Determinants of Dyspnea in Chronic Heart Failure

Perceived dyspnea and experience of hospitalized patients with acute decompensated heart failure undergoing an early MObilization protocol with immersive Virtual rEality: MOVE study protocol for a parallel superiority randomized clinical trial

BACKGROUND

Immersive virtual reality (VR) is an innovative strategy for inpatient rehabilitation programs. Using immersive VR in early mobilization protocols has not yet been investigated in the setting of hospitalized patients with acute decompensated heart failure (ADHF), especially to improve perceived dyspnea, a common symptom of heart failure (HF).

METHODS

This is a single-center parallel superiority randomized clinical trial. The study will be conducted at a public teaching hospital in Brazil from January 2023 to January 2024. The sample will include adult patients with ADHF hospitalized for at least 24 h, randomly assigned in a 1:1 ratio to the control (standard early mobilization protocol conducted in the intensive care unit (ICU)) or intervention group (the same standard early mobilization protocol but associated with immersive VR). The primary outcome will be assessing perceived dyspnea, and the secondary outcome will be assessing patient experience.

DISCUSSION

Using immersive VR in early mobilization protocols in the ICU is expected to improve perceived dyspnea in patients with ADHF as well as patient experience regarding care. This study has the potential to increase patient adherence to early mobilization protocols in the setting of ADHF as well as to promote a positive patient experience. Filling this gap could promote the rational incorporation of technologies in health care.

TRIAL REGISTRATION

This study protocol is in its first version.

CLINICALTRIALS

gov NCT05596292. Registered on 1 December 2022.

Prognostic significance and clinical determinants of residual dyspnoea at discharge in acute heart failure: a single-centre, prospective observational study

OBJECTIVE

This study aimed to assess the prognostic significance of residual (discharge) dyspnoea in acute heart failure (AHF) patients.

DESIGN

Single-centre, prospective observational study.

SETTING

Patients hospitalised for decompensated AHF in a single cardiology centre, in Poland.

PARTICIPANTS

All patients (n=202) who survived the hospitalisation with the primary diagnosis of AHF and were discharged from the hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

1-year all-cause mortality; and the composite endpoint of 1-year all-cause mortality and rehospitalisation for the HF (whichever occurred first).

RESULTS

On admission, 159 (78.7%) AHF patients presented dyspnoea at rest, while residual resting dyspnoea at discharge was present in 16 patients (7.9%). There were 48 (24%) patients with moderate/severe exertional dyspnoea at discharge. In the multivariable model, the resting dyspnoea at discharge was related to a higher risk of both 1-year mortality and composite outcome, with HR (95% CI) 8.0 (3.7 to 17.3) and 5.1 (2.6 to 10.2), respectively, both p<0.0001. Analogically, moderate or severe residual dyspnoea at discharge was related to the heightened risk of study both outcomes, with HR (95% CI) 3.1 (1.8 to 5.4) and 1.8 (1.1 to 2.9), respectively, p<0.01.

CONCLUSIONS

Among AHF patients the residual dyspnoea at discharge was unexpectedly common and was associated with an unfavourable outcome during 1-year follow-up.

Unsupervised machine learning identifies symptoms of indigestion as a predictor of acute decompensation and adverse cardiac events in patients with heart failure presenting to the emergency department

BACKGROUND

Patients with known heart failure (HF) present to emergency departments (ED) with a plethora of symptoms. Although symptom clusters have been suggested as prognostic features, accurately triaging HF patients is a longstanding challenge.

OBJECTIVES

We sought to use machine learning to identify subtle phenotypes of patient symptoms and evaluate their diagnostic and prognostic value among HF patients seeking emergency care.

METHODS

This was a secondary analysis of a prospective cohort study of consecutive patients seen in the ED for chest pain or equivalent symptoms. Independent reviewers extracted clinical data from charts, including nine categories of subjective symptoms reported during initial evaluation. The diagnostic outcome was acute HF exacerbation and prognostic outcome was 30-day major adverse cardiac events (MACE). Outcomes were adjudicated by two independent reviewers. K-means clustering was used to derive latent patient symptom clusters, and their associations with outcomes were assessed using multivariate logistic regression.

RESULTS

Sample included 438 patients (age 65±14 years; 45% female, 49% Black, 18% HF exacerbation, 32% MACE). K-means clustering identified three presentation phenotypes: patients with dyspnea only (Cluster A, 40%); patients with indigestion, with or without dyspnea (Cluster B, 23%); patients with neither dyspnea nor indigestion (Cluster C, 37%). Compared to Cluster C, indigestion was a significant predictor of acute HF exacerbation (OR=1.8, 95%CI=1.0-3.4) and 30-day MACE (OR=1.8, 95%CI=1.0-3.1), independent of age, sex, race, and other comorbidities.

