The unheard-of symptom – Bendopnea

Characterization of a Novel Symptom of Advanced Heart Failure: Bendopnea

JCHF. 2014;2(1):24-31. doi:10.1016/j.jchf.2013.07.009

Objectives:  This study sought to examine the frequency and hemodynamic correlates of shortness of breath when bending forward, a symptom that has been named by the newly coined term “bendopnea.”

Background:  Many heart failure patients describe bendopnea such as when putting on their shoes. This symptom has not previously been characterized.

Methods: This was a prospective study of 102 subjects with systolic heart failure referred for right-heart catheterization. Time to onset of bendopnea was measured prior to catheterization. Forty-six subjects also underwent hemodynamic assessment when sitting and bending. Hemodynamic profiles were assigned on the basis of whether pulmonary capillary wedge pressure (PCWP) was ≥22 mm Hg and cardiac index (CI) was ≤2.2 l/min/m2.

Results: Bendopnea was present in 29 of 102 (28%) subjects with median (25th, 75th percentiles) time to onset of 8 (7, 11) seconds. Subjects with bendopnea had higher supine right atrial pressure (RAP) (p = 0.001) and PCWP (p = 0.0004) than those without bendopnea but similar CI (p = 0.2). RAP and PCWP increased comparably in subjects with and without bendopnea when bending, but CI did not change. In those with, versus without, bendopnea, there was more than a 3-fold higher frequency of a supine hemodynamic profile consisting of elevated PCWP with low CI (55% vs. 16%, respectively, p < 0.001) but no association with a profile of elevated PCWP with normal CI (p = 0.95).

Conclusions: Bendopnea is mediated via a further increase in filling pressures during bending when filling pressures are already high, particularly if CI is reduced. Awareness of bendopnea should improve noninvasive assessment of hemodynamics in subjects with heart failure.

Fetal echocardiography

Congenital anomalies are the leading cause of infant death and congenital heart diseases accounts for 30 to 50 percent of these deaths. As the major cause of the largest single category of mortality, the identification and management of fetal cardiac abnormalities is of paramount importance. Population screening studies have shown that congenital heart disease occurs in 5/1000 to 8/1000 newborns, with about one-half causing major disease and one-half causing minor disease. Fetal echocardiography is a reasonably accurate investigation for the detection of such anomalies. The prospective parents, obstetricians and cardiologists should have some basic concepts about this extremely useful tool.

Indications for fetal echocardiography:

The common indications are divided into three categories: 1. familial 2.maternal 3.fetal. Each is elaborated below

1. Familial risk factors

●First or second degree relatives with congenital heart disease (eg, the fetus’ siblings, parents, and grandparents)

●Syndromes including congenital heart disease (eg, Noonan, tuberous sclerosis, Holt-Oram, velocardiofacial [DiGeorge] syndrome)

2. Maternal risk factors

●Maternal congenital heart disease

●Cardiac teratogen medications (e.g., lithium, methotrexate, thalidomide, drugs for seizure, isotretinoin, paroxetine, warfarin)

●Maternal medical illness (e.g., diabetes, phenylketonuria, anti Ro/SSA or anti La/SSB antibodies)

●Exposure to prostaglandin synthetase inhibitors (can cause premature closure of the ductus arteriosus in the third trimester)

●Rubella infection in the first trimester

●In vitro fertilization

3. Fetal risk factors

●Suspected cardiac anomaly during basic sonogram

●Extracardiac anomaly

●Aneuploidy

●Nonimmune hydrops

●Arrhythmia

●Abnormal fetal situs

●Increased nuchal translucency at 11 to 14 weeks of gestation

●Chromosomal abnormality

●Monochorionic twins, with or without twin-twin transfusion syndrome

What is the timing of fetal echocardiogram?

Usually between 18 to 22 weeks

How accurate is fetal echocardiography for detection of cardiac anomalies?

Studies suggest widely variable sensitivity of fetal echo ranging from 0 to 80%. A reasonable figure would be an accuracy of 40%.

How fetal echocardiography changes the outcome?

Any cardiac anomaly should be properly explained to the parents. Though parents are less interested to know the exact anatomical details of the cardiac problem. What is more important for them is the short-, mid- and long-term prognosis of the child. Also information about place of child birth, and method to be used like- normal labour, LSCS etc. Though fetal cardiac interventions have been tried , they are far from being of routine use in near future.

