title: Breathlessness at rest is not the dominant presentation of patients admitted with heart failure.
abstract: OBJECTIVE
  Many assume that most patients hospitalized with heart failure (HF) are short of breath at rest (SOBAR). The National HF Audit for England and Wales suggests that this assumption is false, which has profound implications for management
  
  
  RESULTS
  A retrospective case-note review was carried out of patients hospitalized with HF to determine how many present with shortness of breath at rest or are comfortable at rest but breathless on slight exertion (CARBOSE). Vital signs were tracked for 24 h and mortality for 180 days. Of 311 patients, those who were SOBAR (42%) had higher median heart rate (HR) (100 vs. 85 b.p.m.; P < 0.001), systolic blood pressure (SBP) (141 vs. 122 mmHg; P < 0.001), and respiratory rate (RR) (24 vs. 18 breaths/min; P < 0.001) compared with those who were CARBOSE (56%). Vital signs changed little in those who were CARBOSE over the first 4-6 h, but SBP (141-128 mmHg; P < 0.001), HR (100-90 b.p.m.; P = 0.002), and RR (24-20 breaths/min; P < 0.001) fell in those who were SOBAR. At presentation, SBP was >125 mmHg in 73% of patients who were SOBAR and in 46% who were CARBOSE, dropping to 52% and 37%, respectively, by 4-6 h. Mortality amongst those who were SOBAR and those who were CARBOSE was, respectively, 19% and 34% (odds ratio 2.29; P = 0.005, 95% confidence interval 1.29-4.06).
  
  
  CONCLUSIONS
  Many patients admitted with HF are CARBOSE. Shortness of breath at rest may be more alarming, but those who are CARBOSE have a worse prognosis, perhaps reflecting more severe right heart dysfunction. Clinical trials of hospitalized HF may inappropriately exclude patients if they focus on shortness of breath at rest rather than peripheral congestion.
authors.affiliation: Department of Cardiology, Hull York Medical School, University of Hull, Castle Hill Hospital, Kingston upon Hull, UK.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Shoaib
authors.forename: Mohammad
authors.initials: M
authors.lastname: Waleed
authors.forename: Saima
authors.initials: S
authors.lastname: Khan
authors.forename: Ali
authors.initials: A
authors.lastname: Raza
authors.forename: Mohamed
authors.initials: M
authors.lastname: Zuhair
authors.forename: Xenophon
authors.initials: X
authors.lastname: Kassianides
authors.forename: Ayse
authors.initials: A
authors.lastname: Djahit
authors.forename: Kevin
authors.initials: K
authors.lastname: Goode
authors.forename: Kenneth
authors.initials: K
authors.lastname: Wong
authors.forename: Alan
authors.initials: A
authors.lastname: Rigby
authors.forename: Andrew
authors.initials: A
authors.lastname: Clark
authors.forename: John
authors.initials: J
authors.lastname: Cleland
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001510:Bed Rest; D001794:Blood Pressure / Q000502:physiology; D002317:Cardiovascular Agents / Q000008:administration & dosage; D004417:Dyspnea / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000503:physiopathology; D006339:Heart Rate / Q000502:physiology; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008297:Male; D010102:Oxygen Inhalation Therapy; D056152:Respiratory Rate / Q000502:physiology; D012189:Retrospective Studies; D012122:Ventilators, Mechanical
chemical_list: D002317:Cardiovascular Agents
keywords: Acute heart failure; Blood pressure; Congestion; Heart rate; Respiratory rate; Symptoms