CONCLUSION

Indigestion symptoms in patients with known HF signify excess risk of adverse events, suggesting that these patients should be triaged as high-risk during initial ED evaluation.

Does thiamine supplementation affect heart failure? A systematic review and meta-analysis of randomized control trials

BACKGROUND

Heart failure is a pathophysiological condition where decreased cardiac output is observed subsequent to any structural deformity or cessation of normal function. Thiamine deficiency is one of the risk factors responsible for causing HF; other risk factors include hypertension, smoking, and obesity.

OBJECTIVE

We conducted a systemic review and meta-analysis of RCTs to scrutinize whether the heart failure patients would benefit from thiamine supplementation or not when compared to placebo.

METHODS

We selected only those double-arm randomized controlled trials (RCTs) which included participants presenting with symptomatic heart failure. We excluded all the articles published in languages other than English Language. Furthermore, all the studies other than RCTs were also omitted. Articles yielded from the electronic search were exported to EndNote Reference Library software to remove any duplicates. Analyses were done using the Review manager 5.4 tool. Mean values and standard deviations were retrieved for the continuous outcomes given as raw data.

RESULTS

The 6 RCTs selected for the statistical analysis consisted of 298 participants (158 in the intervention group, 140 in the placebo group). The outcomes resulted to be non-significant with LVEF p-value= 0.08, NT-pro BNP p-value= 0.94, LVEDV p-value= 0.53, 6MWT p-value=0.59, mortality p-value= 0.61, hospitalization p-value= 0.53 and dyspnea p-value= 0.77. Heart rate is the only significant outcome with a p-value=0.04.

CONCLUSION

To conclude, except for heart rate, thiamine supplementation had no effect on the outcomes of heart failure patients.

Acute Cardiovascular and Cardiorespiratory Effects of JWH-018 in Awake and Freely Moving Mice: Mechanism of Action and Possible Antidotal Interventions?

JWH-018 is the most known compound among synthetic cannabinoids (SCs) used for their psychoactive effects. SCs-based products are responsible for several intoxications in humans. Cardiac toxicity is among the main side effects observed in emergency departments: SCs intake induces harmful effects such as hypertension, tachycardia, chest pain, arrhythmias, myocardial infarction, breathing impairment, and dyspnea. This study aims to investigate how cardio-respiratory and vascular JWH-018 (6 mg/kg) responses can be modulated by antidotes already in clinical use. The tested antidotes are amiodarone (5 mg/kg), atropine (5 mg/kg), nifedipine (1 mg/kg), and propranolol (2 mg/kg). The detection of heart rate, breath rate, arterial oxygen saturation (SpO2), and pulse distention are provided by a non-invasive apparatus (Mouse Ox Plus) in awake and freely moving CD-1 male mice. Tachyarrhythmia events are also evaluated. Results show that while all tested antidotes reduce tachycardia and tachyarrhythmic events and improve breathing functions, only atropine completely reverts the heart rate and pulse distension. These data may suggest that cardiorespiratory mechanisms of JWH-018-induced tachyarrhythmia involve sympathetic, cholinergic, and ion channel modulation. Current findings also provide valuable impetus to identify potential antidotal intervention to support physicians in the treatment of intoxicated patients in emergency clinical settings.

Exertional dyspnea responses to the Dyspnea Challenge in heart failure: Comparison to chronic obstructive pulmonary disease

BACKGROUND

In heart failure (HF), exertional dyspnea is a common symptom, but validated field-based tests for its measurement are limited. The Dyspnea Challenge is a two-minute uphill treadmill walk designed to measure exertional dyspnea in cardiopulmonary disease.

OBJECTIVES

The purpose of this study was to establish the test-retest reliability of the Dyspnea Challenge in HF and to compare the exercise responses to a group with chronic obstructive pulmonary disease (COPD).

METHODS

The study was an experimental, single-blind, randomized, multi-site project that recruited individuals with HF (New York Heart Association I-III) and COPD (Global Initiative for Chronic Obstructive Lung Disease II-IV). Participants completed two visits. On the first visit, participants performed two six-minute walk tests (6MWT), followed by two to three Dyspnea Challenges to calculate treadmill speed and gradient. At Visit Two, participants performed two separate Dyspnea Challenges, with one including measures of pulmonary gas exchange and central hemodynamics.

