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p>Background: Valsalva maneuver one of the oldest method to diagnose heart failure, it’s cheap ,non-invasive ,bedside tool .Its well-studied in systolic heart failure patients which showed abnormal response either square wave or absent phase IV ,however in diastolic heart failure and diastolic dysfunction were not investigated .Methods: 70 patients were included in our study they were divided into three groups group 1 diastolic heart failure based on echocardiography and BNP above 100pgL/ml , group 2 diastolic dysfunction based on echocardiography and BNP less than 100 pg/ml and group 3 systolic heart failure ,they went all clinical examination ,BNP were taken ,Valsalva maneuver at 30 mmhg for at least 15 sec using two sphygmomanometers first connected to mouth piece and the other to monitor blood pressure while the physician auscultates brachial artery patient is asked to perform forced expiratory effort against closed airway for at least 15 second and then asked to release and absence or presence of Korotkoff sounds assessed and heart rate is recorded baseline and after strain and full study echocardiography and using in apical 4 chamber view Simpson method to measure right and left ventricle area at baseline , peak strain and after release .
Results: Group 2 showed overshooting of systolic blood pressure by a mean of 11 ± 6.41mmHg (p value = 0.001), 95% confidence interval (CI): [3.2-15.14] compared to baseline. Moreover, group 3 showed minimal overshooting with a mean of 3.34±4.17mmHg (p value = 0.002), 95% confidence interval (CI): [2.2-8.2], On the other hand, group 1 showed no overshooting, with a mean change of -3.6 ± 0.63mmHg (p value = 0.001), 95% confidence interval (CI): [9.34-2.5].
We demonstrated that Valsalva maneuver could differentiate patients with diastolic heart failure from those with diastolic dysfunction, with a sensitivity of 68%, specificity 75%, positive predictive value 71.4%, and negative predictive value 72%. Only group 2 in our study showed a clinically significant decrease in RV end-diastolic area during strain as compared to the baseline, with a mean value of 4.5 ± 0.14 cm2 (23.5 ± 0.4%; p value = 0.001),95% confidence interval (CI):[6.65+2.25]. On the other hand, group 1 showed a minimal decrease (0.9 ± 0.25 cm2; 5.3 ± 0.6%) and group 3 showed a minimal increase (1 ± 2.23 cm2; 5.6±5%). Group 2 showed a clinically significant decrease in LV end-diastolic area during strain as compared to the baseline, with a mean value of 6.1 ± 1.01 cm2 (19.3 ± 2%; p value = 0.001) 95% confidence interval (CI) :[8.2+-3.96]. Moreover, group 3 showed a smaller, but significant decrease (4.6 ± 0.98 cm2; 12.6 ± 0.7%), while group 1 demonstrated insignificant change.
Conclusion: VM showed significant overshooting in group 2 compared to other two groups ,not all heart failure patients had abnormal response based as risk factors as NYHA class and diuretics ,stiffness in myocardium affected the Valsalva response in diastolic heart failure group followed by systolic heart failure and finally diastolic dysfunction one ,There is decrease in left and right ventricle area during strain and gradually increase after release during normal Valsalva response which is greatly affected in HF patients .

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INTRODUCTION: Musculoskeletal ultrasonography (US) is an objective tool for the evaluation of disease activity in rheumatoid arthritis (RA) patients. There is no consensus on the exact number of joints that should be examined. Examination of reduced joint count is more practical than the comprehensive one.

OBJECTIVES: This is a cross-sectional study investigated the validity of a 7-joint US score (US7) in assessment of joint inflammation in RA patients compared with a simplified 12-joint US score (US12) and correlated both to composite disease activity indices.

METHODS: The activity status of 50 RA patients was assessed clinically and ultrasonographically. The disease activity was calculated using 3 composite indices. Ultrasonography was performed by 1 blinded rheumatologist, using power Doppler (PD) and gray-scale (GS) US examination. The US7 and simplified US12 were performed as originally described. However, the GS synovitis and PD synovitis of US12 were computed in 2 separate scores instead of 1. Two sum US7 scores were added, sum (GS) US7 and sum (PD) US7 after summating synovitis and tenosynovitis scores. Ultrasonography interobserver/intraobserver reliability was evaluated on 40 stored images.

RESULTS: Correlation coefficient between the different ultrasonographic scores showed no difference. The GS scores showed no correlation with disease activity parameters; however, the PD scores did. The sum (PD) US7 was the only score that showed significant correlation with the 3 different composite disease indices.

CONCLUSIONS: All studied US scores proved valid in assessment of disease activity status in RA. This is in favor of using the less-time-consuming US7 scores. The strongest correlation found with sum (PD) US7 confirmed the importance of incorporating the tendon in the disease activity assessment.