Dr Archana Jadhav

Dr Lata Patil

Dr N G Borade

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IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) 
e-ISSN: 2279-0853, p-ISSN: 2279-0861. Volume 4, Issue 4 (Jan.- Feb. 2013), PP 29-32 
www.iosrjournals.org 
 
www.iosrjournals.org                                                             29 | Page 
A Comparative study of heart rate variability during Valsalva 
maneuver in healthy, hypertensive and hypertensive diabetic 
subjects 
 
Dr. Lata Patil
1
,
 
Dr. Archana Jadhav
2
, Dr. N. G. Borade
3
 
1-Dr.D.Y.Patil Medical college and Research Institute/Dr. D. Y. Patil University/Pune, Maharashtra, India. 
2- Dr.D.Y.Patil Medical college and Research Institute/Dr. D. Y. Patil University/Pune, Maharashtra, India 
3-Dr.D.Y.Patil Medical college and Research Institute/Dr. D. Y. Patil University/Pune, Maharashtra, India 
 
Abstract: Background- Hypertension and Diabetes are known to have autonomic dysfunction and indices of 
heart rate variability provide window to understand the autonomic modulation of cardio respiratory systems. 
Hypothesis- Co existing morbidity in Hypertensive diabetic group will cause enhancement of autonomic 
dysfunction. 
Design- Hospital based case-control study. Hypertensive and Hypertensive diabetics (30 males each), not on 
regular medicines were selected from the Medicine and Diabetic OPD over a period of one year,and included in 
the study. Age and sex matched healthy controls were selected from hospital staff.Heart rate variability tests 
were done in the research laboratory of department of Physiology. 
Materials and methods- After proforma the basal heart rate and resting blood pressures were recorded for 
each subject. Valsalva maneuver and the ECG recording was done on Polyrite-D Machine for one minute. 
Valsalva ratio was calculated. 
Statistical analysis- ANOVA, Tuckeys, and Pearson co-relation coefficient tests were used to analyze the 
appropriate data. 
Results- The mean VR of hypertensive subjects was.1.2647 +  0.1608,statistically not significant when 
compared to healthy (1.3137 + 0.1714).The mean VR of hypertensive diabetics was 1.1883+ 0.1302,statistically 
highly significant. 
Key words- valsalva ratio,HRV,autonomic functions,frequency analysis 
 
I. Introduction 
Diabetes mellitus( Type II)  and hypertension are two of the most common diseases in Westernized, 
industrialized civilizations, and the frequency of both diseases increases with increasing age.1 Although diabetes 
mellitus is associated with a considerably increased cardiovascular risk, the presence of hypertension in the 
diabetic(type II)  individual markedly increases morbidity and mortality 
            Several factors are known to regulate blood pressure. The nervous system helps to maintain blood 
pressure by adjusting the size of the blood vessels, and by influencing the heart pumping action.2 The autonomic 
nervous system plays crucial role in blood pressure (BP) and heart rate (HR) control and may thus be an 
important pathophysiological factor in the development of hypertension. It is also known that dysfunction of the 
autonomic nervous system is associated with increased risk of mortality in patients with diabetes, survivors of 
myocardial infarction and unselected middle-aged and elderly subjects.
3
 