For doctors it is important to explain the prognosis in clear terms. One study showed that cardiac anomalies which were amenable to biventricular repair had better outcome than single ventricle physiology (Ultrasound Obstet Gynecol. 1997 Oct;10(4):237-41. PMID 9383873)

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Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options is recommended.

Conclusion:

The following interventions are recommended when a fetal cardiac anomaly is suspected:

•Full fetal echocardiography to evaluate cardiac structure and function, arterial and venous flow, and rhythm.

•Detailed scanning of the fetal anatomy to look for associated anomalies, particularly involving the digits and bones.

•Thorough family history to evaluate for familial abnormalities or syndromes.

•Thorough maternal medical history to identify chronic medical disorders, viral illnesses, or medications which are potential teratogens.

•Fetal karyotype, with screening for deletion in 22q11.2 when conotruncal anomalies are present

•Referral to a maternal-fetal medicine specialist, pediatric cardiologist, geneticist, and/or neonatologist to discuss prognosis, obstetrical and neonatal management, and options.

•Delivery at an institution that can provide neonatal cardiac care, if needed.

Dr. Anupam Jena
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Approach to Dyspnea

History taking in Cardiology Contd….

Continuing our discussion on history taking in cardiology today we will form an approach to dyspnoea.

What is Dyspnea?

A consensus statement of the American Thoracic Society defined dyspnea in the following way1:

“Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses.”

The American Thoracic Society (ATS) statement on the mechanisms, assessment, and management of dyspnea, as well as other ATS guidelines, can be accessed through the ATS web site at www.thoracic.org/statements.

It is one of the most common presentations of a variety of disorders.

What are we looking for when evaluating dyspnea?

In the approach to any symptom we should have a clear understanding of what we are looking for. Among patients who present with undue dyspnoea we are looking for one of the following major conditions:

  1. Respiratory system disease
    1. Asthma
    2. COPD
    3. Interstitial lung disease
    4. Pulmonary hypertension
  2. Cardiac disease
    1. Valvular heart disease
    2. Myocardial dysfunction either systolic or diastolic
    3. Pulmonary hypertension
    4. Pericardial diseases – though they present with symptoms of biventricular dysfunction or predominant right sided heart failure.
  3. Obesity
  4. Anaemia
  5. Deconditioning

Though this list is not complete but for all practical purposes these are the major differential diagnosis.

How to take history of dyspnoea?

General approach to record cardiac history:

In the description of any cardiac symptom you should proceed in a particular order. First describe the baseline (premorbid) functional status of the patient e.g. something like – the patient was able to walk for 5 kms, play golf, do jogging etc. without any symptoms.

Once the baseline functional status is clearly described go for symptoms. Any symptom should be described as ODP i.e. O= onset, D= duration, P= progression.

Describing the history:

  1. Onset of symptoms
  2. Duration of symptoms
  3. Progression (in terms of NYHA class and time to progression). In cardiovascular history always try to quantify symptoms in terms of NYHA class. Because it is the most widely used and validated.
  4. Describe the dyspnea in patient’s language. Try to ascertain that the patient actually has dyspnea. Sometimes the patient may be having predominant fatigue. Some of the common patient expressions of  dyspnea are like-
    • My breathing is shallow.
    • I feel an urge to breathe more.
    • My chest is constricted.
    • My breathing requires effort.
    • I feel a hunger for more air.
    • I feel out of breath.
    • I cannot get enough air.
    • My breath does not go in all the way.
    • My chest feels tight.
    • My breathing requires work.
    • I feel that I am smothering/suffocating.
    • I feel that I cannot get a deep breath.
    • I feel that I am breathing more.
    • My breath does not go out all the way.
    • My breathing is heavy.
    • Other descriptions

The language of dyspnoea can give a clue to the diagnosis e.g.

    1. Chest tightness or constriction is described in  Bronchoconstriction, interstitial oedema (e.g. Asthma, Myocardial ischemia)
    2. Increased work or effort of breathing is the description in – Airways obstruction, neuromuscular disease, reduced chest wall or pulmonary compliance (COPD, moderate to severe asthma, myopathy, pulmonary fibrosis)
    3. Air hunger, need to breathe, urge to breathe is seen in – increased drive to breathe (HF, pulmonary embolism, moderate to severe asthma or COPD)
    4. Rapid, shallow breathing- reduced chest wall or pulmonary compliance       (Interstitial fibrosis)
    5. Suffocating, smothering- Alveolar oedema (Pulmonary oedema)
    6. Heavy breathing, breathing more- Inadequate oxygen delivery to the muscles- Deconditioning

So carefully listen to the language patients use to describe the symptoms.

