Assessment of sympathetic index from the Valsalva maneuver

Objective: Blood pressure (BP) decline and recovery during the Valsalva maneuver (VM) are used to evaluate the degree of sympathetic failure (SF) but a reliable sympathetic index (SI) derived from VM is lacking. Methods: Patients with mild (n = 20), moderate (n = 65), and severe (n = 60) SF and 23 healthy controls were evaluated using a standardized battery of autonomic tests. SF was defined as mild (associated with reduced sudomotor volumes at distal leg); moderate (associated with a fall in systolic BP ≥ 10 < 30 mm Hg during the tilt test); and severe (associated with a fall in systolic BP ≥30 mm Hg during the tilt test). Six SIs were compared: SI1 (BP fall during phase 2), SI2 (BP recovery during phase 2), SI3 (the difference in BP between baseline and the end of phase 2), SI4 (the magnitude of phase 4), SI5 (BP recovery time), and SI6 (baroreflex sensitivity index). Results: All indexes showed overall significant differences among tested groups (p < 0.05). Only SI3 differentiated all subject groups. Compared to other SIs, SI3 correlated the most with orthostatic hypotension (OH; r = 0.62, p < 0.05) during the tilt. Conclusions: SI3 is the optimal method for calculation of SI since it 1) easily differentiates between healthy controls and those with SF; 2) correlates with the OH, a proxy for a sympathetic failure; 3) tracks the full spectrum of SF (mild–moderate–severe). SI3 expands the utility of quantitative autonomic testing.