The association of autonomic imbalance with incident cardiovascular disease and all-cause mortality in 
the general population has been attributed to subclinical coronary artery disease, poor health and glucose 
intolerance.4Subjects with diabetes(type II) are known to be at high risk of developing autonomic dysfunction, 
and autonomic dysfunction is already present in newly diagnosed diabetes(type II). Hypertension in the diabetic 
individual markedly increases the risk and accelerates the course of cardiac disease, peripheral vascular disease, 
stroke, retinopathy, and nephropathy.1 Our understanding of the factors that markedly increase the frequency of 
hypertension in the diabetic individual remains incomplete.             
Heart rate variability is mainly a reflection of the influence of the autonomic nervous system on the 
sinus node of the heart. The heart rate alters with many of the changes in demand on the cardiovascular system 
that are related to changes in respiration, posture and physical or mental activity. These changes are invoked by 
the control mechanism that coordinate the total pattern of activity in the individual. Spectral analysis of HRV 
can be a powerful tool to assess ANS function. It is not only useful when studying the pathophysiological 
process in certain diseases but also may be used in daily clinical practice.4.  
The different types of autonomic function measures so far have not been compared in one single study 
population.3. Studies have identified abnormal HRV in systemic hypertension, The data examining the 
association between HRV and blood pressure in hypertensive and diabetic hypertensive patients  is very small 
A Comparative study of heart rate variability during Valsalva maneuver in healthy, hypertensive and  
www.iosrjournals.org                                                             30 | Page 
scale.5 This work was planned  to study the role of autonomic function tests in hypertensive and hypertensive 
diabetic(type II) patients. The coexistence of the Hypertension and Type II Diabetes predicted to increase the 
autonomic dysfunction, and sympatho-vagal imbalance to be studied with the changes in the frequency 
parameters accordingly. 
The present study was conducted in the Department of Physiology in collaboration with the 
Department of Medicine of Pad. Dr. D. Y. Patil Medical College, Pimpri, Pune,  
90 male subjects in the age group of 40 to 65 years were selected for the study. 30 male subjects were 
patients of Hypertension and 30 male subjects were patients of Hypertension with Type II Diabetes Mellitus 
who attended the OPD of the Department of Medicine of Pad. Dr. D. Y. Patil Medical College, Pimpri, Pune, 
Maharashtra. 30 male healthy subjects of the same age group served as control.. 
 
Settings and design 
Hospital based cross-sectional study 
  
Inclusion criteria 
                Our study design included hypertensive and hypertensive diabetic(type II) subjects attending OPD and 
on treatment were tested for autonomic parameters. Age matched controls were selected simultaneously. 
 
Exclusion criteria-  
Subjects were excluded if they met any of the following criteria: 
1) stroke. 
2) Myocardial infarction or Congestive heart failure, atrial fibrillation, 
3) Organ failure 
4) Parkinson’s disease 
5) Juvenile Diabetes mellitus. 
6) Morbidly obese subjects. 
Thorough clinical examination of each subject was done and detailed history was taken with reference 
to duration of hypertension and diabetes(type II), family history, past history, personal history and drug 
history. General physical examination was done.  
Height (cm), weight (kg) and blood pressure was measured. BMI was calculated from height and 
weight measurements. Blood pressure was recorded in supine position. Three readings were taken and average 
of second and third was used for the study. BP measurement was done by both auscultatory and palpatory 
method. Pulse rate, rhythm and character were assessed. All this information was recorded on a prepared 
questionnaire. Pre-test instructions were given to avoid consumption of any drugs (anti hypertensive and oral 
hypoglycemic drugs) that may alter the autonomic function 48 hours prior to the test. The patients were advised 
to have a silent sleep without medicine at the previous night. On the day of the test, no cigarette, nicotine, 
coffee, food or drugs orally or other routes were permitted for three hours prior to the test. The same procedures 
were also followed for the Healthy male subjects. 
The tests were performed using Polyrite-D (RMS) machine in an equable environment with room 
temperature, in research laboratory room at the Department of Physiology of Pad. Dr. D. Y. Patil Medical 
College, Pimpri, Pune, Maharashtra. The lab is sound proof and air conditioned to provide comfort while 
performing tests. 
 
The subjects were grouped as follows: 
GROUP I- Healthy controls 
GROUP II- Hypertensive patients 
GROUP III-Hypertensive diabetic patients (Type II DM). 
Heart rate response to Valsalva maneuver 
6,7,8,9,10 
 
Apparatus: Polyrite - D, timer, Nose clip and modified mercurial sphygmomanometer. A mercurial manometer 
was improvised by modifying a mercurial sphygmomanometer and connected directly to the tube leading to 
mercury bulb.  
Procedure:- The test was done after another 5 minutes interval of rest in sitting posture. The subject was 
instructed to exhale forcefully through the tube of  the modified Mercurial sphygmomanometer and to maintain 
pressure in the manometer upto 40 mm Hg for 15 seconds. ECG recording were taken during the maneuver and 
continued for about 30 seconds after the performance. The maneuver was repeated three times with few minutes 
time interval of rest. Nasal clip was used     to stop nasal breathing of the subject during this maneuver. 
A Comparative study of heart rate variability during Valsalva maneuver in healthy, hypertensive and  
www.iosrjournals.org                                                             31 | Page 
 Calculation: The ratio of the longest RR interval after blowing to the shortest RR     interval during blowing or 
immediately after was calculated. The highest ratio of the three maneuvers was used as a result of Valsalva 
ratio(VR).  
Frequency domain analysis of heart rate variability- 
Freuency domain analysis values for very low frequency (VLF), High frequency (HF),Low frequency (LF),and 
ratio of low frequency to high frequency (LF/HF) were recorded on Polyrite ECG recordings during Valsalva 
Maneuer for the duration of one minute.11 
 
