Bendopnea prevalence and prognostic value in older patients with heart failure: FRAGILE-HF-SONIC-HF post hoc analysis.

AIMS: This study aimed to investigate the prevalence, clinical characteristics, and prognostic value of bendopnea in older patients hospitalized for heart failure. METHODS AND RESULTS: This post hoc analysis was performed using two prospective, multicentre, observational studies: the FRAGILE-HF (main cohort) and SONIC-HF (validation cohort) cohorts. Patients were categorized based on the presence of bendopnea, which was evaluated before discharge. The primary endpoint was 2-year all-cause mortality after discharge. Among the 1243 patients (median age, 81 years; 57.2% male) in the FRAGILE-HF cohort and 225 (median age, 79 years; 58.2% men) in the SONIC-HF cohort, bendopnea was observed in 31 (2.5%) and 10 (4.4%) patients, respectively. Over a 2-year follow-up period, all-cause death occurred in 20.8 and 21.9% of the patients in the FRAGILE-HF and SONIC-HF cohorts, respectively. Kaplan-Meier survival curves demonstrated significantly higher mortality rates in patients with bendopnea than in those without bendopnea in the FRAGILE-HF (log-rank P = 0.006) and SONIC-HF cohorts (log-rank P = 0.014). Cox proportional hazard analysis identified bendopnea as an independent prognostic factor for all-cause mortality in both the FRAGILE-HF [hazard ratio (HR) 2.11, 95% confidence interval (CI) 1.18-3.78, P = 0.012] and SONIC-HF cohorts (HR 4.20, 95% CI 1.63-10.79, P = 0.003), even after adjusting for conventional risk factors. CONCLUSION: Bendopnea was observed in a relatively small proportion of older patients hospitalized for heart failure before discharge. However, its presence was significantly associated with an increased risk of all-cause mortality.

This study investigated how common it is for older patients with heart failure to have trouble breathing when they bend forward, and whether this affects their chances of survival. The study found that although this problem is not very common, it is linked to a higher risk of death.

Bendopnea Predicts High SYNTAX Score in Patients With Coronary Artery Disease: A Bayesian Approach.

Coronary artery disease (CAD) is one of the major health problems worldwide. CAD severity, as calculated by SYNTAX score (SS), is associated with higher morbidity and mortality. A new symptom of shortness of breath within 30 s while bending forward is described as bendopnea and is related to elevated cardiac filling pressure. It is also known that a high SS is associated with left ventricular (LV) dysfunction which leads to higher LV filling pressure. We aimed to investigate whether there was an association between bendopnea and high SS in CAD patients. A high SS was defined ≥22. Of 374 stable angina pectoris patients, 238 (64%) patients had bendopnea and 136 (36%) patients had no bendopnea in this study. The bendopnea (+) group had higher SS and Gensini scores than the bendopnea (-) group (posterior probabilities >0.999 and 0.995, respectively). The presence of bendopnea was independently associated with a higher SS (odds ratio [OR] = 3.82, 95% credible intervals [CrI] = 1.93-8.17). When different priors were used in the context of meta-analysis, there was only 18% heterogeneity among the results, indicating that the results of our study were robust. This is the first study to report that bendopnea was independently associated with CAD severity.

Effect of Bendopnea on Achievement Medical Treatment Target Doses in Heart Failure.

