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International Journal of Cardiology Sep 2023HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to...
BACKGROUND
HFA-PEFF and cardiopulmonary exercise testing (CPET) are comprehensive diagnostic tools for heart failure with preserved ejection fraction (HFpEF). We aimed to investigate the incremental prognostic value of CPET for the HFA-PEFF score among patients with unexplained dyspnea with preserved ejection fraction (EF).
METHODS
Consecutive patients with dyspnea and preserved EF (n = 292) were enrolled between August 2019 and July 2021. All patients underwent CPET and comprehensive echocardiography, including two-dimensional speckle tracking echocardiography in the left ventricle, left atrium and right ventricle. The primary outcome was defined as a composite cardiovascular event including cardiovascular-related mortality, acute recurrent heart failure hospitalization, urgent repeat revascularization/myocardial infarction or any hospitalization due to cardiovascular events.
RESULTS
The mean age was 58 ± 14.5 years, and 166 (56.8%) participants were male. The study population was divided into three groups based on the HFA-PEFF score: < 2 (n = 81), 2-4 (n = 159), and ≥ 5 (n = 52). HFA-PEFF score ≥ 5, VE/VCO slope, peak systolic strain rate of the left atrium and resting diastolic blood pressure were independently associated with composite cardiovascular events. Furthermore, the addition of VE/VCO and HFA-PEFF to the base model showed incremental prognostic value for predicting composite cardiovascular events (C-statistic 0.898; integrated discrimination improvement 0.129, p = 0.032; net reclassification improvement 1.043, p ≤ 0.001).
CONCLUSIONS
CPET could be exploited for the HFA-PEFF approach in terms of incremental prognostic value and diagnosis among patients with unexplained dyspnea with preserved EF.
Topics: Humans; Male; Adult; Middle Aged; Aged; Female; Stroke Volume; Ventricular Function, Left; Heart Failure; Prognosis; Exercise Test; Dyspnea
PubMed: 37230429
DOI: 10.1016/j.ijcard.2023.05.038 -
Clinical Research in Cardiology :... Sep 2023Dyspnea is a frequent symptom in patients with stable coronary artery disease (CAD) and is recognized as a possible angina equivalent. (Clinical Trial)
Clinical Trial
BACKGROUND
Dyspnea is a frequent symptom in patients with stable coronary artery disease (CAD) and is recognized as a possible angina equivalent.
OBJECTIVES
This study was to assess the impact of percutaneous coronary intervention (PCI) on dyspnea, quality of life, and angina pectoris in patients with stable CAD.
METHODS
The prospective, multi-center PLA-pCi-EBO-pilot trial included 144 patients with symptomatic stable CAD and successful PCI. The prespecified endpoints angina pectoris (Seattle Angina Questionnaire-SAQ) and dyspnea (NYHA scale) were assessed 6 months after PCI. Predictors for symptomatic improvement were assessed with uni- and multivariable logistic regression analyses.
RESULTS
Patients with concomitant dyspnea had worse SAQ physical limitation scores at baseline (49.5 ± 21.0 vs 58.9 ± 22.0, p = 0.013) but showed no difference for angina frequency or quality of life. Overall, symptomatic burden of angina pectoris and dyspnea was alleviated by PCI. However, patients with concomitant dyspnea had markedly worse scores for physical limitation (78.9 ± 25.0 vs 94.3 ± 10.6, p < 0.001), angina frequency (77.9 ± 22.8 vs 91.1 ± 12.4, p < 0.001), and quality of life (69.4 ± 24.1 vs 82.5 ± 14.4, p < 0.001) after PCI. The prevalence of dyspnea (NYHA class ≥ 2) declined from 73% before PCI to 54%. Of 95 initially dyspneic patients, 57 (60%) improved at least one NYHA class 6 months after PCI. In a multivariable logistic regression analysis, "atypical angina pectoris" was associated with improved NYHA class, whereas "diabetes mellitus" had a negative association.
CONCLUSION
PCI effectively reduced dyspnea, which is a frequent and demanding symptom in patients with CAD. The German Clinical Trials Register registration number is DRKS0001752 ( www.drks.de ).
Topics: Humans; Angina Pectoris; Coronary Artery Disease; Dyspnea; Health Status; Percutaneous Coronary Intervention; Prospective Studies; Quality of Life; Treatment Outcome
PubMed: 36100700
DOI: 10.1007/s00392-022-02107-x -
Journal of Pain and Symptom Management Sep 2023Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV)... (Review)
Review
OBJECTIVE
Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU.
SETTING AND DESIGN
Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.
PARTICIPANTS
Adults (age 18 and over) undergoing WMV in the ICU.
MEASUREMENTS
Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.
RESULTS
Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients.
CONCLUSION
High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.
