HFSA: Difficulty breathing is worst symptom for in-hospital HF patients

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BOSTON—Difficulty breathing or fatigue were defined as the “worst” symptoms for 84 percent of hospitalized heart failure patients with objective evidence of congestion, according to a scientific poster presentation on Monday at the 13 th annual meeting of the Heart Failure Society of America (HFSA).

There is conflicting information regarding whether demonstration of symptomatic improvement may reflect heterogeneity of dominant symptoms for heart failure patients, which might be useful to guide therapy, the authors wrote.

Mahoto Kato, MD, and colleagues from the department of cardiovascular medicine at Brigham and Women’s Hospital in Boston sought to determine distribution of worst symptoms in patients admitted with decompensation of chronic heart failure with low ejection fraction; relationship of worst symptoms or admission to hemodynamic profiles; and likelihood of improvement in relation to the worst symptom.

The ESCAPE (Evaluation Study of Congestive heart fAilure and Pulmonary artery catheterization Effectiveness) trial was a randomized multicenter evaluation of the efficiency and safety of pulmonary artery catheter-guided therapy versus clinical assessment alone in 433 patients hospitalized with severe decompensated heart failure.

The patients were asked to choose their worst symptom on admission from four choices: difficulty breathing, fatigue, abdominal discomfort and body swelling. They also were asked to indicate overall comfort on a visual analog scale (VAS). The researchers measured patient characteristics at baseline, and compared among the four groups using parametric or non-parametric analysis of variance. Also, they noted that for patients in whom “difficulty breathing” was their worst symptom, dyspnea VAS scale was still administered, to help internal validation of the patient understanding of the tools.

Among the 371 eligible patients, Kato and colleagues found that 52 percent reported difficulty breathing/dyspnea as the worst symptom, while 32 percent said fatigue, 8 percent said body swelling and 8 percent said abdominal discomfort.

The clinical and lab characteristics were not significantly different, except that BUN and serum sodium were worse in the body swelling group. Also, patients with abdominal discomfort tended to have worse global assessment. However, according to the authors, neither filling pressures nor cardiac output were different between symptom groups.

The researchers said that despite presumed differences in congestion and perfusion, the perceived worst symptoms did not define distinct hemodynamic profiles. Based on their findings, Kato and colleagues concluded that at the time of decompensation, the nature of the worst symptom should not influence selection and intensity of initial therapy. For instance, fatigue may not indicate lower cardiac output.

Finally, they wrote that a patient’s global assessment score appears adequate to capture improvement, regardless of the specific nature of the worst symptom.