Statistical analysis-  
ANOVA, Tuckeys, and Pearson co-relation coefficient tests were used to analyze the appropriate data.12 
 
II. Observation and Results 
 
Table 1. gives the Autonomic function tests result of Valsalva ratio in all three groups. 
HRV Parameters Group I Group II Group III 
VR 1.3137+0.1714 1.2647+0.1608 1.1883+0.1302* 
 
Table 2. Comparision of HRV measures during Valsalva maneuver in GROUP I, II, III (Values are in 
Mean+Std.Dev.) 
HRV measures Group I Group II Group III 
VLF 1.747+6.149 2.087+7.518 3.153+5.336 
LF 2.623+5.563 2.983+5.976 1.867+3.833 
HF 0.8667+0.8612 0.8655+1.518 0.65+1.227 
LF/HF 2.1+2.205 3.363+2.444 2.407+2.44 
 
III. Discussion 
The average ratio in group I was 1.3137+0.1714. As compared to Group I in Group II, VR was  reduced ( 
Average VR 1.2647+0.1608).This could be due to Parasympathetic dysfunction in Hypertension.13 Also in 
Group III VR was significantly reduced 1.1883+0.1302). his may be because of sympathetic dominance and due 
to parasympathetic dysfunction.14.In Group III, VR was more reduced than in Group II. This suggestd that in 
both hypertension and hypertension with diabetes,co existence of disease may have resulted in  sympathetic 
overactivity and parasympathetic dysfunction.15.This autonomic dysfunction was more in hypertension with 
diabetes because of coexisting autonomic neuropathy and was statistically significant.16 It is known that 
Sympathetic and parasympathetic dysfunctions occur differently in Diabetes and hypertension. 
Table 2 Indicated average values of Heart rate variability tests, frequency parameters during  Valsalva aneuver . 
During valsalva maneuver in Group II as compared to Group I, VLF, LF, LF/HF increased indicating 
sympathetic over activity. Although statistically not significant. HF was decreased; may indicate 
parasympathetic dysfunction.17 
In Group III as compared to Group I, LF, HF were decreased and VLF, LF/HF increased. It  may 
indicated parasympathetic dysfunction and sympathetic over activity respectively. 
In Group III as compared to Group II, LF, HF, LF/HF were decreased and VLF was increased. This 
indicated sympathetic over activity. 
Frequency parameters although showed shift indicating sympatho vagal balance disturbance, they were 
not statistically significant. This could be because of small sample size , varied duration of illness.17 
No strong correlation of VR with confounding factors such as BMI, SBP, DBP, but they were 
negatively correlated 18 
 
Results and Conclusion:- 
• Changes in the valsalva maneuver occur due to changes in cardiac vagal efferents and sympathetic 
vasomotor activity which are stimulated by carotid sinus and aortic arch Baroreceptors and other 
intrathoracic stretch receptors. 
• As VR decreases there is failure to decrease HR after strain which suggests Parasympathetic 
dysfunction. 
• Autonomic dysfunction due to co-morbidity contributed highly significant variation compared to 
healthy subjects. 
 
• Our study shows that low heart rate variability in hypertensives and hypertensive diabetics as compared 
to healthy subjects.  
A Comparative study of heart rate variability during Valsalva maneuver in healthy, hypertensive and  
www.iosrjournals.org                                                             32 | Page 
•  Lower HRV is associated with higher values of blood pressures putting subjects with such trends at a 
higher risk of developing hypertension. 
 
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[2] Pikkujämsä SM, Huikuri HV, Airaksinen KE, Rantala AO, Kauma H, Lilja M,  Savolainen MJ, Kesäniemi YA. Heart rate 
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A Comparative study of heart rate variability during Valsalva maneuver in healthy, hypertensive and hypertensive diabetic subjects

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A Comparative study of heart rate variability during Valsalva maneuver in healthy, hypertensive and hypertensive diabetic subjects

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