Prognostic Significance of Dyspnea in Patients Referred for Cardiac Stress Testing
Open accessAbstract
BACKGROUND: Although dyspnea is a common symptom, there has been only limited investigation of its prognostic significance among patients referred for cardiac evaluation. METHODS: We studied 17,991 patients undergoing myocardial-perfusion single-photon-emission computed tomography during stress and at rest. Patients were divided into five categories on the basis of symptoms at presentation (none, nonanginal chest pain, atypical angina, typical angina, and dyspnea). Multivariable analysis was used to assess the incremental prognostic value of symptom categories in predicting the risk of death from cardiac causes and from any cause. In addition, the prognosis associated with various symptoms at presentation was compared in subgroups selected on the basis of propensity analysis. RESULTS: After a mean (+/-SD) follow-up of 2.7+/-1.7 years, the rate of death from cardiac causes and from any cause was significantly higher among patients with dyspnea (both those previously known to have coronary artery disease and those with no known history of coronary artery disease) than among patients with other or no symptoms at presentation. Among patients with no known history of coronary artery disease, those with dyspnea had four times the risk of sudden death from cardiac causes of asymptomatic patients and more than twice the risk of patients with typical angina. Dyspnea was associated with a significant increase in the risk of death among each clinically relevant subgroup and remained an independent predictor of the risk of death from cardiac causes (P<0.001) and from any cause (P<0.001) after adjustment for other significant factors by multivariable and propensity analysis. CONCLUSIONS: In a large series of patients, self-reported dyspnea identified a subgroup of otherwise asymptomatic patients at increased risk for death from cardiac causes and from any cause. Our results suggest that an assessment of dyspnea should be incorporated into the clinical evaluation of patients referred for cardiac stress testing.
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In EAS PheWAS of introgressed loci matching Denisovan/Neanderthal loci, an association was identified with "shortness of breath walking on level ground".
“In our EAS PheWAS of introgressed loci matching Denisovan/Neanderthal loci, we identified an association with “shortness of breath walking on level ground”, which is a trait related to cardiovascular health [36].”
From Denisovan and Neanderthal archaic introgression differentially impacted the genetics of complex traits in modern populations (2022) · cites this paper as [36]
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Stevens, J. P., Baker, K. M., Howell, M. D., & Banzett, R. B. (2016) · PLoS ONE · doi:10.1371/journal.pone.0152601 · Cited by 33 · see citing works
“[12–19] For example, dyspnea outperformed FEV1 as a predictor of 5-year mortality in chronic obstructive pulmonary disease (COPD) patients [16] and outperformed angina during exercise stress testing in predicting cardiac death[20].”
BackgroundRoutine Dyspnea Assessment on Unit Admission
Baker, K. M., Barsamian, J., Leone, D., Donovan, B. C., Williams, D., Carnevale, K., Lansing, R., & Banzett, R. B. (2013) · AJN American Journal of Nursing · doi:10.1097/01.naj.0000437112.43059.a0 · Cited by 34 · see citing works
“In a study of nearly 18,000 patients undergoing cardiac stress testing, the risk of death from any cause was higher among patients with dyspnea than among those without.(3) A fiveyear, prospective, multicenter Japanese study of 227 patients with chronic obstructive pulmonary disease (COPD) found that the level of dysp…”
BackgroundChase, P., Arena, R., Myers, J., Abella, J., Peberdy, M., Guazzi, M., Kenjale, A., & Bensimhon, D. (2008) · American Journal of Cardiology · doi:10.1016/j.amjcard.2008.05.031 · Cited by 33 · see citing works
“It as reported that apparently healthy patients who reported yspnea as the reason for termination of an exercise test had ignificantly higher rates of cardiac and all-cause mortality ompared with patients reporting other symptoms.(1) It was lso reported that patients with and without known cardiac rtery disease referr…”
ResultKoller, D., Wendt, F. R., Pathak, G. A., De Lillo, A., De Angelis, F., Cabrera-Mendoza, B., Tucci, S., & Polimanti, R. (2022) · BMC Biology · doi:10.1186/s12915-022-01449-2 · Cited by 27 · see citing works
“In our EAS PheWAS of introgressed loci matching Denisovan/Neanderthal loci, we identified an association with “shortness of breath walking on level ground”, which is a trait related to cardiovascular health [36].”
BackgroundGuazzi, M., Myers, J., Peberdy, M., Bensimhon, D., Chase, P., & Arena, R. (2010) · International Journal of Cardiology · doi:10.1016/j.ijcard.2009.03.041 · Cited by 31
“Recent research in a large cohort reported that exercise limited by dyspnea upon exertion (DOE) had a significantly worse prognosis compared to other exercise limitations [2].”
