Bendopnea

Bendopnea is a medical term to describe shortness of breath while bending forward. Bendopnea is one of the signs and symptoms of advanced heart failure associated with increased mortality ¹. Bendopnea has been related to an increase in cardiac filling pressures ². Its frequency, repercussions on quality of life and prognosis (mortality and readmission) are uncertain and further investigation is needed before drawing a definite conclusion.

Bendopnea could also occur in people without heart failure, especially in the elderly and in those with higher body mass index (BMI), but this fact has not been studied ³.

Heart failure is classified into heart failure with reduced ejection fraction, mid-range ejection fraction, and preserved ejection fraction ⁴. In 2014, Thibodeau et al. ⁵ proposed bendopnea or “shortness of breath when bending forward”, as a novel symptom of advanced heart failure. The symptom is mediated by increased ventricular filling pressure during bending, which exacerbates an already high filling pressure in patients with heart failure. It was also associated with a worse cardiac index (Fick’s method), pulmonary capillary wedge pressure, right heart pressure, and pulmonary arterial pressure ⁵. Although one study reported a lower cardiac index measured by Fick’s method by cardiac catheterization ⁵, four studies showed no significant difference in the left ventricular ejection fraction evaluated using echocardiography in those with or without bendopnea. The pooled analysis yielded a similar result.

Sajeev et al ⁶ reported that patients without bendopnea were associated with a higher rate of heart failure readmission. However, two other studies reported no significant difference. A pooled analysis showed that the rate of readmission was not associated with bendopnea ¹.

Two studies by Sajeev et al ⁶ and Thibodeau et al ² (both have a follow-up period of 12 months) reported no significant difference between mortality in patients with bendopnea. A study by Baeza-Trinidad et al ⁷, which has a significantly larger sample and event rate, showed that bendopnea was associated with higher mortality (6-month follow-up). A pooled analysis showed that bendopnea was associated with increased mortality with an odds ratio of 2.21. However, Baeza-Trinidad sample has a mean age of 81 years, and this may indicate that the mortality outcome is more relevant in the elderly. Sensitivity analysis by omission of Baeza-Trinidad et al ⁷ study still results in a significant outcome with odds ratio of 2.84. It is also still significant if the random-effect model is used.

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly.

Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications and, in some cases, use of devices that help the heart beat and contract properly.

Bendopnea causes

The pathophysiology of bendopnea is uncertain ⁸. For heart failure patients, postural changes may affect the bronchial vasculature and alter the airway caliber ⁹. Bendopnea is associated with positional elevation of the right and left side filling pressures during bending, but it is not clear if it is due to increased intrathoracic or intrabdominal pressure ². Baeza‐Trinidad et al ³ studied the relationship of those areas with bendopnea and they did not notice an association between cardiomegaly, pleural effusion, or ascites, probably due to the high prevalence of these signs in this sample ¹⁰. However, it was related to hepatomegaly, because an increase in intra‐abdominal pressure may lead to an increase in right atrial pressure. Additionally, our study did not show a relationship between BMI and bendopnea, in contrast to other studies, possibly because in our sample BMI was lower than in previous studies ².

Causes of heart failure include:

• Ischemic heart disease
• Diabetes
• High blood pressure
• Other heart conditions or diseases:
  • Arrhythmia. Happens when a problem occurs with the rate or rhythm of the heartbeat.
  • Cardiomyopathy. Happens when the heart muscle becomes enlarged, thick, or rigid.
  • Congenital heart defects. Problems with the heart’s structure are present at birth.
  • Heart valve disease. Occurs if one or more of your heart valves doesn’t work properly, which can be present at birth or caused by infection, other heart conditions, and age.
• Other factors:
  • Alcohol abuse or cocaine and other illegal drug use
  • HIV/AIDS
  • Thyroid disorders (having either too much or too little thyroid hormone in the body)
  • Too much vitamin E
  • Treatments for cancer, such as radiation and chemotherapy

Bendopnea symptoms

Three studies that reported symptoms showed that dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and abdominal fullness were more frequent in patients with bendopnea ¹¹. Thibodeau et al ⁵ reported more frequent symptoms of angina, weight gain, and palpitations. However, Baeza-Trinidad et al ¹¹ showed that palpitation was not significantly different in patients with or without bendopnea. Thibodeau et al ⁵ and Dominguez-Rodriguez ¹² reported that ankle swelling was not different in patients with bendopnea or not. Early satiety and ascites were also not associated with bendopnea. Pooled analysis showed that dyspnea (odds ratio 69.70), orthopnea (odds ratio3.02), paroxysmal nocturnal dyspnea (odds ratio 2.76) and abdominal fullness (odds ratio 7.50) were more frequent in patients with bendopnea.

