American Journal of Emergency Medicine (2012) 30, 925-931.e2

Brief Report

Trepopnea may explain right-sided pleural effusion in patients with decompensated heart failure^?,??,?

Bruno Schneider de Araujo MS, Roberta Reichert MS, Diego Andre Eifer MS, Stephan A. Soder MS, Manoel B. Schmiedel dos Santos MS,

Nadine Clausell MD, PhD, Luis Beck-da-Silva MD, ScD?

Heart Failure and cardiac transplantation Unit, Cardiology Division at Hospital de Clinicas de Porto Alegre (HCPA), Federal University of Rio Grande do Sul (UFRGS) Medical School, Porto Alegre, Brazil

Received 1 January 2011; revised 21 March 2011; accepted 18 April 2011

Abstract

Background: Physicians often overlook trepopnea as a symptom, and its prevalence and clinical repercussions are not usually described. We propose that trepopnea is a common symptom in heart failure and, because of patient avoidance of left lateral decubitus position, contributes to the greater prevalence of right-sided pleural effusion in patients with HF. Accordingly, this study aimed to determine trepopnea prevalence and to evaluate the association of trepopnea and the laterality of pleural effusion in decompensated HF.

Methods: Consecutive patients (n = 37) with decompensated HF and evidence of pleural effusion by chest x-ray were included. Data were collected at the emergency department by a standard clinical examination in which patients were specifically asked about the presence of trepopnea and preferred decubitus position while recumbent. Chest x-ray and echocardiographic parameters were recorded.

Results: Of the 37 patients, 19 (51%) reported trepopnea. Most patients presented with right-sided pleural effusion; only 2 patients (5.4%) presented with left-sided pleural effusion. Patients who reported trepopnea had predominant right-sided pleural effusion more frequently than patients without this symptom (73.7% vs 26.3%; P = .049). The participants that reported trepopnea or avoidance of left lateral decubitus position while recumbent or both had a greater probability of having predominant right-sided pleural effusion (likelihood ratio, 1.85; 95% confidence interval, 1.02-3.35).

Conclusions: Trepopnea is a common symptom in patients with decompensated HF and is associated with predominant right-sided pleural effusion in this population. Our results indicate that trepopnea may be a contributory factor for pleural effusion laterality in patients with decompensated HF.

(C) 2012

^? Support: RR received a research grant from the Fundo de Incentivo a Pesquisa do Hospital de Clinicas de Porto Alegre. (Incentive Fund to Research of Hospital de Clinicas de Porto Alegre).

^?? Conflict of interest: There are no conflicts of interest to disclose for all authors. All authors had access to the data.

^? Contributions: Study design: LBS, BSA, and RR; data collection and analysis: BSA, RR, DAE, SAS, and MBSS; manuscript preparation: LBS,

BSA, RR, and NC. LBS takes responsibility for the integrity of the work as a whole, from inception to published article.

* Corresponding author. Cardiology Division, Hospital de Clinicas de Porto Alegre (HCPA), CEP 90035-003 Porto Alegre, RS, Brazil. Tel.: +55 51 3359 8843; fax: +55 51 3359 8843.

E-mail address: [email protected] (L. Beck-da-Silva).

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.04.013

Introduction

Dyspnea is a cardinal symptom in medicine, and its manifestation is widely variable depending on underlying clinical conditions. In heart failure , patients usually complain of shortness of breath while lying down, known as orthopnea; and this simple information increases consider- ably the probability of HF diagnosis [1] and determines its prognosis [2,3]. Trepopnea is an uncommon form of orthop- nea limited to 1 lateral decubitus position. Its prevalence, pathophysiology, and clinical repercussions as well as Diagnostic and prognostic value are incompletely understood. Pleural effusion is common in patients with HF and usually causes worsening of dyspnea. It is estimated that up to 87% of patients admitted because of decompensated HF have pleural effusion; in most cases, it is right sided or bilateral [4]. Clinicians and cardiologists consider HF to be the major underlying condition when a patient has predominantly right-sided pleural effusion [5], whereas left pleural effusion is considered a rare clinical finding in

patients with HF [6].

