Assessment of Dyspnea Early in Acute Heart Failure: Patient Characteristics and Response Differences Between Likert and Visual Analog Scales

Abstract

Background Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the ED phase of management. Objectives The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e. five point absolute Likert scale, 10 cm visual analogue scale [VAS], or seven point relative Likert scale). Methods This was a post-hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within one hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement. Results Of the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, though there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five point Likert scale (c-index ranged from 0.708 to 0.831 for each scale). Conclusions Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.

Is there a clinically meaningful difference in patient reported dyspnea in acute heart failure? An analysis from URGENT Dyspnea

“…Another related finding was the lack of concordance between the scales. As discussed in a prior analysis, 10 such discordance suggests each scale may capture different aspects of this subjective symptom.…”

“…9 As a subjective, patient reported symptom, how exactly to assess and measure dyspnea continues to be debated. [9][10][11] While clinical trials now use a more standardized method of dyspnea assessment -formal training, standardized position, only after a period of rest 7 -use of dyspnea as a clinical trial endpoint has fallen out of favor, in part due to the difficulty of demonstrating a significant difference between investigational agents and usual care. 12,13 However, as the predominant AHF symptom, relief from dyspnea is important to patients.…”

Probenecid Improves Cardiac Function in Patients With Heart Failure With Reduced Ejection Fraction In Vivo and Cardiomyocyte Calcium Sensitivity In Vitro

“…The oral probenecid (Watson Pharmaceuticals, Parsippany, NJ) daily dose was 2 g (1 g twice per day), which based on previous publications corresponds to a mean serum concentration of 149 ng/mL 25. Prior dosing studies in animals revealed an EC50 of 49.33 mg/kg or ≈3 to 4 g daily for an average‐weight individual.…”

Patient Selection in Heart Failure With Preserved Ejection Fraction Clinical Trials

“…There are multiple dyspnea scales; those commonly used are the 5-point and 7-point Likert scales, and the 10-cm visual analog scale. A post-hoc analysis of URGENT (Ularitide Global Evaluation in Acute Decompensated Heart Failure) Dypsnea revealed that up to 40% of patients did not have improved dyspnea in the first 6 h; for those who did improve, patient characteristics differed across all 3 scales, with the c-index ranging from 0.71 to 0.83, suggesting that improvement in dyspnea may differ from scale to scale (43). The RELAX-AHF trial evaluating serelaxin used a visual analog scale area under the curve (VAS-AUC) endpoint to assess if serelaxin-treated patients would have improved dyspnea with baseline dyspnea, congestion on chest radiograph, elevated NP levels to Day 5 of the VAS-AUC, and the proportion of patients with moderate or marked dyspnea by the Likert scale during the first 24 h (44).…”