National Cardiovascular Center, Osaka, Japan.
J Card Fail. 2012 Jul;18(7):524-33. doi: 10.1016/j.cardfail.2012.04.012. Epub 2012 May 30.
Patients perceive different symptoms of heart failure decompensation. It is not known whether the nature of the worst symptom relates to hemodynamic profile, response to therapy, or improvement in clinical trials.
Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial were hospitalized with advanced heart failure, ejection fraction ≤30%, and at least 1 sign and 1 symptom of elevated filling pressures. Visual analog scales (VAS) for symptoms were completed by 371 patients, who selected their worst symptom as difficulty breathing, fatigue, abdominal discomfort, or body swelling and also scored breathing and global condition at baseline and discharge. The dominant symptom identified was difficulty breathing by 193 (52%) patients, fatigue by 118 (32%), and abdominal discomfort and swelling each by 30 (8%) patients, combined as right-sided congestion for analysis. Clinical and hemodynamic assessments were not different between groups except that right-sided congestion was associated with more hepatomegaly, ascites, third heart sounds, and jugular venous distention. This group also had greater reduction in jugular venous distention and trend toward higher blood urea nitrogen after therapy. By discharge, average improvements in worst symptom and global score were 28 points and 24 points. For those with ≥10 points in improvement in worst symptom, 84% also improved global assessment ≥10 points. Initial fatigue was associated with less improvement (P = .002) during and after hospitalization, but improvements in symptom scores were sustained when re-measured during 6 months after discharge.
In most patients hospitalized with clinical congestion, therapy will improve symptoms regardless of the worst symptom perceived, with more evidence of baseline fluid retention and reduction during therapy for worst symptoms of abdominal discomfort or edema. Improvement in trials should be similar when tracking worst symptom, dyspnea, or global assessment.
心力衰竭失代偿患者会出现不同的症状。目前尚不清楚，最差症状的性质与血流动力学特征、对治疗的反应或临床试验的改善是否相关。
充血性心力衰竭评估研究和肺动脉导管有效性试验中的患者因晚期心力衰竭、射血分数≤30%以及至少 1 项和 1 项以上升高充盈压的体征和症状而住院。371 例患者完成了症状的视觉模拟量表（VAS）评分，他们选择呼吸困难、疲劳、腹部不适或身体肿胀作为最差症状，并在基线和出院时对呼吸和整体状况进行评分。193 例（52%）患者的主要症状为呼吸困难，118 例（32%）为疲劳，30 例（8%）为腹部不适和肿胀，综合分析为右侧充血。临床和血液动力学评估在各组之间无差异，除了右侧充血与肝肿大、腹水、第三心音和颈静脉扩张更多相关。该组在治疗后颈静脉扩张的减少和血尿素氮升高的趋势也更大。出院时，最差症状和整体评分的平均改善分别为 28 分和 24 分。对于最差症状改善≥10 分的患者，84%的患者整体评估也改善≥10 分。初始疲劳与住院期间和出院后改善较少相关（P=0.002），但出院后 6 个月再次测量时，症状评分的改善仍然持续。
在因临床充血而住院的大多数患者中，无论患者感知到的最差症状如何，治疗都会改善症状，基线时液体潴留的证据更多，治疗过程中最差症状（腹部不适或水肿）的液体潴留减少。在追踪最差症状、呼吸困难或整体评估时，试验的改善应该是相似的。
