ABC Heart Fail Cardiomyop 2024; 4(2): e20240039

Is Your “Dry” Patient Really Not Congested? Physiological Basis and Clinical Use of Valsalva’s Maneuver in Heart Failure

Renata R. T. Castro

DOI: 10.36660/abchf.20240039i

Introduction

In 2003, Nohria et al. published a manuscript considered a game-changer in acute heart failure (HF) treatment. As by this manuscript, patients admitted with heart failure should be clinically classified into four hemodynamic profiles defined by the presence or absence of congestion and hypoperfusion. Congestion was defined by “recent history of orthopnea and/or physical exam evidence of rales, jugular venous distension, hepatojugular reflux, ascites, peripheral edema, left-ward radiation of the pulmonic heart sound, or a square wave blood pressure response to the Valsalva maneuver.”

More than 20 years after this publication, the Valsalva maneuver continues to be routinely used during clinical evaluation of patients admitted to the advanced heart failure service at the Brigham and Women’s Hospital (personal experience), where profiles were created and validated. However, despite the fact that clinical profile determination has become a routine procedure, few physicians have incorporated the Valsalva maneuver in their practices. To date, no study has compared the accuracy of the different clinical methods available for assessing congestion in patients with HF. Therefore, we should not categorize a patient as “dry” before all possibilities of congestion are excluded. It is possible that patients are being categorized as dry when, in fact, they have congestion that would only be identified by the Valsalva maneuver. Correct determination of hemodynamic profile is pivotal, as the existence of congestion and/or hypoperfusion guides the management of patients admitted with heart failure decompensation. This manuscript aims to review the physiological bases of the Valsalva maneuver, justifying and encouraging its use in clinical practice.

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