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Current definitions of heart failure (HF) are vague and impractical. So we suggest a new classification of HF and a plan of management based on this new classification. With a new test, the Expandibility of the Femoral Vein (EFV) test, the patient could have better treatment of HF. Which are the differences between the patients with HF precipitated by new dilated cardiomyopathy and decompensated HF from long standing old chronic dilated cardiomyopathy.
The classification is based on the condition of fluid in 3 compartments of the body. The intravascular part includes the intra-arterial and intravenous compartments. The extravascular compartment is mainly in the tissue (extracellular). HF consists of fluid overload in either intravenous or extravascular compartment and hypo-perfusion in the intra-arterial compartment. 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 which means fluid in the liver. The study group underwent the new Expansibility of the Femoral Vein (EFV) and had treatment based on its results. The EFV is the ultrasound study of the femoral vein examining its size and expansibility during strong cough. In general, the location of the femoral artery and vein to be checked is the sagittal plane immediately proximal to the bifurcation of the superficial and deep femoral artery. The size of the femoral vein is a little larger than the size of the femoral artery. If the size of the femoral vein during cough is 3 times larger than the one at baseline, the test is considered normal. If the size of the femoral vein is >3 times larger than then baseline, it is considered abnormal suggesting excessive venous pooling. If the femoral vein expands only <2 times of the baseline during cough, it is considered abnormal suggesting present or future pulmonary hypertension. If this test was done in conjunction with a right heart catheterization, then the femoral vein pressure at baseline and during cough is recorded. The patient received standard treatment for HF with low EF including the angiogensin-converting enzyme inhibitor (ACEI) and betablockers (BB). Short term fast acting loop diuretics (e.g. furosemide) were used when there was intravenous fluid overload. Long acting, lower dose diuretics (e.g. HCTZ) were given when there was more extravascular fluid overload.
50 patients were enrolled from January 2015 to April 2016. All came with shortness of breath and had a diagnosis of HF in the emergency room. All the patients were diagnosed with HF with low or preserved EF. All patients had intravascular fluid overload. 60% patients with long standing dilated cardiomyopathy had more extravascular fluid overload compared with only 30% patients of recent dilated cardiomyopathy (p<0.05). The patients with new or recent onset of dilated cardiomyopathy recovered faster (within 24 hours) while the other patients took longer to recover. These latter patients also needed more medications (all p<0.05).
Based on the location of the fluid overload, the patients with new onset of HF were faster to recover with less times and lower resources.