BackgroundArena, R. A., MYERS, J. N., & Guazzi, M. (2008) · American Journal of Lifestyle Medicine · doi:10.1177/1559827608323210 · Cited by 29 · see citing works
“In a large cohort of subjects (>17 000) undergoing exercise testing, mortality was significantly higher in subjects reporting dyspnea compared with those reporting no symptoms or angina.(67) Patient reports of moderately severe (3/4) angina or patient request to stop are both absolute exercise test termination criteri…”
BackgroundGibbons, R. J., Araoz, P. A., & Williamson, E. E. (2010) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2009.09.036 · Cited by 2 · see citing works
Nakajima, Y., Kane, G., McCully, R. B., Ommen, S., & Pellikka, P. (2009) · Journal of the American Society of Echocardiography · doi:10.1016/j.echo.2009.04.030 · Cited by 29
Qintar, M., Grantham, J., Sapontis, J., Gosch, K., Lombardi, W., Karmpaliotis, D., Moses, J. W., Salisbury, A. C., Cohen, D. J., Spertus, J., et al. (2017) · Circulation. Cardiovascular Quality and Outcomes · doi:10.1161/circoutcomes.117.003665 · Cited by 28 · see citing works
“Patients who present with dyspnea as their principal symptom of ischemic heart disease are less likely to be recognized as having CAD, less likely to receive evidence-based treatments, and more likely to experience poor in-hospital and long-term outcomes.(1,4,5) Although the assessment of dyspnea as an angina equivale…”
Non-ST Elevation Acute Coronary Syndromes: A Comprehensive Review
Bob‐Manuel, T., Ifedili, I., Reed, G. L., Ibebuogu, U. N., & Khouzam, R. N. (2017) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2017.04.006 · Cited by 30 · see citing works
Nakanishi, R., Rana, J., Shaleṿ, A., Gransar, H., Hayes, S., LaBounty, T. M., Dey, D., Miranda-Peats, R., Thomson, L., Friedman, J., et al. (2013) · American Journal of Cardiology · doi:10.1016/j.amjcard.2013.01.266 · Cited by 28
Self-citationCardiopulmonary laboratory biomarkers in the evaluation of acute dyspnea
Liang, J. J., Dietz, B. W., & Stokes, N. (2016) · Open Access Emergency Medicine · doi:10.2147/oaem.s71446 · Cited by 22 · see citing works
Barnett, L., Prior, J. A., Kadam, U. T., & Jordan, K. P. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-015857 · Cited by 30 · see citing works
Current trends in patients with chronic total occlusions undergoing coronary CT angiography
Opolski, M. P., Hartaigh, B. Ó., Berman, D. S., Budoff, M. J., Achenbach, S. S., Al-Mallah, M. H., Andreini, D., Cademartiri, F., Chang, H., Chinnaiyan, K. M., et al. (2015) · Heart · doi:10.1136/heartjnl-2014-306616 · Cited by 23 · see citing works
Self-citationArgulian, E., Halpern, D. G., Agarwal, V., Agarwal, S. K., & Chaudhry, F. A. (2012) · Journal of the American Society of Echocardiography · doi:10.1016/j.echo.2012.09.012 · Cited by 25 · see citing works
“First, the population in the present study carried a somewhat lower prevalence of known CAD compared with some of the earlier studies, and the mean age of the female-predominant study patients was lower (61 vs 65–71 years).(2,3,9) At the same time, the present study included a multiethnic population that had a higher…”
BackgroundMethodResultInfluentialDiastolic stress echocardiography: the time has come for its integration into clinical practice.
Oh, J., & Kane, G. (2014) · Journal of the American Society of Echocardiography · doi:10.1016/j.echo.2014.08.013 · Cited by 25
Symptom clusters and health-related quality of life in people with chronic stable angina
Kimble, L. P., Dunbar, S. B., Weintraub, W. S., McGuire, D. B., Manzo, S. F., & Strickland, O. L. (2011) · Journal of Advanced Nursing · doi:10.1111/j.1365-2648.2010.05564.x · Cited by 25 · see citing works
“However, research indicates that dyspnea is an independent predictor of adverse cardiac events post AMI (Arnold et al. 2009) and of cardiac and all cause mortality in patients referred for cardiac stress testing (Abidov et al. 2005).”
