Cited by 297Cardiac Imaging and DiagnosticsCardiac Health and Mental HealthCardiovascular and exercise physiology

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Prognostic Significance of Dyspnea in Patients Referred for Cardiac Stress Testing

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Abidov, Aiden, Rozanski, Alan, Hachamovitch, Rory, Hayes, Sean W., Aboul-Enein, Fatma, Cohen, Ishac, Friedman, John D., Germano, Guido, Berman, Daniel S.·2005·New England Journal of Medicine

DOI 10.1056/nejmoa042741

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Abstract

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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Cardiopulmonary Exercise Testing in Heart Failure
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Prognostic Importance of Dyspnea for Cardiovascular Outcomes and Mortality in Persons without Prevalent Cardiopulmonary Disease: The Atherosclerosis Risk in Communities Study
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Gated SPECT in assessment of regional and global left ventricular function: An update
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“We have demonstrated that these patients have mortality outcomes that are even higher than patients with typical angina.(49) From a standpoint of likelihood of disease, unless pulmonary or non-coronary heart disease or other known source of exertional dyspnea is present, these patients should be considered as having a…”
BackgroundSelf-citation
Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission
Stevens, J. P., Dechen, T., Schwartzstein, R. M., O’Donnell, C. R., Baker, K. M., Howell, M. D., & Banzett, R. B. (2018) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2018.02.013 · Cited by 51
“Further, in both the outpatient and inpatient setting, dyspnea has been identified as an alarm of possible patient harm and poor outcome (11, 12, 14).”
Background
Long-term mortality following normal exercise myocardial perfusion SPECT according to coronary disease risk factors
Rozanski, A., Gransar, H., Min, J. K., Hayes, S. W., Friedman, J. D., Thomson, L., & Berman, D. S. (2013) · Journal of Nuclear Cardiology · doi:10.1007/s12350-013-9830-z · Cited by 48
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Approach to Adult Patients with Acute Dyspnea
DeVos, E., & Jacobson, L. (2015) · Emergency Medicine Clinics of North America · doi:10.1016/j.emc.2015.08.008 · Cited by 42
“The subset with no prior known coronary artery disease had more than 4 times the risk of sudden cardiac death versus asymptomatic patients and more than twice the risk of those with typical angina.(31)”
Benefit of Early Revascularization Based on Inducible Ischemia and Left Ventricular Ejection Fraction
Rozanski, A., Miller, R. J. H., Gransar, H., Han, D., Slomka, P. J., Dey, D., Hayes, S. W., Friedman, J. D., Thomson, L., & Berman, D. S. (2022) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2022.04.052 · Cited by 47
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Exertional dyspnoea in pulmonary arterial hypertension
Dumitrescu, D., Sitbon, O., Weatherald, J. C., & Howard, L. (2017) · European Respiratory Review · doi:10.1183/16000617.0039-2017 · Cited by 43
Current but not past smoking increases the risk of cardiac events: insights from coronary computed tomographic angiography
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Meta-Analysis of Prognostic Implications of Dyspnea Versus Chest Pain in Patients Referred for Stress Testing
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“2 studies also reported a greater prevalence of left ventricular enlargement on imaging studies among patients with dyspnea.(10,15) Five studies reported ischemic electrocardiographic changes during stress testing, and ischemia on imaging was reported by 5 studies.”
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Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations
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Validation of the Swedish Multidimensional Dyspnea Profile (MDP) in outpatients with cardiorespiratory disease
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“In patients with suspected heart disease undergoing cardiac stress testing, more severe breathlessness is a strong risk factor for earlier death overall and from cardiac disease.(5) Breathlessness consists of several different qualitatively distinct sensations that vary in intensity.”
Background
An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses
Bailey, C. D., Wagland, R., Dabbour, R. S., Caress, A., Smith, J. A., & Molassiotis, A. (2010) · BMC Pulmonary Medicine · doi:10.1186/1471-2466-10-63 · Cited by 32
“Abidov et al [16] identified increased mortality in patients with known or suspected cardiac disease in whom breathlessness was present, while others [13] comment on the relationship between breathlessness and poor prognosis in non-heart failure populations.”
Background
Prevalence and Predictive Value of Dyspnea Ratings in Hospitalized Patients: Pilot Studies
Stevens, J. P., Baker, K. M., Howell, M. D., & Banzett, R. B. (2016) · PLoS ONE · doi:10.1371/journal.pone.0152601 · Cited by 33
