JACC: Heart Failure Ó 2014 by the American College of Cardiology Foundation Published by Elsevier Inc.
EDITORIAL COMMENT
Observation Is Never Obsolete* Anju Nohria, MD, Lynne Warner Stevenson, MD Boston, Massachusetts
The hallmark signs and symptoms of heart failure reflect congestion, the manifestation of elevated ventricular filling pressures. These are the symptoms that trigger heart failure hospitalizations, 80% to 95% of which are characterized by congestion without hypoperfusion (the “warm and wet” profile) (1). Therapy during acute decompensated heart failure focuses on relief of these symptoms and redesign of a regimen to prevent their recurrence. Implantable hemodynamic monitoring has revealed that intracardiac filling pressures usually increasing more than 2 weeks before symptoms lead to recurrent hospitalization, whether with reduced or preserved left ventricular ejection fraction (2,3). Treatment is not limited to symptom relief, because chronic congestion also contributes to disease progression. Elevated left-sided filling pressures lead to chronic remodeling, worsened by mitral annular dilation with increased regurgitant volume, pulmonary hypertension, and elevation of right ventricular afterload (4). Backward congestion from right-sided heart failure creates hepatic dysfunction (5), malnutrition, and inflammatory stimulation, and is implicated in the cardio-renal syndrome, which heralds further congestion and decline (6). Therefore, astute assessment and intervention to treat congestion are vital to relieving patient symptoms, enhancing quality of life, and improving prognosis, leading to a class I recommendation for both acute and chronic management of heart failure (7). See pages 15 and 24
Clinical signs of elevated filling pressures can generally be directly attributed to elevated left- or right-sided heart pressures. Because the concordance between elevated rightand left-sided filling pressures is 75% to 80% in chronic heart failure (8,9), the signs and symptoms from right and left are often congruent. For instance, Drazner et al. (10) have shown previously that the most reliable sign of elevated left-sided filling pressures is the right-sided sign of elevated jugular venous pressure (JVP). Conversely, the most useful symptom *Editorials published in the Journal of the American College of Cardiology: Heart Failure reflect the views of the author and do not necessarily reflect the views of JACC: Heart Failure or the American College of Cardiology. From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts. Dr. Nohria has served as a consultant for Vertex Pharmaceuticals; and as an investigator for St. Jude Medical. Dr. Stevenson is supported for training clinical investigators by the National Heart, Lung, and Blood Institute (U01 HL084877).
Vol. 2, No. 1, 2014 ISSN 2213-1779/$36.00 http://dx.doi.org/10.1016/j.jchf.2013.12.001
for elevated left-sided pressures is orthopnea, which in a patient with a history of heart failure should be considered due to cardiac congestion unless otherwise explained. Accordingly, in the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, orthopnea predicted a pulmonary capillary wedge pressure >22 mm Hg. Peripheral edema suggests elevated right-sided heart pressures but is less specific and less sensitive than JVP for elevated left-sided filling pressures. Edema is generally absent in young patients with severely elevated filling pressures, who may instead have ascites, whereas edema often occurs in elderly patients, in whom it is related to peripheral factors in the absence of elevated central venous pressures. Symptoms of abdominal discomfort, anorexia, and early satiety are associated more specifically with elevated right-sided filling pressures (11). A new symptom. Clinical assessment remains crucial for the diagnosis and triage of heart failure. This assertion is particularly true when evaluating for decompensation in a patient who has a history of heart failure, which accounts for approximately 80% of heart failure–related hospitalizations. The study by Thibodeau et al. (12) in this issue of the Journal proposes a new item to the classic litany of heart failure symptoms: “bendopnea,” which is shortness of breath or uncomfortable head fullness within 30 s of bending forward while sitting, such as to put on shoes or stockings. This symptom was also described recently as “flexo-dyspnea,” which was associated with an increase in echocardiographic indices of left-sided filling pressures (13). In the study by Thibodeau et al., invasive hemodynamic monitoring demonstrated that bending forward increased venous return and filling