RESULTS

Twenty-one individuals with HF (10 female; 66±11years; ejection fraction:45.3 ± 6.1%; six-minute distance(6MWD) 520 ± 97 m), and 25 COPD (11 female; 68 ± 10 yr; forced expiratory volume in 1 s:47.6 ± 11.5%; 6MWD: 430 ± 101 m). Intraclass correlation coefficients demonstrated excellent test-retest reliability for HF (0.94, P<.01) and COPD (0.95, P<.01). While achieving similar end-exercise exertional dyspnea intensities (P=.60), the HF group walked at a higher average speed (4.2 ± 0.8 vs. 3.5 ± 0.8km·h^-1) and gradient (10.3 ± 2.8 vs. 9.6 ± 2.8%) and a greater oxygen uptake (P<.01) and ventilation (P<.01) than those with COPD. While achieving similar cardiac outputs (P=.98), stroke volumes (P=.97), and heart rates (P=.83), those with HF displayed a larger arteriovenous oxygen difference (P<.01), while those with COPD exhibited greater decreases in inspiratory capacity (P=.03), arterial oxygen saturation (P=.02), and breathing reserve (P<.01).

CONCLUSIONS

The Dyspnea Challenge is a reliable test-retest measure of exertional dyspnea in HF. Typical to their pathologies, HF seemed limited by an inadequate modulation of cardiac output, while ventilatory constraints hampered those with COPD.

Cost-Effectiveness of a Specialized Breathlessness Service Versus Usual Care for Patients With Advanced Diseases

OBJECTIVES

The Munich Breathlessness Service (MBS) significantly improved control of breathlessness measured by the Chronic Respiratory Questionnaire (CRQ) Mastery in a randomized controlled fast track trial with waitlist group design spanning 8 weeks in Germany. This study aimed to assess the within-trial cost-effectiveness of MBS from a societal perspective.

METHODS

Data included generic (5-level version of EQ-5D) health-related quality of life and disease-specific CRQ Mastery. Quality-adjusted life years (QALYs) were calculated based on 5-level version of EQ-5D utilities valued with German time trade-off. Direct medical costs and productivity loss were calculated based on standardized unit costs. Incremental cost-effectiveness ratios (ICER) and cost-effectiveness-acceptance curves were calculated using adjusted mean differences (AMD) in costs (gamma-distributed model) and both effect parameters (Gaussian-distributed model) and performing 1000 simultaneous bootstrap replications. Potential gender differences were investigated in stratified analyses.

RESULTS

Between March 2014 and April 2019, 183 eligible patients were enrolled. MBS intervention demonstrated significantly better effects regarding generic (AMD of QALY gains of 0.004, 95% confidence interval [CI] 0.0003 to 0.008) and disease-specific health-related quality of life at nonsignificantly higher costs (AMD of €605 [95% CI -1109 to 2550]). At the end of the intervention, the ICER was €152 433/QALY (95% CI -453 545 to 1 625 903) and €1548/CRQ Mastery point (95% CI -3093 to 10 168). Intervention costs were on average €357 (SD = 132). Gender-specific analyses displayed dominance for MBS in males and higher effects coupled with significantly higher costs in females.

CONCLUSIONS

Our results show a high ICER for MBS. Considering dominance for MBS in males, implementing MBS on approval within the German health care system should be considered.

State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association

Symptoms of cardiovascular disease drive health care use and are a major contributor to quality of life. Symptoms are of fundamental significance not only to the diagnosis of cardiovascular disease and appraisal of response to medical therapy but also directly to patients' daily lives. The primary purpose of this scientific statement is to present the state of the science and relevance of symptoms associated with cardiovascular disease. Symptoms as patient-reported outcomes are reviewed in terms of the genesis, manifestation, and similarities or differences between diagnoses. Specifically, symptoms associated with acute coronary syndrome, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease are reviewed. Secondary aims include (1) describing symptom measurement methods in research and application in clinical practice and (2) describing the importance of cardiovascular disease symptoms in terms of clinical events and other patient-reported outcomes as applicable.

Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure

BACKGROUND

Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains.

OBJECTIVE

To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure.

DESIGN

We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G).

PARTICIPANTS

We used data from a multi-site randomized clinical trial among outpatients with heart failure.

MAIN MEASURES

We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods.

KEY RESULTS

Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change.

CONCLUSIONS

The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.

Perceived symptoms as the primary indicators for 30-day heart failure readmission

Background

To identify 30-day rehospitalizations in patients discharged with heart failure (HF) based on clinical indications, physiologic measures and symptoms.

Methods

Fifty-six patients with heart failure participated. After discharge to home, clinical indicators of dyspnea, fatigue, orthopnea, dyspnea with exertion, daily weight, edema, heart rate, blood pressure, mental condition, medication adherence, and overall well-being were reported by participants daily for up to 30 days.

Results

Joint modeling of longitudinal and time-to-event approach was applied to assess the association of readmission with longitudinal measurements. There was no association between demographic, physiological, or laboratory variables and re-hospitalization within 30 days post discharge. Perceptions of dyspnea (p = .012) and feeling unwell (p < .001) were associated with rehospitalization. Patients struggling to breath were 10.7 times more likely to be readmitted than those not struggling to breath.