Two studies reported that elevated jugular venous pressure was more frequent in patients with bendopnea ¹³. Baeza-Trinidad et al  ¹¹ reported that hepatomegaly was more frequent in patients with bendopnea, but Dominguez-Rodriguez et al ¹² reported no difference. On pooled meta-analysis ¹, it was found that bendopnea was not associated with BMI, lower extremity edema, or pulmonary edema and/or rales. Hence, the only sign that is more frequent in patients with bendopnea is an elevated jugular venous pressure. However, meta-analysis cannot be done on this sign because there were only two studies.

Bendopnea diagnosis

To diagnose heart failure, your doctor will take a careful medical history, review your symptoms and perform a physical examination. Your doctor will also check for the presence of risk factors, such as high blood pressure, coronary artery disease or diabetes.

Using a stethoscope, your doctor can listen to your lungs for signs of congestion. The stethoscope also picks up abnormal heart sounds that may suggest heart failure. The doctor may examine the veins in your neck and check for fluid buildup in your abdomen and legs.

After the physical exam, your doctor may also order some of these tests:

• Blood tests. Your doctor may take a blood sample to look for signs of diseases that can affect the heart. He or she may also check for a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP) if your diagnosis isn’t certain after other tests.
• Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. Your doctor can also use an X-ray to diagnose conditions other than heart failure that may explain your signs and symptoms.
• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. It helps your doctor diagnose heart rhythm problems and damage to your heart.
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart. This test can help doctors see the size and shape of your heart along with any abnormalities. An echocardiogram measures your ejection fraction, an important measurement of how well your heart is pumping, and which is used to help classify heart failure and guide treatment.
• Stress test. Stress tests measure the health of your heart by how it responds to exertion. You may be asked to walk on a treadmill while attached to an ECG machine, or you may receive a drug intravenously that stimulates your heart similar to exercise. Sometimes the stress test can be done while wearing a mask that measures the ability of your heart and lungs to take in oxygen and breathe out carbon dioxide. If your doctor also wants to see images of your heart while you’re exercising, he or she may use imaging techniques to visualize your heart during the test.
• Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest.
• Magnetic resonance imaging (MRI). In a cardiac MRI, you lie on a table inside a long tubelike machine that produces a magnetic field, which aligns atomic particles in some of your cells. Radio waves are broadcast toward these aligned particles, producing signals that create images of your heart.
• Coronary angiogram. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray, helping doctors spot blockages.
• Myocardial biopsy. In this test, your doctor inserts a small, flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test may be performed to diagnose certain types of heart muscle diseases that cause heart failure.

Results of these tests help doctors determine the cause of your signs and symptoms and develop a program to treat your heart. To determine the most appropriate treatment for your condition, doctors may classify heart failure using two systems:

1. New York Heart Association classification (NYHA)
2. American College of Cardiology/American Heart Association classification

Doctors use this classification system to identify your risk factors and begin early, more aggressive treatment to help prevent or delay heart failure. These scoring systems are not independent of each other. Your doctor often will use them together to help decide your most appropriate treatment options. Ask your doctor about your score if you’re interested in determining the severity of your heart failure. Your doctor can help you interpret your score and plan your treatment based on your condition.

Four studies reported that bendopnea was associated with the New York Heart Association (NYHA) functional class IV, and patients without bendopnea were more likely to have NYHA functional class I, II, or III than patients with bendopnea ¹. On pooled analysis, the odds ratio of bendopnea patient having NYHA IV was 7.58, while the odds ratio of bendopnea patient having NYHA I, II, or III were 0.16; 0.03, 0.19 and 0.56; 0.02, respectively, showing that bendopnea is a sign of advanced heart failure.