pressures, provoking shortness of breath, usually in those patients who had baseline elevated filling pressures and were thus more likely to reach the threshold pressures needed to elicit symptoms. Patients with bendopnea also had a higher body mass index, which may have aggravated their discomfort when bending. Each symptom we can elicit helps to complete the clinical picture, as there is marked heterogeneity between patients regarding their perception of symptoms. We have all encountered patients who endorse 1 symptom but deny another. It is particularly useful to know that bendopnea correlates with elevated right-sided filling pressures. As facility with the jugular venous examination regrettably declines, recognition of bendopnea may help alert clinicians to the likely elevation of right-sided pressures. A portfolio of symptoms is helpful for longitudinal tracking as well. Although there is marked variability between patients in presentation, individual patients tend to have typical early warning signs as congestion occurs. For some patients, difficulty putting on their shoes may alert them to the need to re-evaluate their volume status and diuretic regimen. It is also possible that a symptom such as bendopnea could be used as a simple provocative bedside test to identify patients with elevated filling pressures in the absence of other signs or symptoms of congestion, much as
JACC: Heart Failure Vol. 2, No. 1, 2014 February 2014:32–4
careful observation during the supine physical examination will sometimes reveal increased respiratory rate in a patient unaware of orthopnea until asked. Validation of clinical signs for prognosis. The physical examination has been consistently shown to have prognostic value in heart failure assessments. A post-hoc analysis of the SOLVD (Studies Of Left Ventricular Dysfunction) treatment trial found that an elevated JVP and an audible third heart sound were each associated with an increased risk of death and hospitalization for heart failure (14). Similarly, bedside hemodynamic profiles based on physical examination findings of congestion and inadequate perfusion predicted 1-year mortality and the need for urgent transplantation in patients with heart failure (1). These findings were further supported by an analysis of the ESCAPE trial, in which patients discharged with a “wet” or “cold” profile had a 50% increased risk of death or rehospitalization compared with those with a “dry” or “warm” profile (10). A reassessment of signs and symptoms of heart failure at 1 month after hospital discharge provides further refinement of prognosis, particularly if orthopnea has recurred (15). In this issue of the Journal, Caldentey et al. (16) conducted a post-hoc analysis of patients enrolled in the AFCHF (Atrial Fibrillation and Congestive Heart Failure) trial to evaluate the prognostic value of baseline physical examination findings, including elevated JVP, third heart sound, rales, and peripheral edema, in patients with systolic heart failure. These authors confirmed that physical evidence of congestion, defined by any of the 4 physical findings, is associated with increased mortality and heart failure–related hospitalizations. Although a multivariate analysis was performed, the elevated right- and left-sided heart filling pressures are so strongly aligned that the contribution of related signs cannot be isolated. Furthermore, unlike diagnostic or prognostic tests that require additional resources, there is no need for artificial restriction of the clinical assessment. The components of the assessment are easily collected and drawn into a composite picture that conveys more than just the theoretical risk of death or hospitalization. Does the clinical picture still matter? In an era in which chemical biomarkers and imaging characterization of the heart and hemodynamics are becoming increasingly focused and refined, does the clinical picture still matter? As long as our assessment goals remain the diagnosis, prognosis, and treatment of heart failure, the symptoms and signs will remain highly relevant. To diagnose heart failure. Although supermarket screening could increase the diagnosed prevalence of disease, we will continue to elicit the symptoms and physical signs of heart failure to establish and prioritize diagnoses as patients present with their “chief complaints.” As the population accumulates comorbidities with age, such assessment is even more crucial to determine the relative contribution of each comorbidity to functional limitation. Biomarkers have been particularly helpful in raising awareness about heart failure as
Nohria and Stevenson Observation Is Never Obsolete
