Shortness of breath, or dyspnea, is a common symptom associated with heart failure (HF). Shortness of breath in Heart Failure results from fluid accumulation in the lungs (pulmonary edema), which occurs in the tiny air sacs (interstitium and alveoli) of the lungs. However, dyspnea can be multifactorial and be exacerbated by other psychological or other disease processes as well. According to the American Heart Association (AHA) Guidelines for HF management, dyspnea can reduce exercise capacity, and as patients progress through stages I to IV of the disease, their dyspnea becomes worse with less physical exertion.2 For example, dyspnea can occur when a person lies flat (orthopnea) and tries to sleep at night or can awaken them from sleep (paroxysmal nocturnal dyspnea).2 Orthopnea can be relieved by sitting up; a reason why patients with dyspnea may use multiple stacked pillows to sleep at night. Progressive dyspnea often indicates greater disease severity and worse outcomes.
An analysis of 48,616 Medicare‐linked hospitalizations for acute heart failure stratified patients by self-reported dyspnea severity at admission—8.3% experienced breathlessness only with moderate activity, 40.3% with minimal activity, and 51.4% at rest. Thirty-day mortality rose in parallel with symptom severity (6.3% for moderate-activity dyspnea, 7.6% for minimal-activity, and 11.6% for resting dyspnea), and 30-day heart failure readmission rates similarly increased (7.2%, 9.0%, and 9.4%, respectively). Even after adjusting for age, comorbidities, and other clinical factors, resting dyspnea remained an independent predictor of both higher short-term mortality and rehospitalization compared with dyspnea on moderate exertion.3
Dyspnea in heart failure is influenced by multiple noncardiac factors such as advanced age, elevated body mass index, chronic obstructive pulmonary disease, anxiety, and depressive symptoms.1,2 A cross-sectional study of 152 Chinese adults with heart failure found that 89.5% reported dyspnea and 44.1% exhibited depressive symptoms; dyspnea severity correlated with depression scores (r = 0.54, p < 0.01), and multivariable regression demonstrated that depressive symptoms and left ventricular ejection fraction independently predicted dyspnea after adjusting for age, income, body mass index, and New York Heart Association (NYHA) class.4
References:
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. Sep 21 2021;42(36):3599-3726. doi:10.1093/eurheartj/ehab368
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032. doi:doi:10.1161/CIR.0000000000001063
- Mentz RJ, Mi X, Sharma PP, et al. Relation of dyspnea severity on admission for acute heart failure with outcomes and costs. Am J Cardiol. Jan 1 2015;115(1):75-81. doi:10.1016/j.amjcard.2014.09.048
- Fan X, Meng Z. The mutual association between depressive symptoms and dyspnea in Chinese patients with chronic heart failure. Eur J Cardiovasc Nurs. Aug 2015;14(4):310-6. doi:10.1177/1474515114528071