BACKGROUND: The newly described bendopnea in heart failure (HF) is associated with increased cardiac filling pressures. The aim of the study was to show the effect of bendopnea follow-up on reaching optimal medical treatment doses in HF. METHODS: A total of 413 patients were screened, and we included 203 patients with HF who were previously evaluated for bendopnea. Demographic data, presence or absence of bendopnea, medical history, laboratory findings, and medical treatments were evaluated. Optimal medical therapy target doses at baseline and 3rd month were compared in groups with and without bendopnea. RESULTS: On admission, 64 patients (31.5%) had bendopnea. The rate of patients with bendopnea decreased in the 3rd month (n=42, 20.7%). The proportion of patients who used at least 50% of the recommended medical treatment dose on admission and in the 3rd month was compared; angiotensin-converting enzyme inhibitor /angiotensin receptor blockers use increased from 40.6% to 71.9% in those with bendopnea (P=0.013), from 56.1% to 81.3% in those without bendopnea (P<0.001) and beta-blockers use increased from 28.2% to 60.9% in those with bendopnea (P=0.042), from 31.6% to 69.8% in those without bendopnea (P<0.001). However, aldosterone antagonists use decreased from 70.3% to 67.2% in those with bendopnea (P=0.961), from 68.4 % to 64.1% in those without bendopnea (P=0.334). Bendopnea was independently effective in achieving ACE-I/ARB target doses (OR: 0.359, CI 95%: 0.151-0.854, P=0.020). CONCLUSION: Bendopnea follow-up in HF patients can provide a significant improvement in reaching the recommended treatment target doses.

Bending oxygen saturation index and risk of worsening heart failure events in chronic heart failure.

AIMS: Bendopnea is a clinical symptom of advanced heart failure with uncertain prognostic value. We aimed to evaluate whether bendopnea and the change in oxygen saturation when bending forward (bending oxygen saturation index [BOSI]) are associated with adverse outcomes in ambulatory chronic heart failure (CHF) patients. METHODS AND RESULTS: We prospectively evaluated 440 subjects with symptomatic CHF. BOSI was defined as the difference between sitting and bending oxygen saturation (SpO2 ). The endpoint was the total number of worsening heart failure (WHF) events (heart failure hospitalization or urgent heart failure visit requiring parenteral diuretic therapy). The mean age was 74 ± 10 years, 257 (58.6%) were male, and 226 (51.4%) had a left ventricular ejection fraction <50%. Bendopnea was present in 94 (21.4%) patients, and 120 (27.3%) patients had a BOSI ≥-3%. The agreement between BOSI ≥-3% and bendopnea was moderate (Gwet's AC 0.482, p < 0.001). At a median (p25%-p75%) follow-up of 2.17 years (0.88-3.16), we registered 441 WHF events in 148 patients. After multivariable adjustment, BOSI was independently associated with the risk for total WHF episodes (overall, p < 0.001). Compared to improvement/no change in SpO2 when bending (BOSI 0%), those with BOSI ≥-3% showed an increased risk of WHF events (incidence rate ratio [IRR] 2.16, 95% confidence interval [CI] 1.67-2.79; p < 0.001). In contrast, bendopnea was not associated with the risk of total WHF episodes (IRR 1.04, 95% CI 0.83-1.31; p = 0.705). CONCLUSIONS: In ambulatory and stable CHF patients, BOSI ≥-3% and not bendopnea was independently associated with an increased risk of total (first and recurrent) WHF episodes. Awareness of SpO2 while assessing bendopnea may be a useful tool for predicting heart failure decompensations.

Echocardiographic Parameters Associated with Bendopnea in Patients with Systolic Heart Failure.

Background: Bendopnea, defined as dyspnea while bending, can be observed in patients with heart failure (HF). In this study, we investigated the frequency of this symptom in patients with systolic HF and its association with echocardiographic parameters. Methods: In this study, patients with left ventricular ejection fraction (LVEF) ≤45% and decompensated HF referred to our clinics were prospectively recruited. All the patients were examined by cardiologists for collecting data on the presence of bendopnea and baseline characteristics. They also underwent electrocardiographic and echocardiographic examinations. All findings were compared between the patients with or without bendopnea. Results: A total of 120 patients at a mean age of 65.19±12.62 years were evaluated, and 74.8% were men. Bendopnea was observed in 44.2% of the patients. The etiology of HF was ischemic in most patients (81.9%), and the functional class of most patients (85.9%) was III or IV. The mortality rate at the 6-month follow-up was comparable between the patients with or without bendopnea (6.1% vs 9.5%; P=0.507). The waist circumference (odds ratio [OR], 1.037, 95% confidence interval [CI], 1.005 to 1.070; P=0.023), paroxysmal nocturnal dyspnea (OR, 0.338, 95% CI, 0.132 to 0.866; P=0.024), and right atrial size (OR, 1.084, 95% CI, 1.002 to 1.172; P=0.044) were associated with bendopnea. Conclusion: Bendopnea can be frequently found among patients with systolic HF. This phenomenon is associated with obesity and baseline symptoms of patients and right atrial size upon echocardiographic examinations. It can help clinicians with the risk stratification of HF patients.

