Unlocking the Silent Sign: Understanding a Crucial Heart Failure Symptom (Bendopnea Explained)
Is shortness of breath when bending over a sign of heart failure? Learn about bendopnea, a crucial symptom you might be ignoring. This post explains what it is, why it happens, and its impact on your health.
DR T S DIDWAL MD
6/11/20246 min read
According to research published in the European Journal of Preventive Cardiology,bendopnea is shortness of breath experienced when bending forward, affecting about 28% of heart failure patients. It's linked to higher right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP), but not changes in cardiac index (CI). Patients with bendopnea face a significantly increased risk of all-cause mortality within two years. This symptom can be easily assessed noninvasively, aiding in the evaluation of heart failure severity. Bendopnea is more common in women, those with a higher BMI, and those with severe heart failure. The symptom may result from a volume challenge similar to the Valsalva manoeuvre. Recognizing bendopnea can improve noninvasive hemodynamic assessment and guide treatment, enhancing patient outcomes.
Key Points
Definition and Prevalence: Bendopnea is shortness of breath experienced when bending forward, observed in about 28% of heart failure patients studied.
Hemodynamic Correlates: Bendopnea is associated with higher supine right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) but not with changes in cardiac index (CI).
Prognostic Value: Patients with bendopnea have a significantly increased risk of all-cause mortality within two years, making it a strong independent prognostic marker.
Assessment Simplicity: Bendopnea can be assessed through a simple, noninvasive test by having patients bend forward and noting if they experience shortness of breath.
Clinical Characteristics: Patients with bendopnea are often female, have a higher BMI, more severe heart failure (NYHA Class III or IV), and less likely to be on certain heart failure medications.
Volume Challenge Mechanism: The symptom may be due to a volume challenge when bending forward, similar to the Valsalva maneuver, exacerbating already elevated filling pressures.
Practical Implications: Recognizing bendopnea can aid in noninvasive hemodynamic assessment, help tailor treatment strategies, and improve management and outcomes for heart failure patients.
Heart failure is a chronic condition where the heart's ability to pump blood efficiently is compromised, leading to a range of symptoms like fatigue, swelling, and shortness of breath. Among these, a specific form of shortness of breath that occurs when bending forward, termed "bendopnea," has recently been characterized and studied. This blog post delves into the findings of recent research on bendopnea, its implications for heart failure patients, and how it can be a crucial indicator for noninvasive hemodynamic assessment and prognostication.
What is Bendopnea?
Bendopnea is the onset of shortness of breath when a person bends forward, such as when putting on shoes or picking up an object from the ground. This symptom is particularly relevant to patients with heart failure, where it signifies an exacerbation of their condition. The term was introduced in a study to provide a clear, descriptive label for this specific type of dyspnea.
Background and Importance
Heart failure affects millions worldwide and is a leading cause of hospitalization and mortality. Accurate assessment of the severity and progression of heart failure is crucial for managing the condition and improving patient outcomes. Traditional methods like right-heart catheterization provide detailed hemodynamic information but are invasive. Thus, identifying noninvasive markers like bendopnea can significantly enhance patient care by offering a simpler way to gauge heart failure severity and guide treatment decisions.
The Study on Bendopnea
A significant study aimed to examine the frequency and hemodynamic correlates of bendopnea in patients with systolic heart failure was conducted with 102 subjects referred for right-heart catheterization. Here are the key findings from this research:
Prevalence of Bendopnea: Bendopnea was observed in 29 out of 102 subjects, translating to a prevalence of 28%. The median time to onset of bendopnea was 8 seconds, highlighting its rapid onset upon bending.
Hemodynamic Correlates: Patients with bendopnea had higher supine right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) compared to those without bendopnea. However, the cardiac index (CI) was similar between the two groups. This indicates that bendopnea is associated with elevated filling pressures rather than changes in cardiac output.
Hemodynamic Profiles: The study categorized subjects based on their hemodynamic profiles. Those with bendopnea were more likely to have a profile characterized by elevated PCWP and low CI, suggesting severe heart failure with reduced cardiac output. Conversely, there was no significant association with profiles having elevated PCWP but normal CI.