“[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].”
Background
Routine 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
“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…”
Background
Prognostic usefulness of dyspnea versus fatigue as reason for exercise test termination in patients with heart failure.
Chase, 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
“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…”
Result
Denisovan and Neanderthal archaic introgression differentially impacted the genetics of complex traits in modern populations
Koller, 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
“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].”
Background
Ventilatory efficiency and dyspnea on exertion improvements are related to reduced pulmonary pressure in heart failure patients receiving Sildenafil.
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“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].”
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The Clinical Significance of Aerobic Exercise Testing and Prescription: From Apparently Healthy to Confirmed Cardiovascular Disease
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“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…”
Background
The Year in Cardiac Imaging
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Dyspnea Among Patients with Chronic Total Occlusions Undergoing Percutaneous Coronary Intervention: Prevalence and Predictors of Improvement
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
“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 33
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Cardiopulmonary 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
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Current trends in patients with chronic total occlusions undergoing coronary CT angiography
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Self-citation
Predictors of Ischemia in Patients Referred for Evaluation of Exertional Dyspnea: A Stress Echocardiography Study
Argulian, 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
“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…”
BackgroundMethodResultInfluential
Diastolic 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 28
“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).”
Diabetes Type 2
Gruner, T. (2010) · doi:10.1007/978-3-642-16483-5_1602 · Cited by 25
Accuracy of Traditional Age, Gender and Symptom Based Pre-Test Estimation of Angiographically Significant Coronary Artery Disease in Patients Referred for Coronary Computed Tomographic Angiography
Pickett, C. A., Hulten, E. A., Goyal, M., Surry, L., & Villines, T. C. (2013) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2013.03.015 · Cited by 23
“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…”
BackgroundInfluential
Relation of Dyspnea in Patients Unable to Perform Exercise Stress Testing to Outcome and Myocardial Ischemia
Bernheim, A. M., Kittipovanonth, M., Scott, C. G., McCully, R. B., Tsang, T. S. M., & Pellikka, P. A. (2009) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2009.03.028 · Cited by 26
Gated SPECT in assessment of regional and global left ventricular function: Major tool of modern nuclear imaging
Abidov, A., Germano, G., Hachamovitch, R., & Berman, D. S. (2006) · Journal of Nuclear Cardiology · doi:10.1007/bf02971251 · Cited by 67
Self-citation
How 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…”
Method
Exertional 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
“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
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
“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).”
Background
Diastolic Filling Parameters Derived from Myocardial Perfusion Imaging Can Predict Left Ventricular End-Diastolic Pressure at Subsequent Cardiac Catheterization
Patel, 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).”
Background
The German CPU Registry: Dyspnea independently predicts negative short-term outcome in patients admitted to German Chest Pain Units.
Hellenkamp, 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
What is the most adapted indication of prophylactic pancreatic duct stent within the high‐risk group of post‐endoscopic retrograde cholangiopancreatography pancreatitis? Using the propensity score analysis
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
Arsenic exposure from drinking water and dyspnoea risk in Araihazar, Bangladesh: a population-based study
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
“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)
ORCID: Abidov, Aiden
Rozanski, Alan
Hachamovitch, Rory
Aboul-Enein, Fatma
Germano, Guido
Berman, Daniel S.
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
DOI: 10.1056/nejmoa042741
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 › Physiology (medical) › 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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Prognostic Significance of Dyspnea in Patients Referred for Cardiac Stress Testing

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