Patterns of dyspnoea onset in patients with acute heart failure: clinical and prognostic implications

Abstract

AimsDespite attempts to improve the management of patients with acute heart failure (HF), virtually all therapeutic agents investigated in large clinical trials failed to show any consistent reduction in mortality and morbidity. Complexity of the clinical syndrome of acute HF seems to be likely an underlying explanation. Traditionally, clinical trials studied mixed patient populations with acute HF, and only recently, better clinical characterization of patients has been proposed. Dyspnoea is the most common presenting symptom related to hospital admission for acute HF. Whether in patients with acute HF, the pattern of symptoms onset preceding hospital admission is associated with clinical characteristics, and the outcomes have not yet been established.Methods and resultsWe investigated 137 patients (mean age: 65 ± 13 years; 80% men) hospitalized due to acute HF with dyspnoea as major reported symptom, who were divided according to the time of its onset into those with acute (n = 98) vs. subacute (n = 39) onset (i.e. within 7 days vs. >7 days preceding hospital admission, respectively). On admission, the former group presented higher blood pressure (138 ± 33 vs. 121 ± 32 mmHg), more often moderate–severe pulmonary congestion (33 vs. 8%), and lower bilirubin level [1.07 (0.72–1.60) vs. 1.27 (0.87–2.06); P < 0.05 in all comparisons]. There were no other differences in baseline clinical characteristics and laboratory indices. Higher percentage of patients with an acute dyspnoea onset reported marked/moderate dyspnoea relief after 6 (18% vs. 7%), 24 (59% vs. 24%), and 48 h (80% vs. 46% assessed as an improvement of at least 5 points in self‐reported 10‐point Likert scale; P < 0.05 in all time points). In patients with an acute onset of dyspnoea after 48 h, a decrease of N‐terminal pro BNP was more frequently observed (83% vs. 65%), and the levels of endothelin‐1 were more reduced [−1.1 (−2.9–0.03) vs 0.4 (−2.2–1.4); all P < 0.05]. Patients with acute onset experienced less in‐hospital HF worsening (13% vs. 40%, P = 0.001), and 1 year cardiovascular mortality was significantly lower (20% vs. 41%, P = 0.01). On the multivariable analysis, subacute pattern of dyspnoea was independent predictor of 12 month cardiovascular mortality in patients with acute HF after adjusting for other prognostic factors: systolic blood pressure, urea, and HF de novo [hazard ratio (95% confidence interval): 2.32 (1.13–4.75), P = 0.02].ConclusionsIn patients with acute HF, the pattern of symptoms onset is associated with baseline differences in clinical characteristics, biomarker profile, response to standard treatment, and the long‐term outcomes. This is relevant information for planning future clinical trials.

Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes

“…Our study provides additional interesting finding that the patients with peripheral signs of congestion experienced longer duration of dyspnoea before admission to hospital than patients with pulmonary congestion, in whom dyspnoea onset was more rapid. The aforementioned conclusion also stays in agreement with our previous paper, in which we proved that patients with subacute onset of dyspnoea (>7 days preceding hospital admission) have poorer short‐term and long‐term outcomes in comparison with patients with acute onset (≤7 days) 17 . Almost every third studied patient with AHF manifested as peripheral congestion, either isolated or concurrent with pulmonary congestion, died during 12 months after the index hospitalization.…”

“…These findings indicate the complexity of dyspnoea pathophysiology and suggest that dyspnoea is not a simple equivalent of lung congestion assessed on physical examination 21,35,36 . These data are consistent with our previous study, in which we analysed the pattern of dyspnoea onset in AHF, and we have shown that only 26% of patients with dyspnoea at rest, as a major symptom of AHF on admission, presented moderate/severe pulmonary congestion 17 . Our study provides additional interesting finding that the patients with peripheral signs of congestion experienced longer duration of dyspnoea before admission to hospital than patients with pulmonary congestion, in whom dyspnoea onset was more rapid.…”

“…21,35,36 These data are consistent with our previous study, in which we analysed the pattern of dyspnoea onset in AHF, and we have shown that only 26% of patients with dyspnoea at rest, as a major symptom of AHF on admission, presented moderate/severe pulmonary congestion. 17 Our study provides additional interesting finding that the patients with peripheral signs of congestion experienced longer duration of dyspnoea before admission to hospital than patients with pulmonary congestion, in whom dyspnoea onset was more rapid. The aforementioned conclusion also stays in agreement with our previous paper, in which we proved that patients with subacute onset of dyspnoea (>7 days preceding hospital admission) have poorer short-term and long-term outcomes in comparison with patients with acute onset (≤7 days).…”

“…The aforementioned conclusion also stays in agreement with our previous paper, in which we proved that patients with subacute onset of dyspnoea (>7 days preceding hospital admission) have poorer short-term and long-term outcomes in comparison with patients with acute onset (≤7 days). 17 Almost every third studied patient with AHF manifested as peripheral congestion, either isolated or concurrent with pulmonary congestion, died during 12 months after the index hospitalization. Our study has shown that patients with the involvement of peripheral congestion on admission to the hospital had increased the risk of all-cause death within 1 year by 2.5 times.…”

“…In order to identify a biochemical evidence of myocardial damage and alterations in congestion status, we analysed changes in cardiac biomarkers (troponin I and NT-proBNP) during the first 48 h of hospitalization in studied groups using an approach described in our previous publication. 17 The following endpoints were assessed in the study:…”