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Surface respiratory electromyography and dyspnea in acute heart failure patients.

ABSTRACT: INTRODUCTION AND OBJECTIVES:Dyspnea is the most common symptom among hospitalized patients with heart failure (HF) but besides dyspnea questionnaires (which reflect the subjective patient sensation and are not fully validated in HF) there are no measurable physiological variables providing objective assessment of dyspnea in a setting of acute HF patients. Studies performed in respiratory patients suggest that the measurement of electromyographic (EMG) activity of the respiratory muscles with surface electrodes correlates well with dyspnea. Our aim was to test the hypothesis that respiratory muscles EMG activity is a potential marker of dyspnea severity in acute HF patients. METHODS:Prospective and descriptive pilot study carried out in 25 adult patients admitted for acute HF. Measurements were carried out with a cardio-respiratory portable polygraph including EMG surface electrodes for measuring the activity of main (diaphragm) and accessory (scalene and pectoralis minor) respiratory muscles. Dyspnea sensation was assessed by means of the Likert 5 questionnaire. Data were recorded during 3 min of spontaneous breathing and after breathing at maximum effort for several cycles for normalizing data. An index to quantify the activity of each respiratory muscle was computed. This assessment was carried out within the first 24 h of admission, and at day 2 and 5. RESULTS:Dyspnea score decreased along the three measured days. Diaphragm and scalene EMG index showed a positive and significant direct relationship with dyspnea score (p<0.001 and p = 0.003 respectively) whereas pectoralis minor muscle did not. CONCLUSION:In our pilot study, diaphragm and scalene EMG activity was associated with increasing severity of dyspnea. Surface respiratory EMG could be a useful objective tool to improve assessment of dyspnea in acute HF patients.

SUBMITTER: Luiso D

PROVIDER: S-EPMC7190138 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Surface respiratory electromyography and dyspnea in acute heart failure patients.

Luiso Daniele D Villanueva Jair A JA Belarte-Tornero Laia C LC Fort Aleix A Blázquez-Bermejo Zorba Z Ruiz Sonia S Farré Ramon R Rigau Jordi J Martí-Almor Julio J Farré Núria N

PloS one 20200429 4

<h4>Introduction and objectives</h4>Dyspnea is the most common symptom among hospitalized patients with heart failure (HF) but besides dyspnea questionnaires (which reflect the subjective patient sensation and are not fully validated in HF) there are no measurable physiological variables providing objective assessment of dyspnea in a setting of acute HF patients. Studies performed in respiratory patients suggest that the measurement of electromyographic (EMG) activity of the respiratory muscles ...[more]

PMID: 32348374

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Project description:BackgroundCongestion is a primary driver of symptoms in patients with acute heart failure, and relief of congestion is a critical goal of therapy. Monitoring of response to therapy through the assessment of daily weights and net fluid loss is the current standard of care, yet the relationship between commonly used markers of decongestion and both patient reported symptom relief and clinical outcomes are unknown.Methods and resultsWe performed a retrospective analysis of the randomized clinical trial, diuretic optimization strategy evaluation in acute heart failure (DOSE-AHF), enrolling patients hospitalized with a diagnosis of acute decompensated heart failure. We assessed the relationship among 3 markers of decongestion at 72 hours-weight loss, net fluid loss, and percent reduction in serum N terminal B-type natriuretic peptide (NT-proBNP) level-and relief of symptoms as defined by the dyspnea visual analog scale area under the curve. We also determined the relationship between each marker of decongestion and 60-day clinical outcomes defined as time to death, first rehospitalization or emergency department visit. Mean age was 66 years, mean ejection fraction was 35%, and 27% had ejection fraction ≥50%. Of the 3 measures of decongestion assessed, only percent reduction in NT-proBNP was significantly associated with symptom relief (r=0.13; P=0.04). There was no correlation between either weight loss or net fluid loss and symptom relief, (r=0.04; P=0.54 and r=0.07; P=0.27, respectively). Favorable changes in each of the 3 markers of decongestion were associated with improvement in time to death, rehospitalization, or emergency department visit at 60 days (weight: hazard ratio, 0.91; 95% confidence interval, 0.85-0.97 per 4 lbs; weight lost; fluid hazard ratio, 0.94; 95% confidence interval, 0.90-0.99 per 1000 mL fluid loss; NT-proBNP hazard ratio, 0.95; 95% confidence interval, 0.91-0.99 per 10% reduction). These associations were unchanged after multivariable adjustment with the exception that percent reduction in NT-proBNP was no longer a significant predictor (hazard ratio, 0.97; 95% confidence interval, 0.93-1.02). The rates of death, HF hospitalization, or emergency department visit at 60 days for patients with 0, 1, 2, and 3 markers of decongestion (above the median) were 67%, 64%, 46%, and 38%, respectively (log rank P value=0.05).ConclusionsWeight loss, fluid loss, and NT-proBNP reduction at 72 hours are poorly correlated with dyspnea relief. However, favorable improvements in each of the 3 markers were associated with improved clinical outcomes at 60 days. These data suggest the need for ongoing research to understand the relationships among symptom relief, congestion, and outcomes in patients with acute decompensated heart failure.Clinical trial registrationURL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00577135.