5. Variation in dyspnea – positional, diurnal or seasonal variation
6. Associated cough. If cough is there – dry or productive
7. Any history of wheezing
8. Haemoptysis
9. Orthopnoea or PND,History of PND is suggestive of cardiac disease. So always carefully ask for PND
10. Finally mention the present functional status of the patient.
Go to the next symptom like chest pain, palpitation , fatigue etc……only after you finish describing dyspnea

Once you are finished with describing the symptom of dyspnoea, formulate a short summary of the symptom. I will give an example of a summary – “patient had dyspnea which was insidious in onset and progressed from NYHA II to III/IV in …..Years, it is associated with h/o orthopnoea/PND, presently he is NYHA III.”

I hope this discussion is useful to you. Any suggestion, comments or correction is most welcome.

Dr. Anupam Jena
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Reference:

1.         Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine 2012;185:435-52.

 

History taking in Cardiology

History taking in any branch of medicine is the single most important exercise. Most clinical books open with the idea of history taking. In the initial part of medical training students sometimes fail to understand the importance of history taking. But as we go higher in our training we understand the importance of history gradually.

Why a good history is important?

A good history gives the diagnosis, or a list of differential diagnosis in most of the cases. Then you can channelize your investigations in that direction. Another practical need is for facing your clinical assessments and exams. The more you learn of a subject the more you understand about the history. History taking is a difficult job for the beginner. The skill improves with your knowledge in a field of medicine. These posts on “history taking in cardiology” will be an honest attempt by me to discuss the beauty and depth of history taking in cardiology.

How to take history in cardiology?

It is always safer to follow the standard format of history taking.

Patient particulars:

  1. Name
  2. Age
  3. Sex
  4. Address
  5. Educational status of the patient
  6. Occupation
  7. History given by self or parents/relatives
  8. If history given by relatives what do you think of the reliability of information given

When presenting your case in exams make this part of presentation sound like well-articulated sentences, e.g. the patient mr./mrs x.. ,is  a 55… years old male/female. He/she is a resident of y.. he is educated upto … and he/she works as ….history has been given by self/relative.

Make your presentation in a calm and composed manner, don’t sound haphazard and disorganized.

Presenting Complains:

Write the presenting complains in the proper chronological order. All of you might be aware of the chronological order in which symptoms are written. Usually the longest duration symptoms are mentioned first, followed by the second and so on.

Then comes history of present illness (HOPI)

In HOPI you should try to be systematic and proceeding in a well-directed manner. Now is the time to elaborate your presenting complains. It’s like what you want to keep as your diagnosis and differential diagnosis you talk more about them.

Those points we will discuss subsequently.

Basically history of present illness is analysis of symptoms.

What are symptoms of cardiovascular disease?

The presenting symptoms of cardiovascular disorders are

  1. Dyspnoea
  2. Chest pain
  3. Palpitation
  4. Fatigue
  5. Presyncope/Syncope/dizziness
  6. Pedal edema
  7. Neck pulsations
  8. Cyanosis
  9. Murmur
  10. Chest bulging, stunted growth, cyanotic spell – in paediatric cases

We will discuss about these symptoms one by one and how to analyse them

Past history:

Past history should include information about relevant diseases and conditions like diabetes mellitus, hypertension, bronchial asthma, tuberculosis, and other past medical and surgical conditions. In Indian setup history of rheumatic fever and treatment for same like penicillin prophylaxis should be sought.

Family history (Socio-economic history):

Is very important for cardiovascular diseases.

Personal history:

It includes questions about diet, addictions and substance abuse, etc.

Treatment history:

Ask about all previous investigations, drugs taken, procedures done

Summary of the entire history

Analysis of history

Differential diagnosis from history

Then proceed to physical examination

I will describe each component of the above outline in my subsequent posts

So keep reading. Any feedback or suggestion is welcome

Thank you

DR. ANUPAM JENA
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