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LISBON — Patients with decompensated heart failure who have bendopnea on discharge from hospital appear to be at significantly increased risk for all-cause mortality within 2 years, reported investigators
The research, presented here at the Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2024 and published in the European Journal of Preventive Cardiology, found that across two study cohorts, the risk for all-cause mortality was at least doubled among patients with shortness of breath when bending forward.
“Bendopnea can be assessed through a simple and noninvasive examination,” said lead researcher Taisuke Nakade, MD, from the Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine in Tokyo, who pointed out that the association with mortality is “independent of other known prognostic factors.”
The current analysis follows a study published in The New England Journal of Medicine by cardiologists in Texas who found that almost one third of patients with advanced heart failure who were referred to their cardiac catheterization lab had bendopnea.
The researchers found that these patients were sicker, suggesting they may require adjustment to their medications or further evaluation for advanced heart failure therapy.
High Risk, Low Prevalence
Nakade and his colleagues investigated the prevalence, clinical characteristics, and prognostic value of bendopnea in older patients hospitalized for heart failure using two recently completed prospective studies, FRAGILE-HF and SONIC-HF.
They included a total of 2034 Japanese patients aged 65 years or older hospitalized for heart failure decompensation in line with the Framingham criteria. All patients underwent bendopnea evaluation before discharge, which involved seating them in a chair and asking them to bend forward to touch their ankles and hold the position for as long as possible.
Those unable to hold the position for 30 seconds due to shortness of breath were diagnosed with bendopnea, Nakade said, whereas those stopping for other reasons were not defined as having the condition.
In the FRAGILE-HF cohort, Bendopnea was diagnosed in 2.5% of people and 4.4% of those in the SONIC-HF cohort. Nakade said that the prevalence of bendopnea in the two cohorts is lower than might be expected from previous analyses, which have found a prevalence of anywhere from 18% to 49%, but that may be due to differences in how and when bendopnea was assessed or the profile of the patients included. Previous studies included much smaller numbers of patients with a variety of different heart failure conditions, Nakade pointed out.
Patients with bendopnea were more likely to be female, have a higher body mass index, and be diagnosed with New York Heart Association Class III or IV heart disease. They were also more likely to have a left ventricular ejection fraction of 50% or greater and were less likely to have been treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.
Over 2 years of follow-up, 38.7% of patients with bendopnea in the FRAGILE-HF cohort died compared with 20.7% of those without. In the SONIC-HF cohort, half of those with bendopnea died compared with 20.6% of those without. Cox proportional hazards analysis of all-cause mortality revealed that after adjustment for potentially confounding factors, bendopnea was associated with a significantly increased risk for death, at a hazard ratio of 2.11 in FRAGILE-HF and 4.20 in SONIC-HF.
An Easy Test
Bettina Heidecker, MD, head of Heart Failure and Cardiomyopathy at Charité University Hospital in Berlin, Germany, and chair of the session where Nakade’s data were presented, said that she heard about bendopnea only recently.
However, the mechanism underlying the link between bending forward and breathlessness is still unclear. On possibility, she said, “It sounds like it might be a volume challenge, because when you’re bending, you’re shifting volumes in your body,” she said, similar to the Valsalva maneuver or passive leg raises done in the clinic.
“So this seems to be a similar mechanism,” Heidecker said during an interview.
Heidecker said that testing for bendopnea is an attractive proposition because the test is “very simple and very practical.” It doesn’t cost anything and has no side effects, and it could be especially valuable for cardiologists working in places without much healthcare infrastructure.
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