Increased frequency of occurrence of bendopnea is associated with poor outcomes in heart failure outpatients.

BACKGROUND: Relationship between the frequency of occurrence of bendopnea during the daily life of heart failure (HF) outpatients and clinical outcomes has never been evaluated before. METHODS: Turkish Research Team-Heart Failure (TREAT-HF) is a network between HF centres, which undertakes multicentric observational studies in HF. Herein, the data including stable 573 HF patients with reduced ejection fraction out of seven HF centres were presented. A questionnaire was filled by the patients, with the question 'Do you experience shortness of breath while tying your shoelace?', assessing the presence and frequency of bendopnea. RESULTS: To the question related to bendopnea, 48% of the patients answered 'yes, every time', 31% answered 'yes, sometimes', and 21% answered 'No'. Patients were followed for an average of 24 ± 14 months, and the patients who answered 'yes, every time' and 'yes, sometimes' to the bendopnea question were found having increased risk for both HF-related hospitalisations (HR:3.2, p < .001- HR:2.8, p = .005) and composite outcome consisting of 'HF-related hospitalisations and all-cause death in the multi-variate analysis (HR:3.1, p < .001- HR:3.0, p < .001). Kaplan Meier analysis for HF-related hospitalisation, all-cause death, and the composite of these were provided for these three groups, yielding significant and graded divergence curves with the best prognosis in 'no' group, with the moderate prognosis in 'sometimes' group, and with the worst prognosis in the 'every time' group. CONCLUSION: For the first time in the literature, our study shows that the increased frequency of bendopnea occurrence in daily life is associated with poor outcomes in HF outpatients.

Clinical significance of bendopnea in heart failure-Systematic review and meta-analysis.

BACKGROUND: Bendopnea is a symptom mediated by increased ventricular filling pressure during bending forward. Presence of bendopnea in patients can be easily evaluated without additional maneuver in several countries whose norms, habits, culture, and occupation relates to a higher frequency of bending forward. This information may prove valuable in routine clinical practice. We aimed to analyze the latest evidence on bendopnea in order to further define the clinical significance of this symptom. METHODS: We performed a comprehensive search on bendopnea in heart failure from inception up until January 2019 through PubMed, EuropePMC, EBSCOhost, Cochrane Central Database, and ClinicalTrials.gov. RESULTS: There were 283 patients (31.76%) who have bendopnea, and a total of 891 patients from six studies were included. Bendopnea was associated with the presence of dyspnea [odds ratio (OR) 69.70 (17.35-280.07); <0.001], orthopnea [OR 3.02 (2.02-4.52); <0.001], paroxysmal nocturnal dyspnea [OR 2.76 (1.76-4.32); <0.001], and abdominal fullness [OR 7.50 (4.15-13.58); <0.001]. Association with elevated jugular venous pressure was shown in two studies. New York Heart Association (NYHA) functional class IV was more prevalent in patients with bendopnea [OR 7.58 (4.35-13.22); <0.001]. Bendopnea was also associated with increased mortality [OR 2.21 (1.34-3.66); 0.002]. CONCLUSION: Bendopnea is associated with the presence of several signs and symptoms. This study also showed that bendopnea is one of the signs and symptoms of advanced heart failure associated with increased mortality. However, owing to the limited number of studies, further investigation is needed before drawing a definite conclusion.

Bendopnea and Its Clinical Importance in Outpatient Patients with Pulmonary Arterial Hypertension.

