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

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 [...]