European Heart Journal Advance Access published online on November 11, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp458
The impact of early standard therapy on dyspnoea in patients with acute heart failure: the URGENT-dyspnoea study
1 Department of Anesthesiology and Critical Care Medicine, INSERM U942, University Paris Diderot; Hopital Lariboisiere, Paris, France
2 Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 259 E Erie St, Suite 100, Chicago, IL, 60611 USA
3 Department of Anesthesiology and Critical Care, Hospital Geral de Santo António, Porto, Portugal
4 Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA
5 Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
6 Department of Emergency Medicine, INSERM U942, Lariboisiere Hospital, Paris, France
7 Chef de Clinique des Universités-Assistant des Hôpitaux, Université Paris Decartes, Hôpital Cochin, Service des Urgences, Paris, France
8 Mount Sinai School of Medicine, New York, NY, USA
9 University Hospital Brno, Internal Cardiology Department, Brno, Czech Republic
10 Department of Intensive Care Medicine, Hospital Dos de Maig, Consorci Sanitari Integral, University of Barcelona, Spain
11 Department of Emergency Medicine, The Cleveland Clinic, Cleveland, OH, USA
12 Soweto Cardiovascular Research Unit, CH Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa
13 Department of Cardiology, Heart Failure Unit, Athens University Hospital, Attikon, Greece
14 Department of Cardiology, University of Hull, Kingston-upon-Hull, UK
15 Department of Medicine, Center for Cardiovascular Quality and Outcomes, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
Received 2 February 2009; revised 22 August 2009; accepted 18 September 2009 * Corresponding author. Tel: +1 312 926 7598, Fax: +1 312 926 6274, Email: ppang{at}northwestern.edu
Aims: The vast majority of acute heart failure (AHF) trials to date have targeted dyspnoea. However, they enrolled patients relatively late and did not standardize their methods of dyspnoea measurement. URGENT Dyspnoea was designed to determine changes in dyspnoea in response to initial, standard therapy in patients presenting with AHF using a standardized approach.
Methods and results: URGENT Dyspnoea was an international, multi-centre, observational cohort study of AHF patients managed conventionally and enrolled within 1 h of first hospital medical evaluation. Patient-assessed dyspnoea was recorded in the sitting position at baseline and at 6 hours by Likert and visual analog scales. Less symptomatic patients were placed supine to determine whether this provoked worsening dyspnoea (orthopnoea). Of the 524 patients with AHF, the mean age was 68 years, 43% were women, and 83% received intravenous diuretics. On a 5-point Likert scale, dyspnoea improvement was reported by 76% of patients after 6 h of standard therapy. Supine positioning (orthopnoea test) led to worse dyspnoea in 47% of patients compared to sitting upright.
Conclusion: When sitting upright, dyspnoea in the sitting position improves rapidly and substantially in patients with AHF after administration of conventional therapy, mainly intra-venous diuretics. However, many patients remain orthopnoeic. Improving the methodology of clinical trials in AHF by standardizing the conditions under which dyspnoea is assessed could enhance their ability to identify effective treatments. Relief of orthopnoea is clinically valuable and may represent a useful goal for clinical trials.
Key Words: Acute heart failure • Dyspnoea • Orthopnoea