Topics: Humans; Aged; Adolescent; Respiration, Artificial; Intensive Care Units; Dyspnea; Communication; Death
PubMed: 37244527
DOI: 10.1016/j.jpainsymman.2023.05.009 -
Intensive Care Medicine Feb 2024This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in... (Review)
Review
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
Topics: Adult; Humans; Respiration, Artificial; Medicine; Intensive Care Units; Dyspnea; Pain
PubMed: 38388984
DOI: 10.1007/s00134-023-07246-x -
Postgraduate Medicine Nov 2023Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality globally. In the major revision of the Global Initiative for Chronic... (Review)
Review
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality globally. In the major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report, the scientific committee concluded that the use of long-acting β-agonist/inhaled corticosteroids (LABA/ICS) is not encouraged in patients with COPD. However, current prescribing patterns reveal significant use of LABA/ICS. In this paper, the evidence behind the current practice and the latest treatment recommendations is reviewed. We compare the efficacy and safety of combination therapy with long-acting muscarinic antagonist (LAMA) and LABA vs LABA/ICS and note that LAMA/LABA combinations have reduced the annual rate of moderate/severe exacerbations, delayed the time to first exacerbation, and increased post-dose FEV vs ICS-based regimens. The GOLD 2023 report recommends treatment with LABA and LAMA combination (preferably as a single inhaler) in patients with persistent dyspnea, with initiation of ICS in patients based on the symptoms (dyspnea and exercise intolerance as indicated by modified Medical Research Council [mMRC] score ≥ 2 and COPD Assessment Test [CAT™] > 20), blood eosinophil count (≥ 300 cells/µL), and exacerbation history (history of hospitalizations for exacerbations of COPD and ≥ 2 moderate exacerbations per year despite appropriate long-acting bronchodilator maintenance therapy). We describe practical recommendations for primary care physicians to optimize therapy for their patients and prevent overuse of ICS-based regimens. We advocate adherence to current recommendations and a greater focus on effective treatments to successfully control symptoms, minimize exacerbation risk, preserve lung function, maximize patient outcomes, and reduce the burden of drug-related adverse events.
Topics: Humans; Adrenergic beta-2 Receptor Agonists; Pulmonary Disease, Chronic Obstructive; Muscarinic Antagonists; Administration, Inhalation; Drug Therapy, Combination; Adrenal Cortex Hormones; Dyspnea; Bronchodilator Agents
PubMed: 38032494
DOI: 10.1080/00325481.2023.2284650 -
Emergency Medicine Journal : EMJ Nov 2023
Topics: Male; Humans; Dyspnea; Asthma
PubMed: 38016723
DOI: 10.1136/emermed-2023-213304 -
European Journal of Pharmacology Dec 2023Dapagliflozin may confer additional decongestive and natriuretic benefits to patients with acute heart failure (AHF). Nonetheless, this hypothesis was not clinically... (Randomized Controlled Trial)
Randomized Controlled Trial
AIMS
Dapagliflozin may confer additional decongestive and natriuretic benefits to patients with acute heart failure (AHF). Nonetheless, this hypothesis was not clinically examined. This study aimed primarily to investigate the effect of dapagliflozin on symptomatic relief in those patients.
METHODS
This was a randomized, double-blind study that included 87 patients with AHF presenting with dyspnea. Within 24 h of admission, patients were randomized to receive either dapagliflozin (10 mg/day, N = 45) or placebo (N = 42) for 30 days. The primary outcome was the difference between the two groups in the area under the curve (AUC) of visual analogue scale (VAS) dyspnea score over the first 4 days. Secondary endpoints included urinary sodium (Na) after 2 h of randomization, percent change in NT-proBNP, cumulative urine output (UOP), and differences in mortality and hospital readmission rates.
RESULTS
The results showed that dapagliflozin significantly reduced the AUC of VAS dyspnea score compared to placebo (3192.2 ± 1631.9 mm × h vs 4713.1 ± 1714.9 mm × h, P < 0.001). The relative change of NT-proBNP compared to its baseline was also larger with dapagliflozin (-34.89% vs -10.085%, P = 0.001). Additionally, higher cumulative UOP was found at day 4 (18600 ml in dapagliflozin vs 13700 in placebo, P = 0.031). Dapagliflozin decreased rehospitalization rates within 30 days after discharge, while it did not affect the spot urinary Na concentration, incidence of worsening of heart failure, or mortality rates.
CONCLUSION
Dapagliflozin may provide symptomatic relief and improve diuresis in patients with AHF. Further studies are needed to confirm these findings. https://clinicaltrials.gov/study/NCT05406505.
Topics: Humans; Benzhydryl Compounds; Dyspnea; Glucosides; Heart Failure; Stroke Volume; Double-Blind Method
PubMed: 37923161
DOI: 10.1016/j.ejphar.2023.176179 -
International Journal of Chronic... 2023Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow obstruction with a high morbidity and mortality and significant economic burden. Although... (Review)
Review
Chronic obstructive pulmonary disease (COPD) is a disease defined by airflow obstruction with a high morbidity and mortality and significant economic burden. Although pulmonary function testing is the cornerstone in diagnosis of COPD, it cannot fully characterize disease severity or cause of dyspnea because of disease heterogeneity and variable related and comorbid conditions affecting cardiac, vascular, and musculoskeletal systems. Cardiopulmonary exercise testing (CPET) is a valuable tool for assessing physical function in a wide range of clinical conditions, including COPD. Familiarity with measurements made during CPET and its potential to aid in clinical decision-making related to COPD can thus be useful to clinicians caring for this population. This review highlights pulmonary and extrapulmonary impairments that can contribute to exercise limitation in COPD. Key elements of CPET are identified with an emphasis on measurements most relevant to COPD. Finally, clinical applications of CPET demonstrated to be of value in the COPD setting are identified. These include quantifying functional capacity, differentiating among potential causes of symptoms and limitation, prognostication and risk assessment for operative procedures, and guiding exercise prescription.