33
a possible new diagnosis in the setting of dyspnea. However, in the chronic management of patients with a known diagnosis of heart failure, most clinical assessments are performed to determine instead the level of compensation/decompensation and the response to interventions. To predict outcomes in heart failure. Individual biomarkers such as the natriuretic peptides have been very strong predictors of outcome. This is true ranging from asymptomatic to end-stage disease. As a potential alert to more serious disease, biomarkers can be used to define trial populations for newer therapies, patients in whom diseaseexchanging therapies such as mechanical circulatory assist devices may be considered, and those for whom a discussion of the goals of care should be initiated. However, the clinical portrait of class IV heart failure, drawn from signs and symptoms of congestion at rest or on minimal exertion, remains 1 of the most vivid and robust predictors of poor outcome. The components of this assessment as refined in the 2 accompanying studies (12,16) further enhance this portrait. To guide therapy for heart failure. A target for treatment must be clinically relevant, must respond to the therapies given, and must change quickly and consistently enough to guide serial intervention. The use of biomarkers to guide therapy remains controversial. Using absolute levels of natriuretic peptides as targets has encouraged more vigorous up-titration of guideline-recommended therapies that do not, however, achieve the biomarker targets in most patients (17). Using individualized targets based on hospital discharge levels led to the same interventions as those guided by using clinical assessment (18). There is undeniable face validity in treatment based on signs and symptoms of heart failure. It is these signs and symptoms that make the patients feel and look sick to those who care for them. Even the patients’ preferences to trade survival for comfort can be closely linked to elevated JVP and the overall burden of heart failure symptoms (19,20). Relieving the signs and symptoms of heart failure treats not only the diagnosis but also the patient. Support for the arts. It is encouraging to see these 2 studies sustain a focus on clinical assessment in heart failure, in contrasting settings. The value of physical signs has been noted in large trials focused on the therapy of heart failure, but it is commendable that the physical examination was performed in 1,376 patients with such rigor to confirm its importance in the large AF-CHF trial focused on strategies for atrial fibrillation (16). The legendary caliber of the Canadian cardiovascular training is upheld by the investigators in this trial. At the other end of the spectrum, a detailed study of 102 subjects in a dedicated advanced heart disease program illustrates how the care of each patient continues to provide new insight for the observant (12). The physiological study of the phenomenon of bendopnea encourages perpetual curiosity to discover what makes patients feel sick and what makes them feel better. Far beyond enumeration of
34
JACC: Heart Failure Vol. 2, No. 1, 2014 February 2014:32–4
Nohria and Stevenson Observation Is Never Obsolete
components for billing codes, thoughtful elicitation of the signs and symptoms of heart failure can be trusted to strengthen the transcendent link between patient and physician. Even when our patients cannot be cured, listening may help us render them able to put on their own shoes again.
9. 10. 11.
Reprint requests and correspondence: Dr. Anju Nohria, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. E-mail: [email protected].
12. 13.
REFERENCES
1. Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 2003;41:1797–804. 2. Zile MR, Bennett TD, St. John Sutton M, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 2008;118:1433–41. 3. Stevenson LW, Zile M, Bennett TD, et al. Chronic ambulatory intracardiac pressures and future heart failure events. Circ Heart Fail 2010;3:580–7. 4. Ramasubbu K, Deswal A, Chan W, Aguilar D, Bozkurt B. Echocardiographic changes during treatment of acute decompensated heart failure: insights from the ESCAPE trial. J Cardiac Fail 2012;18:792–8. 5. Battin DL, Ali S, Shahbaz AU, et al. Hypoalbuminemia and lymphocytopenia in patients with decompensated biventricular failure. Am J Med Sci 2010;339:31–5. 6. Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 2009;53:589–96. 7. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62: 1495–539. 8. Drazner MH, Hamilton MA, Fonarow G, Creaser J, Flavell C, Stevenson LW. Relationship between right and left-sided filling
14. 15. 16.