Mechanism of Bendopnea: The symptom appears to be mediated by an increase in filling pressures during bending when these pressures are already elevated, especially if the CI is low. This suggests that bendopnea could be a marker for patients with worse hemodynamic status.
Clinical Implications of Bendopnea
The identification of bendopnea as a symptom in heart failure patients has several important clinical implications:
Noninvasive Assessment: Bendopnea can be easily assessed through a simple, noninvasive examination. Patients can be asked to bend forward and hold the position, and the presence of shortness of breath can be noted. This quick test can provide valuable insights into the patient's hemodynamic status without the need for invasive procedures.
Prognostic Value: Research presented at the Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2024 showed that patients with bendopnea on discharge from the hospital had a significantly increased risk of all-cause mortality within two years. This finding underscores the importance of bendopnea as a prognostic marker. Patients with bendopnea may require closer monitoring and more aggressive management to improve their outcomes.
Guiding Treatment: Awareness of bendopnea can help healthcare providers tailor their treatment strategies. Patients exhibiting this symptom might benefit from adjustments in their medications or further evaluation for advanced heart failure therapies. For instance, managing filling pressures and improving cardiac output could alleviate bendopnea and potentially improve the patient's overall condition.
Bendopnea in Older Patients
A subsequent analysis investigated the prevalence and clinical significance of bendopnea in older patients hospitalized for heart failure. The study included over 2000 Japanese patients aged 65 years or older from two prospective cohorts, FRAGILE-HF and SONIC-HF. The findings were as follows:
Prevalence: Bendopnea was diagnosed in 2.5% of patients in the FRAGILE-HF cohort and 4.4% in the SONIC-HF cohort. The lower prevalence compared to previous studies might be due to differences in patient profiles and assessment methods.
Clinical Characteristics: Patients with bendopnea were more likely to be female, have a higher body mass index, and be diagnosed with more severe heart disease (NYHA Class III or IV). They were also less likely to be on certain heart failure medications like angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
Mortality Risk: Over two years of follow-up, patients with bendopnea had a significantly higher mortality rate. In the FRAGILE-HF cohort, 38.7% of those with bendopnea died compared to 20.7% without. In the SONIC-HF cohort, the mortality rate was 50% for those with bendopnea versus 20.6% for those without. After adjusting for confounding factors, bendopnea remained a strong independent predictor of mortality.
The Mechanism Behind Bendopnea
The exact mechanism linking bending forward to the onset of breathlessness in heart failure patients is not fully understood. One hypothesis suggests that bending forward might create a volume challenge, similar to the Valsalva maneuver or passive leg raises used in clinical settings. This shift in body volume could exacerbate already elevated filling pressures, leading to shortness of breath.
Practical Applications of Bendopnea Assessment
Testing for bendopnea is straightforward, cost-free, and without side effects, making it an attractive addition to clinical practice. For cardiologists, especially those working in resource-limited settings, this simple test can provide critical information about a patient's hemodynamic status and guide management decisions.
Conclusion
Bendopnea is a newly characterized symptom in heart failure patients that signifies an increase in filling pressures during bending, particularly in those with already high pressures and low cardiac output. Recognizing and understanding bendopnea can improve the noninvasive assessment of hemodynamics in heart failure patients, offering a simple yet powerful tool for prognostication and management. As research continues to unravel the mechanisms and implications of bendopnea, it holds promise for enhancing the care and outcomes of patients with heart failure.
By incorporating bendopnea assessment into routine clinical practice, healthcare providers can identify high-risk patients more effectively and tailor their treatment strategies to address the underlying hemodynamic abnormalities, ultimately improving the quality of life and survival for heart failure patients.
Journal Reference
Nakade, T., Maeda, D., Matsue, Y., Fujimoto, Y., Kagiyama, N., Sunayama, T., Dotare, T., Jujo, K., Saito, K., Kamiya, K., Saito, H., Ogasahara, Y., Maekawa, E., Konishi, M., Kitai, T., Iwata, K., Toki, M., Yoshioka, K., Wada, H., . . . Minamino, T. (2024). Bendopnea prevalence and prognostic value in older patients with heart failure: FRAGILE-HF–SONIC-HF post hoc analysis. European Journal of Preventive Cardiology. https://doi.org/10.1093/eurjpc/zwae128
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