USAsuMMARY Thirty-seven patients were evaluated before cardiac catheterisation by bedside physical examination, including Valsalva manoeuvre, to assess the value of the sphygmomanometrically determined arterial pressure responses during the Valsalva manoeuvre and to compare its sensitivity, specificity, and predictive accuracy in the detection of left ventricular dysfunction with that of the commonly used diagnostic signs including the chest x-ray. Patients not on beta-blockade treatment could be separated into three distinct arterial pressure responses detectable at the bedside which corresponded well to three statistically different groups with regard to left ventricular ejection fraction (0-29±0-11, 0-48+0-15, 0-69±0-11) and left ventricular end-diastolic pressure (38±5 mmHg, 24+10 mmHg, 14± 5 mmHg) at subsequent cardiac catheterisation. In patients not on beta-blockade it was shown for the first time that (1) the height ofthe systolic arterial pressure overshoot was directly related to left ventricular ejection fraction and inversely related to left ventricular end-diastolic pressure, and that (2) the bedside sphygmomanometrically determined arterial pressure response during Valsalva manoeuvre provided a semiquantitative estimate of left ventricular function and was unsurpassed in its ability to do so by any of the standard diagnostic signs including the chest x-ray film.Although Weber and not Valsalva first described the circulatory effects of airway straining,1 the clinical manoeuvre consisting of sustained forced expiratory effort against an obstructed airway (closed glottis or colunm of mercury) bears the name "Valsalva" after its description by this man almost two hundred years ago.2 The normal arterial blood pressure response to the Valsalva manoeuvre is an initial rise associated with the onset of straining (phase 1), followed by a sharp fall to below baseline levels as the straining is maintained (phase 2). Release of strain (phase 3) is followed in the normal subject by a distinct overshoot of the arterial pressure (phase 4) creating a typical sinusoidal response (Fig. la)

This study investigated the effects of colesevelam hydrochloride (WelChol; Sankyo Pharma, Parsippany, NJ) and ezetimibe (Zetia; Merck/Schering Plough Pharmaceuticals, North Wales, PA), alone and in combination, for the treatment of hypercholesterolemia in patients who were intolerant to, or refused, HMG-Co-A reductase inhibitor (statin) therapy. Combination therapy with colesevelam HCl/ezetimibe resulted in an additional reduction in low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (HDL-C) levels of approximately 20% (P < 0.005) and 16% (P < 0.01), respectively, compared with monotherapy with either agent. Total cholesterol, LDL-C, and non-HDL-C levels were within National Cholesterol Education Program Adult Treatment Panel III target ranges at the end of the combination therapy regimen in 10 of 12 patients. In conclusion, colesevelam HCl/ezetimibe combination therapy appears to be an efficacious and well-tolerated alternative for patients with hypercholesterolemia.

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