17. 18.
19. 20.
pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant 1999;18:1126–32. Campbell P, Drazner MH, Kato M, et al. Mismatch of right- and leftsided filling pressures in chronic heart failure. J Cardiac Fail 2011;17: 561–8. Drazner MH, Hellkamp AS, Leier CV, et al. Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. Circ Heart Fail 2008;1:170–7. Kato M, Stevenson LW, Palardy M, et al. The worst symptom as defined by patients during heart failure hospitalization: implications for response to therapy. J Cardiac Fail 2012;18:524–33. Thibodeau JA, Turer AT, Gualano SK, et al. Characterization of a novel symptom of advanced heart failure: bendopnea. J Am Coll Cardiol HF 2014;2:24–31. Brandon N, Mehra MR. “Flexo-dyspnea”: a novel clinical observation in the heart failure syndrome. J Heart Lung Transplant 2013;32:844–5. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;345:574–81. Lucas C, Johnson W, Hamilton MA, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J 2000;140:840–7. Caldentey G, Khairy P, Roy D, et al. Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (Atrial Fibrillation and Chronic Heart Failure). J Am Coll Cardiol HF 2014;2:15–23. Jourdain P, Jondeau G, Funck F, et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. J Am Coll Cardiol 2007;49:1733–9. Shah MR, Califf RM, Nohria A, et al. The STARBRITE trial: a randomized, pilot study of B-type natriuretic peptide-guided therapy in patients with advanced heart failure. J Card Fail 2011; 17:613–21. Lewis EF, Johnson PA, Johnson W, Collins C, Griffin L, Stevenson LW. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant 2001;20:1016–24. Stevenson LW, Hellkamp AS, Leier CV, et al. Changing preferences for survival after hospitalization with advanced heart failure. J Am Coll Cardiol 2008;52:1702–8.
Key Words: atrial fibrillation - dyspnea - heart failure hemodynamics - outcomes - physical examination.
-
EDITORIAL COMMENT
Observation Is Never Obsolete* Anju Nohria, MD, Lynne Warner Stevenson, MD Boston, Massachusetts
The hallmark signs and symptoms of heart failure reflect congestion, the manifestation of elevated ventricular filling pressures. These are the symptoms that trigger heart failure hospitalizations, 80% to 95% of which are characterized by congestion without hypoperfusion (the “warm and wet” profile) (1). Therapy during acute decompensated heart failure focuses on relief of these symptoms and redesign of a regimen to prevent their recurrence. Implantable hemodynamic monitoring has revealed that intracardiac filling pressures usually increasing more than 2 weeks before symptoms lead to recurrent hospitalization, whether with reduced or preserved left ventricular ejection fraction (2,3). Treatment is not limited to symptom relief, because chronic congestion also contributes to disease progression. Elevated left-sided filling pressures lead to chronic remodeling, worsened by mitral annular dilation with increased regurgitant volume, pulmonary hypertension, and elevation of right ventricular afterload (4). Backward congestion from right-sided heart failure creates hepatic dysfunction (5), malnutrition, and inflammatory stimulation, and is implicated in the cardio-renal syndrome, which heralds further congestion and decline (6). Therefore, astute assessment and intervention to treat congestion are vital to relieving patient symptoms, enhancing quality of life, and improving prognosis, leading to a class I recommendation for both acute and chronic management of heart failure (7). See pages 15 and 24
Clinical signs of elevated filling pressures can generally be directly attributed to elevated left- or right-sided heart pressures. Because the concordance between elevated rightand left-sided filling pressures is 75% to 80% in chronic heart failure (8,9), the signs and symptoms from right and left are often congruent. For instance, Drazner et al. (10) have shown previously that the most reliable sign of elevated left-sided filling pressures is the right-sided sign of elevated jugular venous pressure (JVP). Conversely, the most useful symptom *Editorials published in the Journal of the American College of Cardiology: Heart Failure reflect the views of the author and do not necessarily reflect the views of JACC: Heart Failure or the American College of Cardiology. From the Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts. Dr. Nohria has served as a consultant for Vertex Pharmaceuticals; and as an investigator for St. Jude Medical. Dr. Stevenson is supported for training clinical investigators by the National Heart, Lung, and Blood Institute (U01 HL084877).
