Author + information
- Thach Nguyen1,2,
- Tran Ngoc Minh Chau2,
- Nguyen Tri Si2,
- Thao Dang2,
- Tu NT. Nguyen2,
- Tarneem Darwish3,
- Gianluca Rigatelli4 and
- Ernest Talarico5
In patients with heart failure (HF), the main physical finding is the sign of fluid accumulation. However, many patients with fluid overload are asymptomatic. If the patient has no symptom of HF, at the very early stage of fluid overload, where is the fluid accumulated?
Patients with low ejection fraction (EF) <35% and current symptoms of HF or history of prior diagnosis of decompensated HF were screened. Then all patients underwent an ultrasound test checking the size and expansion of the FV (SEFV). The SEFV measured the size of the FV on a coronal plane proximal to the bifurcation of the superficial (SFA) and deep femoral artery (PFA). The principle of this SEFV test is that the volume of blood going through the FA and returning through the common FV should be the same. If so, in normal condition, the FV is a little larger than the FA.
If the size of the FV at baseline is 2 times larger than the FA, the patient has significant fluid overload. If the FV can expand >1.5 times during cough, the test showed that the venous system can accommodate more fluid if needed.
In patients with fluid overload (with or without symptomatic HF), the FV does not expand with cough. The diagnosis of asymptomatic fluid overload (or right heart failure) was made when the asymptomatic patients with low EF had enlarged FV. Only the patients with enlarged FV were selected. Then all the patients underwent a detailed physical examination looking for edema in the leg, in the buttocks, signs of fluid infiltration in the abdominal wall, jugular venous distension. Liver fluid congestion was evidenced by enlargement of the liver (hepatomegaly) or pain secondary to a small punch in the right lower rib cage. Detailed exam of the face, the areas around the eyes was done in order to find the sign of fluid overload in the cutaneous vein. Both groups underwent detailed physical examination for fluid overload in six areas: the ankle, buttock, abdominal wall, liver, jugular vein and cutaneous veins. The physical findings of both groups were compared.
For symptomatic HF, the majority of patients had fluid overload in all 6 areas of interest including the enlarged FV (90%). For asymptomatic HF, the majority of patients had fluid overload only in the cutaneous veins and enlarged FV (80%). After 6 months of good treatment, the asymptomatic patients had no enlarged FV and minimal fluid in the cutaneous veins (95%).
Fluid overload in the cutaneous vein was usually overlooked and neglected. However, this is the main area to be focused in order to keep the patient with fluid overload (asymptomatic HF) in stable recovery.