Table 1. New York Heart Association (NYHA) Functional Classification

Class	Patient Symptoms
I	No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II	Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III	Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV	Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

[Source ¹⁴ ]

Table 2. American College of Cardiology/American Heart Association classification 

Stage	Objective Assessment
A	No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
B	Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
C	Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
D	Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

Bendopnea treatment

Bendopnea is a medical term to describe shortness of breath while bending forward. Patients with bendopnea are also more likely in a NYHA functional class IV advanced heart failure group and are also associated with increased mortality ¹.

Currently, heart failure has no cure. You’ll likely have to take medicine and follow a treatment plan for the rest of your life.

The goals of treatment for all stages of heart failure include:

• Treating the condition’s underlying cause, such as ischemic heart disease, high blood pressure, or diabetes
• Reducing symptoms
• Stopping the heart failure from getting worse
• Increasing your lifespan and improving your quality of life

Treatments usually include heart-healthy lifestyle changes, medicines, and ongoing care. If you have severe heart failure, you also may need medical procedures or surgery.

Despite treatment, symptoms may get worse over time. You may not be able to do many of the things that you did before you had heart failure. However, if you take all the steps your doctor recommends, you can stay healthier longer.

Researchers also might find new treatments that can help you in the future.

Heart-healthy lifestyle changes

Your doctor may recommend heart-healthy lifestyle changes if you have heart failure. Heart-healthy lifestyle changes include:

• Heart-healthy eating
• Aiming for a healthy weight
• Physical activity
• Quitting smoking

Medicines

Your doctor will prescribe medicines based on the type of heart failure you have, how severe it is, and your response to certain medicines. The following medicines are commonly used to treat heart failure:

• ACE inhibitors lower blood pressure and reduce strain on your heart. They also may reduce the risk of a future heart attack.
• Aldosterone antagonists trigger the body to remove excess sodium through urine. This lowers the volume of blood that the heart must pump.
• Angiotensin receptor blockers relax your blood vessels and lower blood pressure to decrease your heart’s workload.
• Beta blockers slow your heart rate and lower your blood pressure to decrease your heart’s workload.
• Digoxin makes the heart beat stronger and pump more blood.
• Diuretics (fluid pills) help reduce fluid buildup in your lungs and swelling in your feet and ankles.
• Isosorbide dinitrate/hydralazine hydrochloride helps relax your blood vessels so your heart doesn’t work as hard to pump blood. Studies have shown that this medicine can reduce the risk of death in blacks. More studies are needed to find out whether this medicine will benefit other racial groups.

Take all medicines regularly, as your doctor prescribes. Don’t change the amount of your medicine or skip a dose unless your doctor tells you to. You should still follow a heart healthy lifestyle, even if you take medicines to treat your heart failure.

Medical procedures and surgery

As heart failure worsens, lifestyle changes and medicines may no longer control your symptoms. You may need a medical procedure or surgery.

In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the heart’s pumping. To correct this problem, your doctor might implant a cardiac resynchronization therapy device (a type of pacemaker) near your heart. This device helps both sides of your heart contract at the same time, which can decrease heart failure symptoms.

Some people who have heart failure have very rapid, irregular heartbeats. Without treatment, these heartbeats can cause sudden cardiac arrest. Your doctor might implant an implantable cardioverter defibrillator (ICD) near your heart to solve this problem. An ICD checks your heart rate and uses electrical pulses to correct irregular heart rhythms.

People who have severe heart failure symptoms at rest, despite other treatments, may need:

• A mechanical heart pump, such as a left ventricular assist device. This device helps pump blood from the heart to the rest of the body. You may use a heart pump until you have surgery or as a long-term treatment.
• Heart transplant. A heart transplant is an operation in which a person’s diseased heart is replaced with a healthy heart from a deceased donor. Heart transplants are done as a life-saving measure for end-stage heart failure when medical treatment and less drastic surgery have failed.

Ongoing care

You should watch for signs that heart failure is getting worse. For example, weight gain may mean that fluids are building up in your body. Ask your doctor how often you should check your weight and when to report weight changes.

Getting medical care for other related conditions is important. If you have diabetes or high blood pressure, work with your health care team to control these conditions. Have your blood sugar level and blood pressure checked. Talk with your doctor about when you should have tests and how often to take measurements at home.

Try to avoid respiratory infections like the flu and pneumonia. Talk with your doctor or nurse about getting flu and pneumonia vaccines.

Many people who have severe heart failure may need treatment in a hospital from time to time. Your doctor may recommend oxygen therapy, which can be given in a hospital or at home.

References

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