PURPOSE: Bendopnea is a recently reported novel symptom in patients with heart failure (HF) defined as shortness of breath when bending forward. It has been demonstrated that bendopnea is associated with advanced symptoms and worse outcomes. The aim of this study was to assess the presence of bendopnea and its clinical importance with regards to functional status, hemodynamic and echocardiographic characteristics in outpatient pulmonary arterial hypertension (PAH) patients. METHODS: We conducted this prospective observational study of 53 patients who were admitted to our PAH clinic for routine control visits. We determined the presence of bendopnea and analyzed hemodynamic parameters, World Heart Organization (WHO) functional class, transcutaneous oxygen saturation, 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) and right ventricular (RV) function indicators in patients with and without bendopnea. RESULTS: Bendopnea was present 33.9% of the PAH patients. The mean age was higher in the patients with bendopnea than in those without bendopnea, but the difference was not significant (p = 0.201). The patients with bendopnea had a lower 6-MWD and higher NT-proBNP level (p < 0.001), and worse WHO functional class symptoms (p = 0.010). Mean right atrial pressure, pulmonary artery pressure, and pulmonary vascular resistance were higher in the patients with bendopnea. The patients with bendopnea had a more dilated RV end-diastolic diameter and lower tricuspid annular plane systolic excursion value (p < 0.001 and p = 0.001, respectively). CONCLUSIONS: Bendopnea was associated with worse functional capacity status, hemodynamic characteristics and RV function in our outpatient PAH patients.

The Role of the Clinical Examination in Patients With Heart Failure.

Despite advances in biomarkers and technology, the clinical examination (i.e., a history and physical examination) remains central in the management of patients with heart failure. Specifically, the clinical examination allows noninvasive assessment of the patient's underlying hemodynamic state, based on whether the patient has elevated ventricular filling pressures and/or an inadequate cardiac index. Such assessments provide important prognostic information and help guide therapeutic decision-making. Herein, the authors critically assess the utility of the clinical examination for these purposes and provide practical tips we have gleaned from our practice in the field of advanced heart failure. The authors note that the ability to assess for congestion is superior to that for inadequate perfusion. Furthermore, in current practice, elevated left ventricular filling pressures are inferred by findings related to an elevated right atrial pressure. They discuss an emerging classification system from the clinical examination that categorizes patients based on whether elevation of ventricular filling pressures occurs on the right side, left side, or both sides.

[Symptoms and signs of heart failure in the Russian clinical guidelines of 2016: lost and displaced].

Using the example of Russian and European clinical guidelines on diagnosis and treatment of heart failure the article addressed issues, which may arise from word-for-word or component-wise translation to Russian of some English medical terms, such as bendopnea (or flexodyspnea, a symptom of shortness of breath when bending forward), a symptom (subjective symptom), and a sign (objective symptom).

Demographical and clinicopathological characteristics in heart failure and outcome predictors: a prospective, observational study.

AIMS: The aims of the study were to study the demographical and clinicopathological characteristics of patients presenting with heart failure and evaluate the 1 year outcomes and to identify risk predictors if any. METHODS AND RESULTS: A prospective observational study was conducted in consecutive patients of systolic heart failure. The study was divided into two parts-an initial 6 month enrolment phase followed up for 1 year for major adverse cardiovascular events. All patients were treated according to the Institutional Heart Failure Protocol. Demographical and clinicopathophysiological characteristics were studied, and results were analysed. A total of 143 patients were enrolled. The mean age of subjects was 56.4 years with male subjects constituting almost two-thirds of the study population. The commonest aetiology of heart failure was ischemic with valvular heart disease being the commonest cause of non-ischemic heart failure. Bendopnea, a recently described symptom of heart failure, was found in a significant number of subjects. By univariate analysis, male sex (P = 0.042) and cardiomegaly (P = 0.035) were predictors of rehospitalization, whereas the univariate predictors of mortality were ischemic aetiology (P = 0.000), age > 50 years (P = 0.007), hypertension (P = 0.012), worsening NYHA class (P = 0.003), diabetes mellitus (P = 0.009), and hypokalaemia (P = 0.006). Multivariate analysis performed showed age > 50 years [P = 0.007; OR (CI) = 13.547 (2.034-90.238)], NYHA class [P = 0.002; OR (CI) = 32.300 (3.733-276.532)], and hypokalaemia [P = 0.031; OR (CI) = 7.524 (1.208-46.862)] as significant predictors of mortality during long-term follow-up. CONCLUSIONS: The study will definitely help us to throw more light in identifying risk predictors of heart failure and help in improving clinical outcomes.