Vol. 2, No. 1, 2014 ISSN 2213-1779/$36.00 http://dx.doi.org/10.1016/j.jchf.2013.12.001
for elevated left-sided pressures is orthopnea, which in a patient with a history of heart failure should be considered due to cardiac congestion unless otherwise explained. Accordingly, in the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, orthopnea predicted a pulmonary capillary wedge pressure >22 mm Hg. Peripheral edema suggests elevated right-sided heart pressures but is less specific and less sensitive than JVP for elevated left-sided filling pressures. Edema is generally absent in young patients with severely elevated filling pressures, who may instead have ascites, whereas edema often occurs in elderly patients, in whom it is related to peripheral factors in the absence of elevated central venous pressures. Symptoms of abdominal discomfort, anorexia, and early satiety are associated more specifically with elevated right-sided filling pressures (11). A new symptom. Clinical assessment remains crucial for the diagnosis and triage of heart failure. This assertion is particularly true when evaluating for decompensation in a patient who has a history of heart failure, which accounts for approximately 80% of heart failure–related hospitalizations. The study by Thibodeau et al. (12) in this issue of the Journal proposes a new item to the classic litany of heart failure symptoms: “bendopnea,” which is shortness of breath or uncomfortable head fullness within 30 s of bending forward while sitting, such as to put on shoes or stockings. This symptom was also described recently as “flexo-dyspnea,” which was associated with an increase in echocardiographic indices of left-sided filling pressures (13). In the study by Thibodeau et al., invasive hemodynamic monitoring demonstrated that bending forward increased venous return and filling pressures, provoking shortness of breath, usually in those patients who had baseline elevated filling pressures and were thus more likely to reach the threshold pressures needed to elicit symptoms. Patients with bendopnea also had a higher body mass index, which may have aggravated their discomfort when bending. Each symptom we can elicit helps to complete the clinical picture, as there is marked heterogeneity between patients regarding their perception of symptoms. We have all encountered patients who endorse 1 symptom but deny another. It is particularly useful to know that bendopnea correlates with elevated right-sided filling pressures. As facility with the jugular venous examination regrettably declines, recognition of bendopnea may help alert clinicians to the likely elevation of right-sided pressures. A portfolio of symptoms is helpful for longitudinal tracking as well. Although there is marked variability between patients in presentation, individual patients tend to have typical early warning signs as congestion occurs. For some patients, difficulty putting on their shoes may alert them to the need to re-evaluate their volume status and diuretic regimen. It is also possible that a symptom such as bendopnea could be used as a simple provocative bedside test to identify patients with elevated filling pressures in the absence of other signs or symptoms of congestion, much as
JACC: Heart Failure Vol. 2, No. 1, 2014 February 2014:32–4
careful observation during the supine physical examination will sometimes reveal increased respiratory rate in a patient unaware of orthopnea until asked. Validation of clinical signs for prognosis. The physical examination has been consistently shown to have prognostic value in heart failure assessments. A post-hoc analysis of the SOLVD (Studies Of Left Ventricular Dysfunction) treatment trial found that an elevated JVP and an audible third heart sound were each associated with an increased risk of death and hospitalization for heart failure (14). Similarly, bedside hemodynamic profiles based on physical examination findings of congestion and inadequate perfusion predicted 1-year mortality and the need for urgent transplantation in patients with heart failure (1). These findings were further supported by an analysis of the ESCAPE trial, in which patients discharged with a “wet” or “cold” profile had a 50% increased risk of death or rehospitalization compared with those with a “dry” or “warm” profile (10). A reassessment of signs and symptoms of heart failure at 1 month after hospital discharge provides further refinement of prognosis, particularly if orthopnea has recurred (15). In this issue of the Journal, Caldentey et al. (16) conducted a post-hoc analysis of patients enrolled in the AFCHF (Atrial Fibrillation and Congestive Heart Failure) trial to evaluate the prognostic value of baseline physical examination findings, including elevated JVP, third heart sound, rales, and peripheral edema, in patients with systolic heart failure. These authors confirmed that physical evidence of congestion, defined by any of the 4 physical findings, is associated with increased mortality and heart