Evolution of bendopnea during admission in patients with decompensated heart failure

Bendopnea prevalence and prognostic value in older patients with heart failure: FRAGILE-HF-SONIC-HF post hoc analysis

AIMS

This study aimed to investigate the prevalence, clinical characteristics, and prognostic value of bendopnea in older patients hospitalized for heart failure.

METHODS

This post hoc analysis was performed using two prospective, multicenter, observational studies: the FRAGILE-HF (main cohort) and SONIC-HF (validation cohort) cohorts. Patients were categorized based on the presence of bendopnea, which was evaluated before discharge. The primary endpoint was 2-year all-cause mortality after discharge.

RESULTS

Among the 1,243 patients (median age, 81 years; 57.2% male) in the FRAGILE-HF cohort and 225 (median age, 79 years; 58.2% men) in the SONIC-HF cohort, bendopnea was observed in 31 (2.5%) and 10 (4.4%) patients, respectively. Over a 2-year follow-up period, all-cause death occurred in 20.8% and 21.9% of the patients in the FRAGILE-HF and SONIC-HF cohorts, respectively. Kaplan-Meier survival curves demonstrated significantly higher mortality rates in patients with bendopnea than in those without bendopnea in the FRAGILE-HF (log-rank P = 0.006) and SONIC-HF cohorts (log-rank P = 0.014). Cox proportional hazard analysis identified bendopnea as an independent prognostic factor for all-cause mortality in both the FRAGILE-HF (hazard ratio [HR] 2.11, 95% confidence interval [CI] 1.18-3.78, P = 0.012) and SONIC-HF cohorts (HR 4.20, 95% CI 1.63-10.79, P = 0.003), even after adjusting for conventional risk factors.

CONCLUSIONS

Bendopnea was observed in a relatively small proportion of older patients hospitalized for heart failure before discharge. However, its presence was significantly associated with an increased risk of all-cause mortality.

Medical management of acute heart failure

Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.

[Risk Assessment of Development of the Major Adverse Cardiac Events in Patients with Chronic Heart Failure with a Preserved and Intermediate Ejection Fraction in the Presence of a Bendopnea Symptom]

Aim To evaluate the risk of major cardiovascular complications (CVC) in patients with chronic heart failure (CHF) with intermediate and preserved ejection fraction (EF) depending on the presence of bendopnea symptom.Material and methods The study included 104 patients with stage II CHF and left ventricular EF ≥40 %. Mean age of the patients was 72.8±10.6 years. A test for detection of bendopnea symptom was performed for all patients. Two groups were formed: group 1, 69 patients with the bendopnea symptom and group 2, 35 patients with a negative test. Follow-up duration was 24 months. The composite endpoint (CEP) was death and hospitalization for any CVC.Results Mean time to the bendopnea symptom was 17.3±6.61 s. At two years of follow-up, the CEP was observed in 36 (34.6 %) patients, including 30 (43.5 %) patients in group 1 and 6 (17.1 %) patients in group 2. 12 patients died, and 9 of them had the bendopnea symptom. 21 patients of group 1 were hospitalized for CVC. Risk of CEP was significantly 1.7 times higher for men (relative risk, RR 1.7 [1.1; 2.6]) than for women. The presence of bendopnea symptom increased the risk of CEP 1.4 times (ОР 1.4 [1.1;1.9]) for women and 2.3 times (RR 2.3 [1.4; 3.6]) for men.Conclusion Results of the study demonstrated an unfavorable effect of bendopnea symptom on risk of CEP during the two-year follow-up of CHF patients with preserved and intermediate EF.

Clinical significance of bendopnea in heart failure-Systematic review and meta-analysis

Background

Bendopnea is a symptom mediated by increased ventricular filling pressure during bending forward. Presence of bendopnea in patients can be easily evaluated without additional maneuver in several countries whose norms, habits, culture, and occupation relates to a higher frequency of bending forward. This information may prove valuable in routine clinical practice. We aimed to analyze the latest evidence on bendopnea in order to further define the clinical significance of this symptom.

Methods

We performed a comprehensive search on bendopnea in heart failure from inception up until January 2019 through PubMed, EuropePMC, EBSCOhost, Cochrane Central Database, and ClinicalTrials.gov.

Results

There were 283 patients (31.76%) who have bendopnea, and a total of 891 patients from six studies were included. Bendopnea was associated with the presence of dyspnea [odds ratio (OR) 69.70 (17.35–280.07); <0.001], orthopnea [OR 3.02 (2.02–4.52); <0.001], paroxysmal nocturnal dyspnea [OR 2.76 (1.76–4.32); <0.001], and abdominal fullness [OR 7.50 (4.15–13.58); <0.001]. Association with elevated jugular venous pressure was shown in two studies. New York Heart Association (NYHA) functional class IV was more prevalent in patients with bendopnea [OR 7.58 (4.35–13.22); <0.001]. Bendopnea was also associated with increased mortality [OR 2.21 (1.34–3.66); 0.002].

Conclusion

Bendopnea is associated with the presence of several signs and symptoms. This study also showed that bendopnea is one of the signs and symptoms of advanced heart failure associated with increased mortality. However, owing to the limited number of studies, further investigation is needed before drawing a definite conclusion.