Conclusion

Perceived measures, particularly dyspnea and feeling unwell were more important factors than demographic, physiological, or laboratory parameters in predicting 30-day rehospitalizations in this racially diverse cohort. The symptomatic experience of heart failure is an important indicator of rehospitalization.

Patterns and predictors of dyspnoea following left ventricular assist device implantation

AIMS

Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation.

METHODS AND RESULTS

This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement.

CONCLUSION

Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.

COPD - do the right thing

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Web-Based Training and Telephone Follow-up of Patients With Heart Failure: Randomized Controlled Trial

This study was carried out to determine the effect of Web-based training and telephone follow-up on symptom burden and health status in patients with heart failure. Patient training and postdischarge follow-up are necessary to improve symptom management and quality of life in patients with heart failure. In Turkey, Web-based education and phone monitoring are not very common yet. In this parallel randomized controlled trial, patients were allocated to a control group (n = 32) or an intervention group (n = 32). The control group received routine care, and the intervention group was administered the following interventions in addition to routine care: Web-based training, four-session telephone follow-up, and one text message weekly. All results regarding symptom management and quality of life were assessed beginning and at the 12th week. The Consolidated Standards of Reporting Trials checklist was used. In the 12th week after discharge, patients in the intervention group showed a significant improvement in terms of symptom burden and health status compared with the control group.

Breathlessness and Respiratory Disability After Kidney Transplantation

BACKGROUND

Dyspnea is a common symptom in patients with end-stage kidney disease being treated with dialysis. This study aimed to ascertain the level of respiratory disability in patients after kidney transplantation through assessing a cohort of kidney allograft recipients for respiratory compromise and thereby identifying a potential target for therapeutic intervention.

METHODS

Kidney transplant recipients who were under active observation in a single tertiary referral center were invited to take part in this prevalence study at the time of clinic follow-up. All patients agreed to take part in the study, which involved completing a Medical Research Council (MRC) dyspnea scale, completing the St George's Respiratory Questionnaire, and performing basic spirometry. An MRC score of ≥2 and/or a forced expiratory volume in 1 second <90% predicted prompted formal clinical assessment by a respiratory physician.

RESULTS

This study enrolled 103 patients; 35% of all patients reported breathlessness, and 56% of all patients warranted formal respiratory medicine review. After completion of their investigations, 33 patients were found to have an underlying condition accounting for their symptoms.

CONCLUSION

Our study highlights the issues of respiratory disability and breathlessness in patients who have undergone kidney transplantation. Although extensive cardiologic evaluation is performed routinely and can rule out many causes of dyspnea, respiratory assessment is not a preoperative prerequisite. This study could suggest that a formal pulmonological evaluation and basic spirometry should be part of the pretransplant evaluation of the kidney transplant recipient.

The effects of breathing training on dyspnea and anxiety among patients with acute heart failure at emergency department

BACKGROUND

Anxiety-related dyspnea is a compelling symptom among patients with acute heart failure (AHF). Breathing training is a nonpharmacological intervention to relieve dyspnea and anxiety. This study aimed to investigate the effects of breathing training on dyspnea and anxiety among patients with AHF at the emergency department (ED).

METHODS

Two-group pre-post intervention study was conducted at the ED of one university hospital in the northeast of Thailand. Data were collected among 96 patients with AHF, which were equally assigned to breathing training (BT) and control groups. The training group received pursed-lip mindfulness breathing training, whereas the control group received usual care (UC). The pursed-lip mindfulness breathing was delivered from the first 40 min of arrival to the 4th hour in the ED. The breathing training consisted of positioning the patients in Fowler's position with the head of the bed elevated at 60 degrees or higher, supporting both arms with pillows, and breathing in through the nose with breathing out via the mouth with pursed lip while counting. Dyspnea and anxiety scores were measured with Dyspnea Visual Analog Scale and Anxiety Visual Analog Scale, respectively.

RESULTS

The dyspnea and anxiety scores significantly decreased after four hours in both groups. Dyspnea score decreased from 8.85 (SD 1.220) to 3.63 (SD 1.468) after BT (t = 26.111, p < 0.001) in the experimental group whereas in the control group it decreased from 8.98 (SD 1.194) to 6.94 (SD 1.590) after UC (t = 16.181, p < 0.001). Comparing between the groups, dyspnea score reductions were 5.22 (SD 1.468) in the experimental and 2.04 (SD 1.590) in the control (t = 0.101, p < 0.001). Anxiety score decreased from 9.35 (SD 1.000) to 4.44 (SD 1.219) after BT (t = 25.231, p < 0.001) in the experimental while the scores in the control group decreased from 9.48 (SD 1.072) to 8.15 (SD 1.502) after UC (t = 8.131, p < 0.001). The anxiety score reductions were 4.91 (SD 1.219) and 1.33 (SD 1.502) in the experimental and the control groups, respectively (t = 0. 066, p < 0.001). Both the dyspnea and anxiety scores after the intervention were significantly different between the experimental and control groups.