Association of types of dyspnea including 'bendopnea' with cardiopulmonary disease in primary care. / Associação dos tipos de dispneia e da "flexopneia" com as patologias cardiopulmonares nos cuidados de saúde primários.

INTRODUCTION: Dyspnea is the symptom most commonly reported by patients with heart failure (HF) and/or pulmonary disease, the obese and the elderly. Recently 'bendopnea' (shortness of breath when bending forward) has been described in patients with HF. OBJECTIVE: To determine the association of exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea and bendopnea with chronic disease, especially heart failure, and their phenotypes in primary care. METHODS: This cross-sectional study included 633 individuals aged between 45 and 99 years enrolled in a primary care program in Niteroi, Brazil. Participants underwent clinical assessment and laboratory tests and completed a questionnaire, all on the same day. RESULTS: Paroxysmal nocturnal dyspnea and bendopnea were associated with HF (unadjusted OR 2.42, 95% CI 1.10-5.29 and OR 2.59, 95% CI 1.52-4.44, respectively). In multivariate models, chronic obstructive pulmonary disease, coronary heart disease and myocardial infarction were not associated with bendopnea. CONCLUSIONS: Bendopnea was the only type of dyspnea not linked to respiratory disease or coronary heart disease. Even after adjusting for depression and body mass index, the association remained with HF with or without preserved ejection fraction, and bendopnea thus appears to be a promising symptom to differentiate HF from the other two disease groups.

Assessment of bendopnea impact on decompensated heart failure.

AIMS: We have often found that patients with heart failure had shortness of breath when bending forward. The frequency of bendopnea in patients with decompensated heart failure (DHF), its repercussions on quality of life (QoL), and its prognosis have not yet been studied. This study was carried out to evaluate the characteristics, degree of limitation, and short-term prognosis of patients with bendopnea and DHF. METHODS AND RESULTS: We conducted a study of 250 patients admitted with DHF. Bendopnea was considered when shortness of breath occurred within 30 s of bending forward. It was present in 122 patients (48.8%). The mean time of onset was 13.4 ± 6.9 s. Patients with bendopnea presented a higher frequency of orthopnoea, paroxysmal nocturnal dyspnoea, oliguria, oedema, elevated jugular venous pressure, abdominal fullness, and worse functional class (P < 0.001). An enlargement of both atria was more frequent in these patients (P < 0.001). Pulmonary artery systolic pressure (PASP) was higher in the bendopnea group (P = 0.001). Body mass index and LVEF were not associated with presence of bendopnea. Subjective QoL limitation was present in 80.3% (36.1% mild, 44.2% moderate to severe limitation). Patients with bendopnea had a higher mortality rate (P = 0.025) and more advanced NYHA class (P < 0.001). Patients who died had a lower LVEF (P = 0.001), increased PASP (P = 0.08), and lower mean duration of shortness of breath than those who survived (P = 0.01). CONCLUSION: Bendopnea is related to advanced HF symptoms and it is associated with mortality in the short term and advanced NYHA functional class. This symptom produces moderate to severe limitation of QoL.

[Update on therapy of chronic heart failure. Innovations and studies from last year]. / Update zur Therapie der chronischen Herzinsuffizienz. Neue Erkenntnisse und Studien des letzten Jahres.

Chronic heart failure is one of the most common chronic diseases worldwide with increasing prevalence and incidence. Due to the high morbidity and mortality a standardized and evidence-based therapy is crucial. The present review article gives an overview about the innovations in 2014 based on the current guidelines of the European Society of Cardiology. First, improvements in established medication regimens regarding beta blockers and mineralocorticoid receptor antagonists as well as treatment options for heart rate reduction will be explained. Second, new pharmacological developments, such as angiotensin receptor neprilysin inhibition will be discussed. Finally, new insights into common comorbidities of patients with chronic heart failure, such as atrial fibrillation and hyperkalemia will be presented.