Project description:Background and importanceDiagnosing acute heart failure (AHF) is difficult in elderly patients presenting with acute dyspnea to the emergency department.ObjectivesTo assess the diagnostic accuracy of NT-proBNP, high-sensitivity cardiac troponin-I (Hs-cTnI), soluble ST2 (ST2), galectin-3 and CD146 alone and in combination for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency department.Design, settings and participantsThis was a prospective, multicenter study performed between September 2016 and January 2020, including elderly patients presenting with acute dyspnea to the emergency department of 6 French hospitals.InterventionMeasurement of NT-proBNP, hs-cTnI, ST2, galectin-3 and CD146.Outcome measure and analysisThe reference standard, AHF, was adjudicated by two independent physicians based on ED and hospitalization clinical, biological (excluding biomarkers), radiological and echocardiography data (performed by a cardiologist in the cardiology department specifically for this study). Three exploratory methods (two using a cross-sectional approach with logistic regression and counting all biomarker combinations, and one using a sequential approach with gray zone optimizations) were applied to create comprehensive combinations of the 5 biomarkers for measuring diagnostic accuracy.Main resultsTwo hundred thirty-eight patients (median age of 85 years, IQR = 8) were analyzed, and 110 (46%) were diagnosed with AHF. The accuracies of NT-proBNP, CD146, hs-cTnI, galectin-3, and ST2 were 0.72 [95% confidence interval (CI) 0.66-0.77], 0.63 (95% CI 0.57-0.69), 0.59 (95% CI 0.53-0.65), 0.55 (95% CI 0.49-0.61) and 0.51 (95% CI 0.45-0.57), respectively. Regardless of the approach used or how the 5 biomarkers were combined, the best accuracy for diagnosing AHF (0.73, 95% CI 0.67-0.78) did not differ from that of NT-proBNP alone.ConclusionIn this study, NT-proBNP alone exhibited the best diagnostic accuracy for diagnosing AHF in elderly patients presenting with acute dyspnea to the emergency departments. None of the other biomarkers alone or combined improved the accuracy compared to NT-proBNP, which is the only biomarker to use in this setting.

Project description:Background and Objectives: Acute dyspnea is a common chief complaint in the emergency department (ED), with acute heart failure (AHF) as a frequent underlying disease. Early diagnosis and rapid therapy are highly recommended by international guidelines. This study evaluates the accuracy of point-of-care B-line lung ultrasound in diagnosing AHF and monitoring the therapeutic success of heart failure patients. Materials and Methods: This is a prospective mono-center study in adult patients presenting with undifferentiated acute dyspnea to a German ED. An eight-zone pulmonary ultrasound was performed by experienced sonographers in the ED and 24 and 72 h after. Along with the lung ultrasound evaluation patients were asked to assess the severity of shortness of breath on a numeric rating scale. The treating ED physicians were asked to assess the probability of AHF as the underlying cause. Final diagnosis was adjudicated by two independent experts. Follow-up was done after 30 and 180 days. Results: In total, 102 patients were enrolled. Of them, 89 patients received lung ultrasound evaluation in the ED. The sensitivity of lung ultrasound evaluation in ED in diagnosing AHF was 54.2%, specificity 97.6%. As much as 96.3% of patients with a positive LUS test result for AHF in ED actually suffered from AHF. Excluding diuretically pretreated patients, sensitivity of LUS increased to 75% in ED. Differences in the sum of B-lines between admission time point, 24 and 72 h were not statistically significant. There were no statistically significant differences in the subjectively assessed severity of dyspnea between AHF patients and those with other causes of dyspnea. Of the 89 patients, 48 patients received the final adjudicated diagnosis of AHF. ED physicians assessed the probability of AHF in patients with a final diagnosis of AHF as 70%. Roughly a quarter (23.9%) of the overall cohort patients were rehospitalized within 30 days after admission, 38.6% within 180 days of follow-up. Conclusion: In conclusion, point-of-care lung ultrasound is a helpful tool for the early rule-in of acute heart failure in ED but only partially suitable for exclusion. Of note, the present study shows no significant changes in the number of B-lines after 24 and 72 h.

