Valsalva Maneuver

Article Author:
Shival Srivastav
Article Author:
Radia Jamil
Article Editor:
Roman Zeltser
2/28/2020 1:34:23 PM
PubMed Link:
Valsalva Maneuver


Antonio Maria Valsalva, an Italian physician, first described the Valsalva maneuver (VM) in his work De Aure Humana Tractatus in 1704.[1][2] The maneuver has references in multiple clinical domains ranging from the evaluation of autonomic dysfunction to the treatment of arrhythmias and a marker for heart failure.[3][4][5]

Valsalva maneuver is the performance of forced expiration against a closed glottis. Many activities of our daily lives such as straining during defecation or playing the saxophone entail performance of Valsalva maneuver. The key event occurring during the maneuver is increasing intrathoracic pressure leading to the reduction of preload to the heart. The reflex's cardiovascular changes during and post the maneuver are because of reduced preload engaging baroreflex and other compensatory reflex mechanisms.

Anatomy and Physiology

Based on the characteristic hemodynamic changes, Valsalva maneuver divides into four phases.

Phase I, which corresponds to the onset of strain, is associated with a transient rise in blood pressure because of emptying of some blood from the large veins and pulmonary circulation.

Phase II follows this when positive intrathoracic pressure leads to a reduced venous return to the heart. Because of reduced venous return and thus reduced preload, stroke volume falls; this leads to a fall in blood pressure activating the baroreceptors in the carotid sinus and aortic arch. Vagal withdrawal followed by increased sympathetic discharge ensues, leading to marked tachycardia, increased cardiac output, and vasoconstriction which leads to the recovery of blood pressure to the normal values in healthy individuals.

Phase III is the transient phase involving the release of strain which leads to a sudden dip in blood pressure. The release of positive pressure leads to expansion of the pulmonary vascular bed and reduces left ventricular cross-sectional area resulting in a transient fall in blood pressure.[6]

Phase IV is the overshoot of the blood pressure above the baseline, which is because of resumption of normal venous return to the heart stimulated by the sympathetic nervous system during Phase II. The overshoot of blood pressure leads to stimulation of baroreflex leading to bradycardia and return of blood pressure to the baseline.[4][7]


Valsalva maneuver is used for assessment of autonomic function status, as a marker for heart failure, for termination of arrhythmias, murmur differentiation, and various other indications.


Valsalva maneuver is relatively safe and can be performed in all patients. Side effects reported are rare. However, since there is a rise in intra-ocular and intra-abdominal pressure, therefore the test must be avoided in patients with retinopathy and intra-ocular lens implantation. Valsalva retinopathy may result in susceptible patients.[8][9] Also, there are reports of syncope, chest pain, and arrhythmias due to the performance of VM. Therefore, caution is necessary for patients with pre-existing coronary artery disease, valvular disease or congenital heart disease.[1][2]


The maneuver can be performed in the cardiovascular laboratory or at the bedside by using a disposable syringe/mouthpiece connected to a manometer. A small leak is created in the syringe/mouthpiece to ensure sustained effort throughout the period of forced exhalation.[10] Adequacy of the expiratory effort can be gauged by subjective signs such as visible strain, flushing, and engorgement of the neck veins.[1] Simultaneous acquisition of the ECG signal can help us to assess autonomic indices, such as Valsalva ratio. Measurement of continuous beat to beat blood pressure can help in testing baroreflex sensitivity.


The patient can perform the maneuver in the sitting, supine, or recumbent position. Some reports advocate recumbent position,[10] while others report an increased incidence of abnormal blood pressure responses in the supine position.[11] While different combinations of pressure and duration have been tried, an optimal combination for autonomic function assessment is 40 mm Hg for 15 seconds. Lower pressures may not be sufficient while higher pressures suffer from poor reproducibility.[10]

Clinical Significance

  1. Autonomic function assessment: Valsalva maneuver is an integral part of Ewing’s battery of tests used for evaluation of cardiac autonomic neuropathy.[8] Valsalva ratio, the ratio of the longest inter-beat (RR) interval after the expiratory strain and the shortest inter-beat interval during the strain, is an index of parasympathetic function. Also, determination of baroreflex sensitivity (BRS) can be performed using Valsalva maneuver to assess the integrity of the baroreflex by estimating the slope of a regression plot between RR intervals and systolic blood pressure values during Phase II and IV of the maneuver.[9][10][11][12]
  2. Assessment of heart failure: VM is useful for assessment of heart failure. Patients with heart failure show an abnormal blood pressure overshoot in response to Valsalva maneuver due to impaired ventricular function.[13]
  3. Termination of Arrhythmias: VM is also useful for termination of paroxysmal supraventricular tachycardia (PSVT) with variable success. Increased vagal activity, leading to increased refractoriness of AV nodal tissue interrupting re-entry, has been proposed as the mechanism for termination of PSVT.[14]
  4. Diagnosis of murmurs: VM may be used to differentiate between different murmurs. Since the maneuver reduces preload and thus end-diastolic volume, it can help accentuate some murmurs while diminishing others. The murmur of aortic stenosis (AS) is reduced in intensity on the administration of VM because reduced end-diastolic volume (EDV) diminishes the blood available for ejection through the stenosed aortic orifice.[15] Contrary to AS, the murmur of hypertrophic obstructive cardiomyopathy (HOCM) accentuates in response to VM because reduced EDV during VM leads to the worsening of the obstruction in hypertrophic obstructive cardiomyopathy.[15][16][17]
  5. Miscellaneous uses: Besides the indications outlined above, VM has also found use in various other indications. It has been used to detect bleeding points post thyroid surgery and for the diagnosis of varicocele. It may assist in the radiological diagnosis of liver hemangiomas,[12] venous disease,[13] and foramen ovale.[14]