There are several theories to explain the laterality of Pleural effusions in patients with HF, and these theories are derived from anatomical considerations that were published almost a century ago. The right lung, when challenged by pulmonary edema, might allow greater accumulation of fluid due to its wider surface; alternatively, movement of the heart due to gravity might distort the pulmonary veins in a way that impairs venous return from the lungs. In right lateral decubitus position, the right pulmonary center is approxi- mately 10 cm below the left ventricle, whereas in left lateral decubitus position, the left pulmonary center is only 2 to 4 cm below the left ventricle. The latter generates higher hydrostatic pressure toward the right lung. Importantly, none of these theories have been confirmed. Most conditions that would increase cardiac filling pressures would increase hydrostatic pressure in pulmonary veins and cause plasmatic transudation toward the pleural space; thus, this does not explain why right pleural effusion is predominant [7].

In our practice, we observed that our patients frequently prefer to lie on their right sides when they sleep. If questioned, many report having trepopnea (ie, dyspnea in the left lateral decubitus position). In fact, it has been reported that patients with HF lie on their right side for over half of the time from 3:00 AM to 6:00 AM [8]. By reviewing patients’ nocturnal polysomnography results, Bradley et al found that patients with HF spontaneously avoid the left lateral decubitus position during sleep [9]. This may be explained by evidence of increased cardiac Sympathetic activity and decreased Vagal tone in patients with HF when assuming a left lateral decubitus position; these are normalized when patients assume a right lateral decubitus position [10].

There is evidence that patients with HF avoid the left lateral decubitus position, and there is a lack of understand- ing of the observed predominance of right-sided pleural

effusion in HF. We hypothesize that trepopnea or the avoidance of the left lateral decubitus position is associated with right-sided pleural effusion in patients with decom- pensated HF. Accordingly, in this study, we investigated the presence of trepopnea in patients who presented at the emergency department (ED) because of decompensated HF and who showed pleural effusion on the chest x-ray.

Methods

Subjects, study site, and design

Thirty-seven patients with decompensated HF who presented at the ED were included in a prospective cross- sectional study conducted in Porto Alegre, Brazil. A flow chart depicting the number of patients screened, reasons for exclusions, and final study sample are shown in Fig. 1.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) older than 18 years; (2) admitted to the ED because of signs and symptoms of HF; (3) diagnosis of HF established by the ED assistant physicians based on clinical examination, chest radiograph, and echocardiogram; (3) evidence of pleural effusion and pulmonary interstitial edema on chest radiograph; and (4) able to provide informed consent. All clinical diagnoses were reviewed by the investigator (cardiologist, LBS); and at least a combination of 2 of the following signs/symptoms was needed: dyspnea, orthopnea, edema, jugular venous disten- sion, and third heart sound.

The exclusion criteria were established to avoid Potential causes of pleural effusion other than HF: (1) clinical or radiographic evidence of respiratory tract infection; (2) evidence of extrapulmonary infection with systemic com- promise; (3) any chronic inflammatory condition, such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and/or inflammatory bowel disease; (4) thoracic or abdominal surgery in the previous month; (5) active cancer; or (6) refusal to participate in the study.

Study procedures

All comers during work days from January 2010 to August 2010 were screened, looking for the study inclusion criteria. After providing written informed consent, patients who met the inclusion criteria and none of the exclusion criteria were given a standardized questionnaire. The patients were consi- dered to have trepopnea if they reported avoiding the left lateral decubitus position because it worsened dyspnea, fatigue, or thoracic discomfort or because it led to an uncom- fortable sensation of the heart beating against the chest wall. The patient’s preferred decubitus position when recumbent was classified as: right, left, dorsal, ventral, or no preference.

Fig. 1 Flow chart.

All patients had a posteroanterior and lateral chest radiograph performed. Pleural effusion was diagnosed by a radiologist blinded to the conduct of the study. Pleural effusion was classified as follows: (1) right pleural effusion,

(2) bilateral pleural effusion with right predominance, (3) left pleural effusion, (4) bilateral pleural effusion with left predominance, or (5) bilateral pleural effusion without predominance. The first and second groups were considered predominant right-sided pleural effusion, and the remaining groups were considered to have no right-sided predominance. Data from echocardiogram were collected if it was performed during the first 48 hours of ED management. Patients who could not perform an echocardiogram in the first 48 hours but had an echocardiogram scan performed in the last 6 months were included because no other major cardiovas- cular event had happened within this period. This study was

approved by the local ethics and research committee.