failure–related hospitalizations. Although a multivariate analysis was performed, the elevated right- and left-sided heart filling pressures are so strongly aligned that the contribution of related signs cannot be isolated. Furthermore, unlike diagnostic or prognostic tests that require additional resources, there is no need for artificial restriction of the clinical assessment. The components of the assessment are easily collected and drawn into a composite picture that conveys more than just the theoretical risk of death or hospitalization. Does the clinical picture still matter? In an era in which chemical biomarkers and imaging characterization of the heart and hemodynamics are becoming increasingly focused and refined, does the clinical picture still matter? As long as our assessment goals remain the diagnosis, prognosis, and treatment of heart failure, the symptoms and signs will remain highly relevant. To diagnose heart failure. Although supermarket screening could increase the diagnosed prevalence of disease, we will continue to elicit the symptoms and physical signs of heart failure to establish and prioritize diagnoses as patients present with their “chief complaints.” As the population accumulates comorbidities with age, such assessment is even more crucial to determine the relative contribution of each comorbidity to functional limitation. Biomarkers have been particularly helpful in raising awareness about heart failure as
Nohria and Stevenson Observation Is Never Obsolete
33
a possible new diagnosis in the setting of dyspnea. However, in the chronic management of patients with a known diagnosis of heart failure, most clinical assessments are performed to determine instead the level of compensation/decompensation and the response to interventions. To predict outcomes in heart failure. Individual biomarkers such as the natriuretic peptides have been very strong predictors of outcome. This is true ranging from asymptomatic to end-stage disease. As a potential alert to more serious disease, biomarkers can be used to define trial populations for newer therapies, patients in whom diseaseexchanging therapies such as mechanical circulatory assist devices may be considered, and those for whom a discussion of the goals of care should be initiated. However, the clinical portrait of class IV heart failure, drawn from signs and symptoms of congestion at rest or on minimal exertion, remains 1 of the most vivid and robust predictors of poor outcome. The components of this assessment as refined in the 2 accompanying studies (12,16) further enhance this portrait. To guide therapy for heart failure. A target for treatment must be clinically relevant, must respond to the therapies given, and must change quickly and consistently enough to guide serial intervention. The use of biomarkers to guide therapy remains controversial. Using absolute levels of natriuretic peptides as targets has encouraged more vigorous up-titration of guideline-recommended therapies that do not, however, achieve the biomarker targets in most patients (17). Using individualized targets based on hospital discharge levels led to the same interventions as those guided by using clinical assessment (18). There is undeniable face validity in treatment based on signs and symptoms of heart failure. It is these signs and symptoms that make the patients feel and look sick to those who care for them. Even the patients’ preferences to trade survival for comfort can be closely linked to elevated JVP and the overall burden of heart failure symptoms (19,20). Relieving the signs and symptoms of heart failure treats not only the diagnosis but also the patient. Support for the arts. It is encouraging to see these 2 studies sustain a focus on clinical assessment in heart failure, in contrasting settings. The value of physical signs has been noted in large trials focused on the therapy of heart failure, but it is commendable that the physical examination was performed in 1,376 patients with such rigor to confirm its importance in the large AF-CHF trial focused on strategies for atrial fibrillation (16). The legendary caliber of the Canadian cardiovascular training is upheld by the investigators in this trial. At the other end of the spectrum, a detailed study of 102 subjects in a dedicated advanced heart disease program illustrates how the care of each patient continues to provide new insight for the observant (12). The physiological study of the phenomenon of bendopnea encourages perpetual curiosity to discover what makes patients feel sick and what makes them feel better. Far beyond enumeration of
34
JACC: Heart Failure Vol. 2, No. 1, 2014 February 2014:32–4
Nohria and Stevenson Observation Is Never Obsolete
components for billing codes, thoughtful elicitation of the signs and symptoms of heart failure can be trusted to strengthen the transcendent link between patient and physician. Even when our patients cannot be cured, listening may help us render them able to put on their own shoes again.