Gruner, T. (2010) · doi:10.1007/978-3-642-16483-5_1602 · Cited by 25
Pickett, C. A., Hulten, E., Goyal, M., Surry, L., & Villines, T. (2013) · American Journal of Cardiology · doi:10.1016/j.amjcard.2013.03.015 · Cited by 24
“Additionally, modern studies would benefit from the inclusion of contemporary risk factor definitions and should explore other symptom and clinical features not addressed in the DF classification that may improve pretest estimates of angiographically significant CAD.(14) Our study had several limitations that warrant…”
BackgroundInfluentialBernheim, A., Kittipovanonth, M., Scott, C., McCully, R. B., Tsang, T. S. M., & Pellikka, P. (2009) · American Journal of Cardiology · doi:10.1016/j.amjcard.2009.03.028 · Cited by 24
Abidov, A., Germano, G., Hachamovitch, R., & Berman, D. S. (2006) · Journal of Nuclear Cardiology · doi:10.1007/bf02971251 · Cited by 67 · see citing works
Self-citationHow Patients With Heart Failure Perform Daily Life Activities
Mapelli, M., Salvioni, E., Bonomi, A., Gugliandolo, P., de Martino, F., Vignati, C., Berna, G., & Agostoni, P. (2020) · Circulation: Heart Failure · doi:10.1161/circheartfailure.120.007503 · Cited by 22
“The different exercises were chosen with the aim of collecting data on 3 different kinds of activities: (1) exercises with patient-controlled intensity and time of execution (ADL1, 2, 3, 4, 6), (2) exercises with patient-controlled intensity but fixed time of execution (ADL5 and 6MWT), and (3) exercises with both fixe…”
MethodExertional Dyspnoea in Chronic Respiratory Diseases: From Physiology to Clinical Application
Dubé, B., Vermeulen, F., & Laveneziana, P. (2016) · Archivos de Bronconeumología · doi:10.1016/j.arbr.2016.11.003 · Cited by 16 · see citing works
“Dyspnoea is worth documenting and accurately assessing for at least the following reasons: (1) exertional dyspnoea is frequently one of the earliest and more troublesome symptoms that lead patients with chronic cardiac or pulmonary illnesses to seek medical care; (2) it usually progresses with the severity of the unde…”
Should we use gait speed in COPD, FEV1in frailty and dyspnoea in both?
Bousquet, J. J., Dinh‐Xuan, A. T., Similowski, T., Malva, J. O., Ankri, J., Barbagallo, M., Fabbri, L. M., Humbert, M. J. C., Mercier, J. G., Cordeiro, C. R., et al. (2016) · European Respiratory Journal · doi:10.1183/13993003.00633-2016 · Cited by 23 · see citing works
Swedish translation and linguistic validation of the multidimensional dyspnoea profile
Ekström, M. P., & Sundh, J. (2016) · European Clinical Respiratory Journal · doi:10.3402/ecrj.v3.32665 · Cited by 20 · see citing works
“In patients with suspected heart disease undergoing cardiac stress testing, more severe dyspnoea is a strong risk factor for earlier death from cardiac disease and for earlier death overall (8).”
BackgroundPatel, D., Robinson, V., Arteaga, R. B., & Thornton, J. (2008) · Journal of Nuclear Medicine · doi:10.2967/jnumed.107.049395 · Cited by 22
“The vast majority of these patients have preserved systolic function and sometimes present with symptoms of dyspnea, which is considered an equivalent of angina (29,30).”
BackgroundHellenkamp, K., Darius, H., Giannitsis, E., Erbel, R., Haude, M., Hamm, C., Hasenfuss, G., Heusch, G., Mudra, H., Münzel, T., et al. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2014.11.199 · Cited by 21
Takenaka, M., Fujita, T., Sugiyama, D., Masuda, A., Shiomi, H., Sugimoto, M., Sanuki, T., Hayakumo, T., Azuma, T., & Kutsumi, H. (2014) · Journal of hepato-biliary-pancreatic sciences · doi:10.1002/jhbp.24 · Cited by 21
Pesola, G. R., Parvez, F., Chen, Y., Ahmed, A., Hasan, R., & Ahsan, H. (2011) · European Respiratory Journal · doi:10.1183/09031936.00042611 · Cited by 21 · see citing works
“Since dyspnea is associated with an increase in mortality over time [32-36], smoking is clearly a risk factor for mortality in Bangladesh.”
Background
- Authors
- Abidov, A., Rozanski, A., Hachamovitch, R., Hayes, S. W., Aboul-Enein, F., Cohen, I., Friedman, J. D., Germano, G., & Berman, D. S.
- Affiliations
- Cedars-Sinai Medical Center (US)
- St. Luke's-Roosevelt Hospital Center (US)
- University of Southern California (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2005-11-03
- Volume
- 353
- Issue
- 18
- Pages
- 1889-1898
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2156185661
- Cited by
- 297
- References
- 32
- Citations by year
- 2026: 6 · 2025: 12 · 2024: 14 · 2023: 16 · 2022: 14 · 2021: 12 · 2020: 12 · 2019: 11 · 2018: 5 · 2017: 18 · 2016: 17 · 2015: 15 · 2014: 13 · 2013: 24 · 2012: 11
- FWCI
- 10.87
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Keywords
- dyspnea, prognosis, cardiac stress testing, myocardial perfusion imaging, sudden cardiac death, mortality, coronary artery disease, asymptomatic patients, chest pain, angina pectoris, symptom assessment
- MeSH terms
- Aged, Angina Pectoris, Coronary Disease, Dyspnea, Exercise Test, Female, Follow-Up Studies, Heart Diseases, Humans, Male, Middle Aged, Mortality, Prognosis, Risk Factors, Thallium Radioisotopes, Tomography, Emission-Computed, Single-Photon
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