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Current definitions of heart failure (HF) are vague and impractical. So we devise a new classification of HF which can guide its management and improve its outcome. The classification is based on the status of fluid volume in 3 compartments of the body. The intravascular compartment includes the intra-arterial and intravenous fluid. The extravascular compartment is mainly the fluid in the tissue (extracellular). This new definition classifies patients according to the fluid overload in either intravenous or extravascular compartment or hypo-perfusion in the intra-arterial compartment.
The patients were enrolled and physical examination was recorded for fluid overload in the venous system, mainly by the presence of rales in the lung and by painful sensation with a minimal punch in the right lower rib cage (to check for liver congestion). Fluid overload in the extravascular system consists of fluid infiltration in the abdominal wall, edema at the ankle, thigh, dependent areas (e.g. presacral area, etc). Low perfusion in the arterial compartment consists of low blood pressure, cerebral hypoperfusion (causing dizziness, sleepiness or change of mental status), renal perfusion (causing pre-renal azotemia (increased blood urea nitrogen and creatinine) and distal peripheral arterial system perfusion (causing fatigue or exercise intolerance). Intravenous loop diuretics were used when there is intravenous fluid overload. Long term loop or convoluted tube diuretics were used to remove fluid from the extravascular compartment. Angiotensin converting enzyme inhibitor was given to patients with low EF. Number of medication, length of stay, re-admission rate and mortality were recorded up to one year follow-up.
100 patients were enrolled from January 2015 to April 2016. All were diagnosed with HF in the emergency room.
The length of stay, number of medications used, mortality in one year and re-admission rate were much better when there was no intravascular fluid overload.
The new classification of HF and its management are based on fluid status in the intravascular compartment (mainly venous) and extravascular compartment. The use of diuretics is more specifically focused at the removal of fluid in the intravascular compartment in the acute phase and in the extravascular compartment in the chronic phase. Patient without intravascular fluid overload had better prognosis. This new classification and management are more successful in speeding up recovery, sustaining the asymptomatic period, improving the long term prognosis while lowering the cost of care for patients with HF. Another important aspect of this classification is its ability to separate the sick patients who may need to be admitted and the stable patients who could be treated as outpatients. Randomized studies with higher number of patients are needed to validate the above preliminary data.