Improvements in Signs and Symptoms During Hospitalization for Acute Heart Failure Follow Different Patterns and Depend on the Measurement Scales Used: An International, Prospective Registry to Evaluate the Evolution of Measures of Disease Severity in Acute Heart Failure (MEASURE-AHF)

Abstract

Background The natural evolution of signs and symptoms during acute heart failure (AHF) is poorly characterized. Methods and Results We followed a prospective international cohort of 182 patients hospitalized with AHF. Patient-reported dyspnea and general well-being (GWB) were measured daily using 7-tier Likert (–3 to +3) and visual analog scales (VAS, 0–100). Physician assessments were also recorded daily. Mean age was 69 years and 68% had ejection fraction <40%. Likert measures of dyspnea initially improved rapidly (day 1, 0.22; day 2, 1.31; P <.001) with no significant improvement thereafter (day 7, 1.51; day 2 versus 7 P = .16). In contrast, VAS measure of dyspnea improved throughout hospitalization (day 1, 50.1; day 2, 64.7; day 7, 83.2; day 1 versus 2 P < .001, day 2 versus 7 P < .001). Symptoms of dyspnea and GWB tracked closely (correlation r = .813, P < .001). Physical signs resolved more completely than did symptoms (eg, from day 1 to discharge/day 7, absence of edema increased from 33% to 72% of patients, whereas significant improvements in dyspnea increased from 27% to 52% of patients; P < .001). Conclusions Changes in patient-reported symptoms and physician-assessed signs followed different patterns during an AHF episode and are influenced by the measurement scales used. Multiple clinical measures should be considered in discharge decisions and evaluation of AHF therapies.

Hemodynamic Determinants of Dyspnea Improvement in Acute Decompensated Heart Failure

“…25 In the Initiation Management Pre-discharge Assessment of Carvedilol Therapy in Heart Failure registry, the degree of weight loss during hospitalization for ADHF was not associated with the degree of improvement in dyspnea at rest. 26 The MEASURE-AHF registry 27 and the PROTECT pilot study 9 also reported that changes in body weight were not related to changes in symptoms. By contrast, in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, reductions in body weight in response to tolvaptan on day 1 were accompanied by significant improvements in patient-assessed dyspnea.…”

Assessment of Dyspnea Early in Acute Heart Failure: Patient Characteristics and Response Differences Between Likert and Visual Analog Scales

“…6 Past studies demonstrate that the VAS better captures changes in dyspnea over time compared to Likert-type scales, and that patient positioning during measurement (sitting upright vs. supine) affects responses. 5,7 Timing of dyspnea assessment is also important, as earlier treatment is associated with greater dyspnea relief, although many patients remain symptomatic despite early therapeutic intervention. 3,4,8,9,10 Early dyspnea relief has also been associated with improved 30-day outcomes.…”

Clinical Trials of Pharmacological Therapies in Acute Heart Failure Syndromes

“…Recently, several efforts have been made to evaluate the evolution of symptoms in AHFS, the relative change in various instruments compared with each other, and the association of such changes with other outcomes. 46,47 A recent proposal for standardized dyspnea assessment is an important first step toward better application of patient reported outcomes in clinical trails in AHFS. 48 As with breathlessness, the evaluation of congestion is dependent on relatively qualitative measures (jugular venous pressure, peripheral edema, rales, congestion on chest radiograph) that may not be highly correlated with more objective measures.…”