CONCLUSION

Both UC and BT with UC can reduce dyspnea and anxiety in patients admitted to ED with AHF. However, the effect of BT combined with UC was larger comparing to UC only.

Pulmonary and cardiac variables associated with persistent dyspnea after pulmonary embolism

INTRODUCTION

Persistent dyspnea is common in follow-up after pulmonary embolism (PE), but the underlying mechanisms are poorly understood.

MATERIAL AND METHODS

This cross-sectional study included subjects aged 18-75 years with confirmed PE by computed tomography pulmonary angiography (CTPA) 6-72 months earlier. A total of 180 participants underwent clinical examination, incremental shuttle walk test, laboratory tests, transthoracic echocardiography, pulmonary function tests and ventilation/perfusion scintigraphy. In further analysis, we divided participants into two groups; "dyspnea" or "no dyspnea", based on interview and questionnaires at inclusion. The association of cardiac and pulmonary variables with persistent dyspnea was assessed using multiple logistic regression analysis.

RESULTS

In total, 44% (95% CI: 39%-51%) of the participants reported persistent dyspnea after PE. Age (adjusted odds ratio (aOR) 0.93 per year, 95% CI: 0.90-0.97, P = 0.001), body mass index (BMI) (aOR 1.14 per kg/m², 95% CI: 1.04-1.25, P = 0.004), recurrent venous thromboembolism (VTE) (aOR 3.69, 95% CI: 1.45-9.38, P = 0.006) and diffusion capacity of the lung for carbon monoxide (DLCO) (aOR 0.95 per increase of 1%, 95% CI: 0.92-0.98, P = 0.001) were independently associated with persistent dyspnea.

CONCLUSIONS

Persistent dyspnea was prevalent after PE. Age, BMI and recurrent VTE were independently associated with dyspnea. Apart from reduced DLCO, no other cardiac or pulmonary variables were associated with persistent dyspnea.

Symptom-based clusters in patients with advanced chronic organ failure identify different trajectories of symptom variations

BACKGROUND

Healthcare needs are complex and heterogeneous in advanced chronic organ failure. However, based on symptom clusters, groups of patients with similar quality of life, care dependency and life-sustaining treatment preferences can be identified.

AIMS

To evaluate the stability of symptom-based clusters over time, and whether and to what extent the clusters are able to predict patients' 2-year survival and hospitalization rates.

METHODS

This is a secondary analysis of a longitudinal observational study including 95 outpatients with chronic obstructive pulmonary disease (COPD) GOLD stage III-IV, 80 outpatients with chronic heart failure (CHF) NYHA stage III-IV and 80 outpatients with chronic renal failure (CRF) requiring dialysis. Patients were clustered into three groups applying K-means algorithm on baseline symptoms' severity and were then longitudinally evaluated. 2-year survival and hospital admissions during 1 year were estimated using Kaplan-Meier curves and Cox models. 1-year tendencies in symptom variation, using mixed linear models, and clusters comparison over time were performed.

RESULTS

The three clusters were unable to predict patients' survival and hospital admissions. Noteworthy, they show different trajectories of symptom variation, with Cluster 1 patients experiencing a worsening of symptoms, associated with an increased care dependency, and Cluster 2 and Cluster 3 patients being stable or having a relief in some symptoms. Although Cluster 1 is becoming more similar to Cluster 2, the three clusters preserve the overall characteristics and differences.

DISCUSSION

Symptom-based clusters might help to identify patients with different trajectories of symptom variations.

CONCLUSION

Symptom clusters do not predict survival and hospital admissions and are stable over time.

Identifying unique profiles of perceived dyspnea burden in heart failure

BACKGROUND

Dyspnea is a common symptom of heart failure (HF) but dyspnea burden is highly variable.

OBJECTIVES

Identify distinct profiles of dyspnea burden and identify predictors of dyspnea symptom profile.

METHODS

A secondary analysis of data from five studies completed at Oregon Health and Science University was conducted. The Heart Failure Somatic Perception Scale was used to measure dyspnea burden. Latent class mixture modeling identified distinct profiles of dyspnea burden in a sample of HF patients (n = 449). Backwards stepwise multinomial logistic regression identified predictors of latent profile membership.