9. 10. 11.
Reprint requests and correspondence: Dr. Anju Nohria, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. E-mail: [email protected].
12. 13.
REFERENCES
1. Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 2003;41:1797–804. 2. Zile MR, Bennett TD, St. John Sutton M, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation 2008;118:1433–41. 3. Stevenson LW, Zile M, Bennett TD, et al. Chronic ambulatory intracardiac pressures and future heart failure events. Circ Heart Fail 2010;3:580–7. 4. Ramasubbu K, Deswal A, Chan W, Aguilar D, Bozkurt B. Echocardiographic changes during treatment of acute decompensated heart failure: insights from the ESCAPE trial. J Cardiac Fail 2012;18:792–8. 5. Battin DL, Ali S, Shahbaz AU, et al. Hypoalbuminemia and lymphocytopenia in patients with decompensated biventricular failure. Am J Med Sci 2010;339:31–5. 6. Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 2009;53:589–96. 7. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62: 1495–539. 8. Drazner MH, Hamilton MA, Fonarow G, Creaser J, Flavell C, Stevenson LW. Relationship between right and left-sided filling
14. 15. 16.
17. 18.
19. 20.
pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant 1999;18:1126–32. Campbell P, Drazner MH, Kato M, et al. Mismatch of right- and leftsided filling pressures in chronic heart failure. J Cardiac Fail 2011;17: 561–8. Drazner MH, Hellkamp AS, Leier CV, et al. Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. Circ Heart Fail 2008;1:170–7. Kato M, Stevenson LW, Palardy M, et al. The worst symptom as defined by patients during heart failure hospitalization: implications for response to therapy. J Cardiac Fail 2012;18:524–33. Thibodeau JA, Turer AT, Gualano SK, et al. Characterization of a novel symptom of advanced heart failure: bendopnea. J Am Coll Cardiol HF 2014;2:24–31. Brandon N, Mehra MR. “Flexo-dyspnea”: a novel clinical observation in the heart failure syndrome. J Heart Lung Transplant 2013;32:844–5. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;345:574–81. Lucas C, Johnson W, Hamilton MA, et al. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J 2000;140:840–7. Caldentey G, Khairy P, Roy D, et al. Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (Atrial Fibrillation and Chronic Heart Failure). J Am Coll Cardiol HF 2014;2:15–23. Jourdain P, Jondeau G, Funck F, et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. J Am Coll Cardiol 2007;49:1733–9. Shah MR, Califf RM, Nohria A, et al. The STARBRITE trial: a randomized, pilot study of B-type natriuretic peptide-guided therapy in patients with advanced heart failure. J Card Fail 2011; 17:613–21. Lewis EF, Johnson PA, Johnson W, Collins C, Griffin L, Stevenson LW. Preferences for quality of life or survival expressed by patients with heart failure. J Heart Lung Transplant 2001;20:1016–24. Stevenson LW, Hellkamp AS, Leier CV, et al. Changing preferences for survival after hospitalization with advanced heart failure. J Am Coll Cardiol 2008;52:1702–8.
Key Words: atrial fibrillation - dyspnea - heart failure hemodynamics - outcomes - physical examination.
-