Project description:Background: Dyspnea is the most common presenting symptom among patients hospitalized for acute heart failure (AHF). Dyspnea relief constitutes a clinically relevant therapeutic target and endpoint for clinical trials and regulatory approval. However, there have been no widely accepted dyspnea measurement standards in AHF. By systematic review and mapping the current evidence of the applied scales, timing, and results of measurement, we hope to provide some new insights and recommendations for dyspnea measurement. Methods: PubMed, Embase, Cochrane Library, and Web of Science were searched from inception until August 27, 2020. Randomized controlled trials (RCTs) with dyspnea severity measured as the endpoint in patients with AHF were included. Results: Out of a total of 63 studies, 28 had dyspnea as the primary endpoint. The Likert scale (34, 54%) and visual analog scale (VAS) (22, 35%) were most widely used for dyspnea assessment. Among the 43 studies with detailed results, dyspnea was assessed most frequently on days 1, 2, 3, and 6 h after randomization or drug administration. Compared with control groups, better dyspnea relief was observed in the experimental groups in 21 studies. Only four studies that assessed tolvaptan compared with control on the proportion of dyspnea improvement met the criteria for meta-analyses, which did not indicate beneficial effect of dyspnea improvement on day 1 (RR: 1.16; 95% CI: 0.99-1.37; p = 0.07; I 2 = 61%). Conclusion: The applied scales, analytical approaches, and timing of measurement are in diversity, which has impeded the comprehensive evaluation of clinical efficacy of potential therapies managing dyspnea in patients with AHF. Developing a more general measurement tool established on the unified unidimensional scales, standardized operation protocol to record the continuation, and clinically significant difference of dyspnea variation may be a promising approach. In addition, to evaluate the effect of experimental therapies on dyspnea more precisely, the screening time and blinded assessment are factors that need to be considered.

Project description:The goal of this study was to examine the ability of emergency physicians who are not experts in emergency ultrasound (US) to perform lung ultrasonography and to identify B-lines. The hypothesis was that novice sonographers are able to perform lung US and identify B-lines after a brief intervention. In addition, the authors examined the diagnostic accuracy of B-lines in undifferentiated dyspneic patients for the diagnosis of acute heart failure syndrome (AHFS), using an eight-lung-zone technique as well as an abbreviated two-lung-zone technique.This was a prospective, cross-sectional study of patients who presented to the emergency department (ED) with acute dyspnea from May 2009 to June 2010. Emergency medicine (EM) resident physicians, who received a 30-minute training course in thoracic US examinations, performed lung ultrasonography on patients presenting to the ED with undifferentiated dyspnea. They attempted to identify the presence or absence of sonographic B-lines in eight lung fields based on their bedside US examinations. An emergency US expert blinded to the diagnosis and patient presentation, as well as to the residents' interpretations of presence of B-lines, served as the criterion standard. A secondary outcome determined the accuracy of B-lines, using both an eight-lung-zone and a two-lung-zone technique, for predicting pulmonary edema from AHFS in patients presenting with undifferentiated dyspnea. Two expert reviewers who were blinded to the US results determined the clinical diagnosis of AHFS.A cohort of 66 EM resident physicians performed lung US on 380 patients with a range of 1 to 28 examinations, a mean of 5.8 examinations, and a median of three examinations performed per resident. Compared to expert interpretation, lung US to detect B-lines by inexperienced sonographers achieved the following test characteristics: sensitivity 85%, specificity 84%, positive likelihood ratio (+LR) 5.2, negative likelihood ratio (-LR) 0.2, positive predictive value (PPV) 64%, and negative predictive value (NPV) 94%. Regarding the secondary outcome, the final diagnosis was AHFS in 35% of patients (134 of 380). For novice sonographers, one positive lung zone (i.e., anything positive) had a sensitivity of 87%, a specificity of 49%, a +LR of 1.7, a -LR of 0.3, a PPV of 50%, and an NPV of 88% for predicting AHFS. When all eight lung zones were determined positive (i.e., totally positive) by novice sonographers, the sensitivity was 19%, specificity was 97%, +LR was 5.7, -LR was 0.8, PPV was 76%, and NPV was 68% for predicting AHFS. The areas under the curve for novice and expert sonographers were 0.77 (95% CI = 0.72 to 0.82) and 0.76 (95% CI = 0.71 to 0.82), respectively.Novice sonographers can identify sonographic B-lines with similar accuracy compared to an expert sonographer. Lung US has fair predictive value for pulmonary edema from acute heart failure in the hands of both novice and expert sonographers.

Dataset Information

Surface respiratory electromyography and dyspnea in acute heart failure patients.

Publications

Surface respiratory electromyography and dyspnea in acute heart failure patients.

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