RESULTS

Four profiles of dyspnea burden were identified: no dyspnea/not bothered by dyspnea, mild dyspnea, moderate exertional dyspnea, and moderate exertional dyspnea with orthopnea and PND. Higher age was associated with greater likelihood of not being bothered by dyspnea than having moderate exertional dyspnea with orthopnea and PND. Higher NYHA class, anxiety, and depression were associated with greater likelihood of greater dyspnea burden.

CONCLUSIONS

Burden of dyspnea is highly variable among HF patients. Clinicians should account for the nuances of dyspnea and the activities that induce dyspnea when assessing HF patients.

Surface respiratory electromyography and dyspnea in acute heart failure patients

Introduction and Objectives: Dyspnea is the most common symptom among hospitalized patients with heart failure (HF) but besides dyspnea questionnaires (which reflect the subjective patient sensation and are not fully validated in HF) there are no measurable physiological variables providing objective assessment of dyspnea in a setting of acute HF patients. Studies performed in respiratory patients suggest that the measurement of electromyographic (EMG) activity of the respiratory muscles with surface electrodes correlates well with dyspnea. Our aim was to test the hypothesis that respiratory muscles EMG activity is a potential marker of dyspnea severity in acute HF patients. Methods: Prospective and descriptive pilot study carried out in 25 adult patients admitted for acute HF. Measurements were carried out with a cardio-respiratory portable polygraph including EMG surface electrodes for measuring the activity of main (diaphragm) and accessory (scalene and pectoralis minor) respiratory muscles. Dyspnea sensation was assessed by means of the Likert 5 questionnaire. Data were recorded during 3 min of spontaneous breathing and after breathing at maximum effort for several cycles for normalizing data. An index to quantify the activity of each respiratory muscle was computed. This assessment was carried out within the first 24 h of admission, and at day 2 and 5. Results: Dyspnea score decreased along the three measured days. Diaphragm and scalene EMG index showed a positive and significant direct relationship with dyspnea score (p<0.001 and p = 0.003 respectively) whereas pectoralis minor muscle did not. Conclusion: In our pilot study, diaphragm and scalene EMG activity was associated with increasing severity of dyspnea. Surface respiratory EMG could be a useful objective tool to improve assessment of dyspnea in acute HF patients.

Significance of Dyspnoea as a symptom in the Emergency Department of the Primary Healthcare Centre

Background/Aim: Dyspnoea represents a subjective feeling of laboured breathing of different intensity. The aim of this study was to determine how often patients come with dyspnoea to a local Emergency Department of the Primary Healthcare Centre (EDPHC) and to analyse the assumed aetiology, diagnostics and therapy of the dyspnoeic patients. Methods: The records of the EDPHC of the City of Banja Luka for the period between 1 October 2019 to 31 December 2019 of all patients older than 15 years of age that have reported laboured breathing were identified and analysed. Following parameters were recorded: age, gender, diagnostics performed, administered therapy, whether the patient was examined in the field or in the ambulance, as well as whether the patient was referred to a hospital (Cardiology, Pulmonology or another department) or not. Results: Laboured breathing was reported by 665 patients. Out of this number, 108 patients were examined by their family doctor, 407 patients in EDPHC ambulance and 150 patients in the field. The average age of the patient was 61.03 ± 19.17, with an equal distribution in males and females. The aetiology of dyspnoea was cardiac and pulmonary in one-third of patients each, whereas the diagnosis in the other patients was versatile, from anxiety disorders, musculoskeletal diseases and active malignancy to unspecified chest pain that could not receive a definitive diagnosis. One half of the patients (N = 261 or 46.86 %) was completely taken care of in the ambulance or in the field, 199 (35.73 %) patients were sent to a cardiologist, 87 (15.62 %) to a pulmonologist and 10 (1.80 %) of patients to another specialist. Referral to hospital was registered more often in men (ch2 = 9.195, p = 0.027), elderly (ch2 = 53.29, p < 0.001), people with lower peripheral oxygen saturation (SpO2 ) (ch2 = 120.61, p < 0.001) and people with significant deviation of normal blood pressure values (ch2 = 120.61, p < 0.001). Conclusion: Dyspnoea can be caused by an array of different diseases and more than one diagnostic method is necessary to confirm/exclude any of the most common causes of dyspnoea. A broader diagnostical palette in ED would be preferred for purposes of ascertaining a timely diagnosis.

The lived experience of breathlessness for people diagnosed with heart failure: a qualitative synthesis of the literature

PURPOSE OF REVIEW

The experience of breathlessness in patients with heart failure is understudied. This review was aimed at evaluating the most recent qualitative findings regarding the experience of breathlessness in persons diagnosed with heart failure.

