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Current definitions of diastolic heart failure (DHF) or HF with preserved ejection fraction (EF) are vague and impractical. So we suggest a new classification of DHF. The classification is based on the presence fluid overload in 2 compartments of the body: intravenous and extravascular compartment. Because the ejection fraction is normal so the patient should not have hypo-perfusion in the arterial system, unless the patient is over-diuresed.
From the emergency room, the patients with diagnosis of HF with preserved EF were enrolled. The 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 liver is congested or overloaded with fluid). Fluid overload in the extravascular system is defined by fluid infiltration in the abdominal wall, edema at the ankle, thigh, dependent areas. Low perfusion in three other arterial compartments, mainly cerebral (causing dizziness or change of mental status), renal (causing pre-renal azotemia (increased blood urea nitrogen) and distal peripheral arterial system (causing fatigue or exercise intolerance). 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.
25 patients were enrolled from January 2015 to April 2016. 20/25 (80%) patients with HF and preserved EF showed extravascular fluid overload while the size of the femoral vein is small or mildly enlarged without good expansion upon cough. This finding explains that the cause of intravenous fluid overload is due to the inability of the venous system to expand in order to accommodate the larger amount of blood. This means that the cause of diastolic dysfunction is from the peripheral veins and not from the central pulmonary artery.
The patients with HF and preserved EF, the presence of edema mainly in the extravascular compartment is caused by the failure of the venous system to accommodate larger amount of fluid. This is a new disease caused by increased stiffness of the venous system. Larger scale of clinical trial or registries of this new technique are needed.