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Pathophysiology and Clinical Evaluation of the Patient with Acute Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Georgios Bakosis, Vasiliki Bistola, Eftyhia Polyzogopoulou, John Parissis
The primary target in each patient with suspected AHF is to assess hemodynamic and respiratory status and provide appropriate management if hemodynamic instability or respiratory distress are present. In such cases, urgent admission to and management in an intensive care unit is required. Assessment of vital signs (pulse oximetry and systolic blood pressure [SBP]) is the first step in the diagnostic evaluation of AHF. Unfavorable findings include low (<100 mmHg) SBP and high (>25 breaths/min) or disproportionately low (<8 breaths/min) respiratory rate despite evident dyspnea, along with accessory muscles use to augment breathing, indicating the need for supportive ventilation.30 After initial assessment, an in-depth clinical evaluation should follow to assess the presence of symptoms and signs of HF. Clinical manifestations most frequently reflect volume overload and/or redistribution (peripheral congestion and/or pulmonary edema), and less often low cardiac output with peripheral hypoperfusion. Dyspnea of any kind (breathlessness on exertion, orthopnea, paroxysmal nocturnal dyspnea, bendopnea, nocturnal cough) indicates elevated ventricular filling pressures and is usually the main reason to seek medical help. Physical examination may reveal tachycardia, sometimes with irregular pulse, a displaced apical impulse due to cardiac enlargement and a late (S4) or early (S3) diastolic sound. A murmur due to valvular regurgitation may be present. Tachypnea, hypoxia, use of accessory respiratory muscles, and pathological lung auscultation (rales, crackles, dullness of lung bases due to pleural effusion, wheezing) may be present. Right-sided congestion is evident as jugular vein distention, hepatojugular reflux, bilateral peripheral edema, ascites, hepatomegaly with icterus, and increased body weight. Finally, clinical manifestations of hypoperfusion include hypotension (SBP <90 mmHg), narrow pulse pressure, cold extremities, oliguria (<30 mL/h or 0.5 mL/kg/h), dizziness, and confusion.1
Cardiac Disease
Published in Vincenzo Berghella, Maternal-Fetal Evidence Based Guidelines, 2022
Preethi Pirlamarla, Gregary D. Marhefka
Dilated cardiomyopathy (DCM) is characterized by abnormal cardiac structure and function in the absence of other known causes. In dilated cardiomyopathy, cardiac structure is abnormal with left ventricular dilatation. Dilated cardiomyopathy differs from peripartum cardiomyopathy in timing of diagnosis; while peripartum cardiomyopathy developed within the last month of pregnancy to the first five months after birth, dilated cardiomyopathy is pre-existing. As discussed previously, plasma volume increases throughout the course of pregnancy. Patients with pre-existing DCM can be intolerant of this increase in volume. This increase in volume, plus the need for cessation of neurohormonal blockade therapy used in heart failure due their risk of teratogenicity, can precipitate heart failure exacerbations in patients with DCM. It is imperative to monitor patients for symptoms of heart failure (orthopnea, bendopnea, paroxysmal nocturnal dyspnea) and differentiate from symptoms of normal pregnancy, particularly towards the end of gestation when circulating volume is highest (Table 2.1) [39]. Pregnancy in patients with pre-existing cardiomyopathy carries a high rate of morbidity and mortality, with adverse events including progression of cardiomyopathy, ventricular and atrial arrhythmias, and sudden cardiac death, and can occur in as high as 60% of patients with DCM [39]. Therefore, pre-pregnancy counseling is imperative, as well as close, frequent follow-up with serial echocardiography as often as monthly to monitor for symptoms [40]. Management of patients with DCM should be team based and multidisciplinary, with Advanced Heart Failure and high-risk Maternal Fetal Medicine collaborating care as part of the cardio-obstetrics team. As with pulmonary hypertension, labor and delivery should be planned through a multidisciplinary approach. The patient should have continuous monitoring with pulse oximetry, intra-arterial line, and central venous pressure monitoring [9]. In select cases, invasive hemodynamic monitoring with a pulmonary artery catheter can be beneficial to monitor biventricular filling pressures. In patients with DCM, vaginal delivery with regional anesthesia is preferred with plan for cesarean section as back up if necessary [39].
Increased frequency of occurrence of bendopnea is associated with poor outcomes in heart failure outpatients
Published in Acta Cardiologica, 2021
Hakkı Kaya, Anıl Şahin, Hakan Güneş, Lütfü Bekar, Ahmet Çelik, Yüksel Çavuşoğlu, Vedat Çaldır, Hasan Güngör, Mehmet Birhan Yılmaz
Shortness of breath is the most basic symptom in HF patients, and subtypes such as exercise dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea have long been considered as HF symptoms [3]. A new symptom, called bendopnea, was introduced by Thibodeau et al., which was described as shortness of breath within the first 30 sec. after leaning forward [4]. Thibodeau et al. also associated bendopnea with increased filling pressures, and then their subsequent research associated bendopnea with poor outcomes in HF outpatients [5]. HF course is a dynamic process for pathophysiological reasons. Symptoms such as orthopnea, paroxysmal nocturnal dyspnoea, and bendopnea, which are particularly related to increased filling pressures, may appear and disappear from time to time in HF patients due to the variable course of filling pressures [6–8]. In this study, we aimed to evaluate the relationship between the frequency of occurrence of bendopnea and long-term prognosis in HF outpatients, for the first time in the literature.
Bendopnea related to poor prognosis
Published in Acta Cardiologica, 2021
Ramón Baeza-Trinidad, Jose Daniel Mosquera-Lozano
To the Editor, We have read with great interest the article by Kaya et al. [1] about bendopnea in heart failure outpatients. Since Thibodeau et al. [2] described bendopnea as shortness of breath within the first 30 s in 2014, we have learned that it was related to readmissions [3] and mortality [4]. Also, this symptom changed during heart failure (HF) admission [5].