RECENT FINDINGS

A literature search was conducted using Pubmed, Psycinfo, BNI, Cinahl and Google Scholar including studies on breathlessness experience in patients with heart failure, published between 2017 and 2018. Only three studies were identified, and findings were categorized into five themes: acknowledgment of breathlessness, prevailing consequences of breathlessness, breathlessness in daily life, recognising when breathlessness is a problem and communicating breathlessness. Understanding the experience of breathlessness was different before and after heart failure diagnosis. Patients experienced similar physical and emotional consequences of breathlessness but varied in strategies to manage the symptom. Patients often do not report breathlessness symptom, or are not asked to describe their symptom by the provider.

SUMMARY

Recent studies show those at risk for and those who have heart failure need appropriate education to recognize breathlessness as a critical symptom. In addition, adequate communication between patients and providers of the breathlessness symptom is needed to support management.

The effect of inspiratory muscle training on fatigue and dyspnea in patients with heart failure: A randomized, controlled trial

AIM

Fatigue and dyspnea are debilitating symptoms in patients with heart failure (HF). The purpose of this study was to evaluate the effects of inspiratory muscle training (IMT) on dyspnea, fatigue and the New York Heart Association (NYHA) functional classification in patients with HF.

METHODS

In this prospective, randomized, controlled trial, 84 patients with HF (NYHA classes II-III/IV) with a mean age of 56.62 ± 9.56 years were randomly assigned to a 6-week IMT (n = 42) or a sham IMT (n = 42) program. The IMT was performed at 40% of the maximal inspiratory pressure (MIP) in the IMT group and at 10% in the sham group. The main outcomes were assessed at baseline and after the intervention and included dyspnea severity scale (Modified Medical Research Council [MMRC], Fatigue Severity Scale [FSS] and the NYHA functional classification (based on the presenting symptoms).

RESULTS

The between-group analysis showed significant improvements in dyspnea, fatigue and the NYHA functional classification in the IMT group compared to the sham group (P < .05). The within-group analysis showed significant improvements in dyspnea (from 2.63 ± 0.79 to 1.38 ± 0.66, P < .001), fatigue (from 43.36 ± 8.5 to 28.95 ± 9.11, P < .001) and the NYHA functional classification (from 2.73 ± 0.5 to 2.1 ± 0.6, P = .001) in the IMT group, while fatigue and dyspnea increased significantly in the sham group.

CONCLUSIONS

The 6-week home-based IMT was found to be an effective and safe tool for reducing dyspnea and fatigue and improving the NYHA functional classification.

Comparison of functional and maximal exercise capacity, respiratory and peripheral muscle strength, dyspnea, and fatigue in patients with heart failure with pacemakers and healthy controls: a cross-sectional study

Background: Despite major breakthroughs that have recently been made in pacemakers implanted in patients with heart failure (HF), it is clear that functional impairments and symptoms often remain. However, only limited studies have investigated exercise capacity, muscle strength, pulmonary function, dyspnea, and fatigue in these patients. Therefore, we aimed to compare aforementioned outcomes in patients and healthy controls. Methods: A cross-sectional study. Fifty patients with HF with pacemakers (58.90 ± 10.69 years, NYHA II-III, LVEF: 30.79 ± 8.78%) and 40 controls (56.33 ± 5.82 years) were compared. Functional (6-Minute Walking test (6-MWT)) and maximal exercise capacity (Incremental Shuttle Walk test (ISWT)), respiratory (Mouth pressure device) and peripheral muscle strength (Dynamometer), pulmonary function (Spirometry), dyspnea (Modified Medical Research Council Dyspnea scale), and fatigue (Fatigue Severity scale) were evaluated. ClinicalTrial number: NCT03701854. Results: 6-MWT (412.62 ± 96.51 m versus 610.16 ± 59.48 m) and ISWT (279.97 m versus 655 m) distances (p ˂ 0.001), pulmonary function (p˂0.001), respiratory and peripheral muscle strength (p ˂ 0.001) were significantly lower; dyspnea (p ˂ 0.001) and fatigue (p = .030) scores were higher in patients compared with controls. Conclusion: Maximal and functional exercise capacity is impaired in the majority of patients with HF with pacemakers, respiratory and peripheral muscles are weakened, dyspnea and fatigue perceptions are increased. Patients with pacemakers have to be included in cardiac rehabilitation programs to improve impairments.

Clinical characteristics of heart failure associated with functional dependence at admission in hospitalized elderly

Objective

to identify which clinical features of heart failure are associated with a greater chance of functional dependence for the basic activities of daily living in hospitalized elderly.

Method

cross-sectional study conducted with elderly hospitalized patients. The clinical characteristics of heart failure were assessed by self-report, medical records and scales. Dependency was assessed by the Katz Index. The Fisher’s Exact Test was used to analyze associations between the nominal variables, and logistic regression to identify factors associated with dependence.

