and bioimpedance measurements to identify haemodialysis patients at risk of acute congestive heart failure (CHF).
Continuous BP response (Finapres) to a Valsalva manoeuvre, clinical assessment by nephrologists, and bioimpedance estimations of extracellular fluid volume were determined before and after haemodialysis, once every week during a 5-week period. Acute CHF was defined according to preset clinical and radiological criteria.
Participants (age 60+/-19 years, six females, nine males) had an average predialysis weight of 66.8+/-11.8 kg. Patients were dialysed for 3.8+/-0.8 h with a mean ultrafiltration of 2.4+/-1.1 litres. Valsalva systolic BP ratios (phase 2 to 1) decreased significantly during dialysis from 0.81+/-0.11 to 0.73+/-0.10 (P<0.05). Five patients experienced an episode of acute CHF. The Valsalva BP ratios for these patients before and after dialysis (0.89+/-0.05 and 0.78+/-0.05 respectively) were higher than for the remaining ten patients (0.77+/-0.10 and 0.70+/-0.11, respectively) (P<0.05). A cutoff Valsalva BP ratio of 0.82 resulted in positive and negative predictive values for CHF of 62 and 100% respectively. No differences in clinical assessment or bioimpedance parameters were found, with the exception of postdialysis diastolic BP and predialysis ankle oedema. After treatment of CHF, Valsalva BP ratios decreased significantly without changes in the other hydration parameters.
Non-invasive assessment of the BP response to a Valsalva manoeuvre appears to be a potential tool for identifying patients at risk of acute CHF during maintenance haemodialysis.
在心脏充盈压升高的情况下，瓦尔萨尔瓦动作用力阶段的血压（BP）下降减弱或消失。我们比较了无创测量的瓦尔萨尔瓦动作血压反应与临床评估及生物阻抗测量在识别急性充血性心力衰竭（CHF）风险的血液透析患者中的应用。
在为期5周的时间里，每周一次在血液透析前后测定对瓦尔萨尔瓦动作的连续血压反应（Finapres）、肾病学家的临床评估以及细胞外液量的生物阻抗估计值。急性CHF根据预设的临床和放射学标准进行定义。
参与者（年龄60±19岁，6名女性，9名男性）透析前平均体重为66.8±11.8 kg。患者透析3.8±0.8小时，平均超滤量为2.4±1.1升。透析期间，瓦尔萨尔瓦收缩压比值（第2阶段与第1阶段）从0.81±0.11显著降至0.73±0.10（P<0.05）。5名患者发生急性CHF发作。这些患者透析前后的瓦尔萨尔瓦血压比值（分别为0.89±0.05和0.78±0.05）高于其余10名患者（分别为0.77±0.10和0.70±0.11）（P<0.05）。瓦尔萨尔瓦血压比值临界值为0.82时，CHF的阳性和阴性预测值分别为62%和100%。除透析后舒张压和透析前脚踝水肿外，临床评估或生物阻抗参数未发现差异。CHF治疗后，瓦尔萨尔瓦血压比值显著下降，其他水化参数无变化。
无创评估瓦尔萨尔瓦动作的血压反应似乎是识别维持性血液透析期间急性CHF风险患者的一种潜在工具。
