title: The worst symptom as defined by patients during heart failure hospitalization: implications for response to therapy.
abstract: BACKGROUND
  Patients perceive different symptoms of heart failure decompensation. It is not known whether the nature of the worst symptom relates to hemodynamic profile, response to therapy, or improvement in clinical trials.
  
  
  RESULTS
  Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial were hospitalized with advanced heart failure, ejection fraction ≤30%, and at least 1 sign and 1 symptom of elevated filling pressures. Visual analog scales (VAS) for symptoms were completed by 371 patients, who selected their worst symptom as difficulty breathing, fatigue, abdominal discomfort, or body swelling and also scored breathing and global condition at baseline and discharge. The dominant symptom identified was difficulty breathing by 193 (52%) patients, fatigue by 118 (32%), and abdominal discomfort and swelling each by 30 (8%) patients, combined as right-sided congestion for analysis. Clinical and hemodynamic assessments were not different between groups except that right-sided congestion was associated with more hepatomegaly, ascites, third heart sounds, and jugular venous distention. This group also had greater reduction in jugular venous distention and trend toward higher blood urea nitrogen after therapy. By discharge, average improvements in worst symptom and global score were 28 points and 24 points. For those with ≥10 points in improvement in worst symptom, 84% also improved global assessment ≥10 points. Initial fatigue was associated with less improvement (P = .002) during and after hospitalization, but improvements in symptom scores were sustained when re-measured during 6 months after discharge.
  
  
  CONCLUSIONS
  In most patients hospitalized with clinical congestion, therapy will improve symptoms regardless of the worst symptom perceived, with more evidence of baseline fluid retention and reduction during therapy for worst symptoms of abdominal discomfort or edema. Improvement in trials should be similar when tracking worst symptom, dyspnea, or global assessment.
authors: National Cardiovascular Center, Osaka, Japan.
authors: Mahoto
authors: M
authors: Kato
authors: Lynne W
authors: LW
authors: Stevenson
authors: Maryse
authors: M
authors: Palardy
authors: Patricia M
authors: PM
authors: Campbell
authors: Christopher W
authors: CW
authors: May
authors: Neal K
authors: NK
authors: Lakdawala
authors: Garrick
authors: G
authors: Stewart
authors: Anju
authors: A
authors: Nohria
authors: Joseph G
authors: JG
authors: Rogers
authors: J Thomas
authors: JT
authors: Heywood
authors: Mihai
authors: M
authors: Gheorghiade
authors: Eldrin F
authors: EF
authors: Lewis
authors: Xiaojuan
authors: X
authors: Mi
authors: Soko
authors: S
authors: Setoguchi
mesh_terms: D015746:Abdominal Pain / Q000209:etiology*; D001201:Ascites / Q000453:epidemiology; D001806:Blood Urea Nitrogen; D002407:Catheterization, Swan-Ganz; D004417:Dyspnea / Q000209:etiology*; D004487:Edema / Q000209:etiology*; D005221:Fatigue / Q000209:etiology*; D005260:Female; D006333:Heart Failure / Q000150:complications* / Q000628:therapy*; D006529:Hepatomegaly / Q000453:epidemiology; D006760:Hospitalization; D006801:Humans; D007601:Jugular Veins; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D011673:Pulsatile Flow; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015431:Weight Loss