Results

the sample consisted of 191 cases. The prevalence of functional dependence was 70.2%. Most of the elderly were partially dependent (66.6%). Clinical characteristics associated with dependence at admission were dyspnea (Odds Ratio 8.5, Confidence Interval 95% 2.668-27.664, p <0.001), lower limb edema (Odds Ratio 5.7, 95% Confidence Interval 2.148-15.571, p <0.001); cough (Odds Ratio 9.0, 95% confidence interval 1.053-76.938, p <0.045); precordial pain (Odds Ratio 4.5, 95% confidence interval 1.125-18.023, p <0.033), and pulmonary crackling (Odds Ratio 4.9, 95% Confidence Interval 1.704-14.094, p <0.003).

Conclusion

functional dependence in admitted elderly patients with heart failure is more associated with congestive signs and symptoms.

Airflow limitation more than doubles the risk for hospitalization/mortality in patients with heart failure

BACKGROUND

Comorbid chronic obstructive pulmonary disease is found in approximately one-third of patients with heart failure. Survival in patients with chronic obstructive pulmonary disease generally decreases as lung function declines. However, the association between lung function, hospitalization and survival is less clear for patients with heart failure.

AIM

The purpose of this study was to determine the predictive power of spirometry measures for event-free survival (combined all-cause hospitalization and/or mortality) in patients with heart failure.

METHODS

In this secondary analysis of data from three prospective, longitudinal studies, we selected patients with a confirmed diagnosis of heart failure who completed airflow limitation assessment using spirometry measures ( n=137): forced vital capacity, forced expiratory volume/second, and forced expiratory volume/second/forced vital capacity. Cox proportional hazards modeling was used to determine the relationship between spirometry and all-cause hospitalization/mortality with and without adjusting for demographic and clinical covariates over a four-year follow-up period.

RESULTS

A majority (74%) exhibited some degree of airflow limitation (forced expiratory volume/second<80% predicted value) and 26 (19%) met the spirometric criterion for chronic obstructive pulmonary disease (forced expiratory volume/second/forced vital capacity⩽0.70). Cox proportional hazards regression models compared all-cause hospitalization/mortality between those with and without airflow limitation. Patients with airflow limitation were 2.2 times more likely to be hospitalized or die compared to those without airflow limitations (hazard ratio: 2.20, 95% confidence interval 1.06-4.53, p=0.03).

CONCLUSION

Patients with comorbid heart failure and airflow limitation were at more than double the risk for an event. Spirometric measures may be useful to patients with heart failure, as tailored management of airflow limitation may impact event-free survival.

Palliative Care in Heart Failure

PURPOSE OF REVIEW

This review illustrates the dynamic role of palliative care in heart failure management and encapsulates the commonly utilized pharmacologic and non-pharmacologic therapeutic strategies for symptom palliation in heart failure. In addition, we provide our experience regarding patient care issues common to the domain of heart failure and palliative medicine which are commonly encountered by heart failure teams.

RECENT FINDINGS

Addition of palliative care to conventional heart failure management plan results in improvement in quality of life, anxiety, depression, and spiritual well-being among patients. Palliative care should not be confused with hospice care. Palliative care teams should be involved early in the care of heart failure patients with the aims of improving symptom palliation, discussing goals of care and improving quality of life without compromising utilization of evidence-based heart failure therapies. A consensus on the appropriate timing of involvement and evidence for many symptom palliation therapies is still emerging.

Association of anxiety sensitivity-physical concerns and FVC with dyspnea severity in sarcoidosis

OBJECTIVE

The purpose of the study was to evaluate the relationship of an objective functional lung parameter (FVC) and a subjective psychological factor (physical symptom concerns) with dyspnea in sarcoidosis. Dyspnea constitutes one of the most common and burdensome symptoms in sarcoidosis, yet little is known about its mechanisms and, in particular, psychological.

METHOD

A total of 107 hospitalized sarcoidosis patients (Female=50, M_age=45.3years) volunteered to take part in the correlational research study. Participants underwent spirometry and completed the MRC Dyspnea Scale and the Anxiety Sensitivity Index-3 (ASI) questionnaire. Linear hierarchical regression analysis was used to determine the relationship between the studied predictors and dyspnea severity.

RESULTS

The best fitting model predicted 18% of variance in dyspnea severity. Physical symptom concerns subscale of ASI (β=0.24) and FVC (β=-0.23) were significantly related to dyspnea MRC severity, but only physical concerns remained significantly related to dyspnea when both predictors were in the model.

CONCLUSIONS

The current results suggest that both psychological and physiological factors should be taken into account when explaining subjective dyspnea severity in sarcoidosis. More specifically, these findings call for including cognitive vulnerability factors related to anxiety (physical symptom concerns) into the diagnostic procedures and management of dyspnea in sarcoidosis.