Enhancing Healthcare Team Outcomes

Valsalva maneuver (VM) is a simple non-invasive test that can be easily performed using a mouthpiece and a manometer. While the maneuver is relatively safe, it is prudent to rule out any pre-existing disease of the retina before performing the maneuver. Therefore, one should consult an ophthalmologist and seek a thorough examination of the fundus in patients with suspected retinopathy. Similarly, the opinion of a cardiologist may assist in patients with pre-existing ischemic or valvular heart disease before the performance of VM.

It can assist the neurologist to identify patients suffering from autonomic neuropathy. Dysautonomia usually manifests as an absence of blood pressure overshoot and reflex bradycardia after the maneuver.[10] Valsalva ratio, assessed using inter-beat intervals during and post the maneuver, is a marker of parasympathetic reactivity. A value of less than 1.21 is considered abnormal,[15]but recently proposed age-specific cutoffs may be more relevant.[16][17] Also, beat to beat blood pressure and heart rate can be used to evaluate the integrity of the baroreflex arc by computation of baroreflex sensitivity. The maneuver may be useful to the cardiologist as it may help diagnose heart diseases based on the accentuation or diminution of murmur intensity. To sum up, this simple maneuver may give insight into underlying physiological functions as well as serve as a diagnostic and therapeutic modality in the laboratory and clinics.


[1] Junqueira LF Jr, Teaching cardiac autonomic function dynamics employing the Valsalva (Valsalva-Weber) maneuver. Advances in physiology education. 2008 Mar;     [PubMed PMID: 18334576]
[2] Pstras L,Thomaseth K,Waniewski J,Balzani I,Bellavere F, The Valsalva manoeuvre: physiology and clinical examples. Acta physiologica (Oxford, England). 2016 Jun;     [PubMed PMID: 26662857]
[3] DERBES VJ,KERR A Jr, Valsalva's maneuver and Weber's experiment. The New England journal of medicine. 1955 Nov 10;     [PubMed PMID: 13266051]
[4] Nishimura RA,Tajik AJ, The Valsalva maneuver and response revisited. Mayo Clinic proceedings. 1986 Mar;     [PubMed PMID: 3511334]
[5] Felker GM,Cuculich PS,Gheorghiade M, The Valsalva maneuver: a bedside     [PubMed PMID: 16443410]
[6] Aebischer N,Malhotra R,Connors L,Kappenberger L,Parisi AF, Ventricular interdependence during Valsalva maneuver as seen by two-dimensional echocardiography: new insights about an old method. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 1995 Jul-Aug;     [PubMed PMID: 7546791]
[7] Looga R, The Valsalva manoeuvre--cardiovascular effects and performance technique: a critical review. Respiratory physiology     [PubMed PMID: 15848122]
[8] Nagar A,Dhingra N, Valsalva retinopathy. Postgraduate medical journal. 2017 Mar;     [PubMed PMID: 27634635]
[9] El-Khayat AR, Valsalva haemorrhagic retinopathy in pregnancy after yoga. BMJ case reports. 2017 Aug 11;     [PubMed PMID: 28801333]
[10] Low PA, Testing the autonomic nervous system. Seminars in neurology. 2003 Dec;     [PubMed PMID: 15088262]
[11] Singer W,OpferGgehrking TL,McPhee BR,Hilz MJ,Low PA, Influence of posture on the Valsalva manoeuvre. Clinical science (London, England : 1979). 2001 Apr;     [PubMed PMID: 11256984]
[12] Won HJ,Kim PN,Lee JS, Changes in echogenicity of hepatic hemangiomas during the valsalva maneuver. Journal of clinical ultrasound : JCU. 2017 Jul 8     [PubMed PMID: 28186622]
[13] Ricci S,Moro L,Minotti GC,Incalzi RA,De Maeseneer M, Valsalva maneuver in phlebologic practice. Phlebology. 2018 Mar     [PubMed PMID: 28081660]
[14] Rodrigues AC,Picard MH,Carbone A,Arruda AL,Flores T,Klohn J,Furtado M,Lira-Filho EB,Cerri GG,Andrade JL, Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2013 Nov     [PubMed PMID: 23993693]
[15] Ewing DJ,Martyn CN,Young RJ,Clarke BF, The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes care. 1985 Sep-Oct;     [PubMed PMID: 4053936]
[16] Novak P, Quantitative autonomic testing. Journal of visualized experiments : JoVE. 2011 Jul 19;     [PubMed PMID: 21788940]
[17] Ravits JM, AAEM minimonograph     [PubMed PMID: 9236782]