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(Circulation. 1995;92:47-53.)
© 1995 American Heart Association, Inc.
Articles |
Dissociation Between Exertional Symptoms and Circulatory Function in Patients With Heart Failure
From the Cardiology Division of the Vanderbilt University Medical Center, Nashville, Tenn.
Correspondence to John R. Wilson, MD, Cardiology Division, Room CC-2218 MCN, Vanderbilt University Medical Center, Nashville, TN 37232-2170.
Background Patients with heart failure frequently report exertional dyspnea and fatigue. These symptoms are usually attributed to circulatory dysfunction and therefore are typically treated with cardiovascular medications. Serial assessment of exertional symptoms has also become the principal method used to assess drug efficacy in heart failure. Nevertheless, the relation between exertional symptoms in heart failure and circulatory dysfunction remains uncertain.
Methods and Results This study was undertaken to investigate the
relation between exertional symptoms, ventilatory and skeletal muscle
dysfunction, and circulatory function in patients with heart failure.
To this end, 52 ambulatory patients with heart failure underwent
hemodynamic monitoring during maximal treadmill exercise testing.
During exercise, the severity of dyspnea and fatigue was evaluated on a
scale of 6 to 20 (Borg scale). The level of perceived exercise
intolerance during daily activities was evaluated with the Minnesota
Living With Heart Failure Questionnaire and the Yale Dyspnea-Fatigue
Index. Maximal treadmill exercise increased the
O2 to 13.4±2.8
mL · min-1 · kg-1, the dyspnea
score to 15.7±2.3, the fatigue score to 14.8±3.4, the pulmonary
wedge
pressure to 28±11 mm Hg, and the pulmonary artery lactate
concentration to 34.5±16.3 mg/dL and decreased the pulmonary artery
hemoglobin oxygen saturation to 30±9%. The level of perceived dyspnea
had no relation to the pulmonary wedge pressure and correlated only
minimally with the level of excessive ventilation (r=.39).
The level of perceived fatigue correlated only weakly with blood
lactate concentration (r=.55). Eleven patients (21%)
exhibited a normal cardiac output and wedge pressure <20 mm Hg during
exercise, 22 (42%) exhibited a normal cardiac output but wedge
pressure >20 mm Hg during exercise, and 19 (37%) exhibited reduced
cardiac output and wedge pressure >20 mm Hg during exercise. Despite
these markedly different hemodynamic responses, all three groups
exhibited similar levels of fatigue and dyspnea at comparable workloads
and had comparable total scores for the Minnesota Living With Heart
Failure Questionnaire and the Yale Dyspnea-Fatigue Index. There was no
relation between the Living With Heart Failure Questionnaire and peak
exercise O2 and only a weak
correlation between the Dyspnea-Fatigue Index and peak
O2 (r=.48).
Conclusions The level of exercise intolerance perceived by patients with heart failure has little or no relation to objective measures of circulatory, ventilatory, or metabolic dysfunction during exercise. In patients who report severe exertional symptoms, it may be desirable to directly measure hemodynamic response to exercise to ensure that these symptoms are due to circulatory dysfunction.
Key Words: heart failure • transplantation • exercise
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