Topics: Humans; Pulmonary Disease, Chronic Obstructive; Exercise Test; Lung; Respiratory Function Tests; Dyspnea; Exercise Tolerance
PubMed: 38089541
DOI: 10.2147/COPD.S432841 -
Journal of Cardiac Failure Sep 2023Prior studies indicate significant physiological differences between obese and nonobese patients with heart failure (HF), but none have evaluated differences in...
BACKGROUND
Prior studies indicate significant physiological differences between obese and nonobese patients with heart failure (HF), but none have evaluated differences in hemodynamic patterns in these patient populations during treatment for acute decompensated HF (ADHF).
OBJECTIVES
In this study, we assessed differences in hemodynamic trends between obese and nonobese patients during treatment for ADHF.
METHODS
Obese (body mass index (BMI) >30, n = 63) and nonobese (BMI < 25, n = 69) patients with ADHF in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) study who had pulmonary artery catheterization data available through the duration of treatment were evaluated. Hemodynamics were analyzed at baseline and optimal day. Changes in BNP levels, weight, creatinine, BUN, 6MWT, orthopnea and dyspnea scores were assessed.
RESULTS
Despite similar baseline hemodynamics, obese patients had significantly less absolute and relative pulmonary arterial wedge pressure (PAWP) reduction (-16 ± 28 vs -32 ± 29%; P = 0.03) during treatment. Obese patients also had higher PAWPs (19.9 + 8 vs 15.5 + 6.8 mmHg; P = 0.01) and PA pressures at optimization compared with nonobese patients. Obese and nonobese patients had similar relative improvements in weight, BNP, 6-minute walk test distance, dyspnea and orthopnea scores, and similar changes in creatinine and BUN levels.
CONCLUSIONS
Obese patients treated for ADHF display less reduction in invasively measured left heart filling pressures, despite similar improvements in symptoms, weight loss, and noninvasive surrogates of congestion. Our findings suggest a degree of decoupling between left heart filling pressures and congestive symptoms in obese patients undergoing treatment for ADHF.
Topics: Humans; Heart Failure; Creatinine; Obesity; Hemodynamics; Dyspnea
PubMed: 36963608
DOI: 10.1016/j.cardfail.2023.02.016 -
Palliative Medicine Oct 2023Opioids are recommended to treat advanced refractory dyspnoea despite optimal therapy by the American Thoracic Society clinical practice guidelines, while newly... (Meta-Analysis)
Meta-Analysis Review
Effectiveness and safety of opioids on breathlessness and exercise endurance in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis of randomised controlled trials.
BACKGROUND
Opioids are recommended to treat advanced refractory dyspnoea despite optimal therapy by the American Thoracic Society clinical practice guidelines, while newly published randomised controlled trials of opioids in chronic obstructive pulmonary disease yield conflicting results.
AIM
This study aimed to evaluate the effectiveness and safety of opioids for patients with chronic obstructive pulmonary disease.
DESIGN
Systematic review and meta-analysis (PROSPERO CRD42021272556).
DATA SOURCES
Databases of PubMed, EMBASE and CENTRAL were searched from inception to 2022 for eligible randomised controlled trials.
RESULTS
Twenty-four studies including 975 patients, were included. In cross-over studies, opioids improved breathlessness (standardised mean difference, -0.43; 95% CI, -0.55 to -0.30; = 18%) and exercise endurance (standardised mean difference, 0.22; 95% CI, 0.02-0.41; = 70%). However, opioids failed to improve dyspnoea (standardised mean difference, -0.02; 95% CI, -0.22 to 0.19; = 39%) and exercise endurance (standardised mean difference, 0.00; 95% CI, -0.27 to 0.27; = 0%) in parallel control studies that administered sustained-release opioids for more than 1 week. The opioids used in most crossover studies were short-acting and rarely associated with serious adverse effects. Only minor side effects such as dizziness, nausea, constipation and vomiting were identified for short-acting opioids.
CONCLUSIONS
Sustained-release opioids did not improve dyspnoea and exercise endurance. Short-acting opioids appeared to be safe, have potential to lessen dyspnoea and improve exercise endurance, supporting benefit in managing episodes of breathlessness and providing prophylactic treatment for exertional dyspnoea.
Topics: Humans; Analgesics, Opioid; Delayed-Action Preparations; Pulmonary Disease, Chronic Obstructive; Dyspnea; Exercise; Quality of Life; Randomized Controlled Trials as Topic
PubMed: 37710987
DOI: 10.1177/02692163231194838