Study end points

As a cross-sectional study, predominant right-sided pleural effusion was taken as an end point; and trepopnea, as a predictor variable. The main aim was to ascertain whether trepopnea is associated with the fact that pleural

effusion in the context of decompensated HF predominates on the right side. This study design also allowed us to assess the prevalence of trepopnea in patients with decompensated HF and to explore correlations of Diastolic function, ventricular dimensions, and trepopnea.

Statistical analysis

We could not calculate the estimated sample size because of the lack of any previous study that evaluated the association of trepopnea, preferred recumbent position, and laterality of pleural effusion in congestive HF. Therefore, we consider the present work to be a pilot study.

The association between trepopnea and preferred decu- bitus position during sleep and laterality of pleural effusion was evaluated by ?2 test or Fisher exact test depending on the sample size. Echocardiographic measurements were compared by the Student t test for independent samples or by Mann-Whitney U test, depending on sampling distribu- tion of the groups. Continuous variables are presented as mean +- SD or SE or as median for asymmetric data. Categorical variables are presented as percentages. SPSS software version 16.0 (SPSS, Chicago, IL) was used to perform the statistical analyses.

Table 1 Population characteristics according to trepopnea presence or predominance of pleural effusion

Trepopnea (n = 19)		No trepopnea (n = 18)	P	Right-sided predominance (n = 21)	No right-sided predominance (n = 16)	P
Age (y)	67.1 +- 11.8	63.8 +- 13.4	.44	66.8 +- 10.6	64 +- 14.7	.44
Male sex (%)	36.8	61.1	.19	42.8	56.2	.41
White (%)	84.2	77.8	.69	38.1	75	.04
Current or previous Tobacco use (%)	52.6	27.8	.18	71.4	75	1
Ischemic etiology (%)	36.8	38.9	1	38.1	37.5	1
NYHA functional class III or IV (%)	100	88.9	.23	100	87.5	.18
Paroxysmal nocturnal dyspnea (%)	73.7	83.3	.48	76.2	81.3	.71
Jugular venous turgence (%)	94.7	72.2	.09	95.2	68.7	.03
Pulmonary crackles (%)	94.7	100	.32	95.2	100	.37
Peripheral edema (%)	94.7	83.3	.67	95.2	81.2	.49
Third heart sound (%)	5.3	16.7	.34	9.5	12.5	.77
Systolic arterial pressure (mm Hg) a	128.5 +- 28	127.4 +- 25	.9	123 +- 27	133 +- 24	.27
Diastolic arterial pressure (mm Hg) a	79 +- 16	80 +- 16	.75	79 +- 16	81 +- 17	.76
Heart rate (beats per minute) a	91 +- 21	98 +- 27	.42	92 +- 24	98 +- 26	.55
Ejection fraction N55% (%)	26.3	5.6	.08	19	12.5	.59
Body mass index (kg/m2) a	27 +- 5	28 +- 7	.48	26 +- 5	29 +- 7	.14
Systemic Arterial hypertension (%)	73.7	72.2	.92	71.4	75	.80
Diabetes mellitus (%)	57.9	66.7	.58	57.1	68.8	.47
COPD (%)	26.3	11.1	.24	19	18.8	.98
Previous cerebrovascular event (%)	10.5	11.1	.95	14.3	6.3	.43
Previous cancer (%)	10.5	5.6	.58	9.5	6.3	.71
HIV infection (%)	0	5.6	.29	4.8	0	.37
Peripheral vascular disease (%)	15.8	11.1	.67	9.5	18.8	.63
Chronic liver disease (%)	5.3	11.1	.51	9.5	6.3	.71
Atrial fibrillation (%)	56.6	29.4	.19	45	37.5	.65
Hypothyroidism (%)	21.1	11.1	.41	19	12.5	.68
Hyperthyroidism (%)	0	0	1	0	0	1
HF admissions in previous year (mean +- SD)	3.5 +- 5.6	1.9 +- 3.6	.314	4.0 +- 5.7	1.0 +- 1.9	.04
Time from HF diagnosis (mo)	88.1 +- 117	67 +- 100	.57	68.4 +- 96	90.7 +- 125	.54
Hemoglobin level (g/dL)	13.1 +- 2.0	12.9 +- 1.4	.69	13.3 +- 1.9	12.6 +- 1.5	.26
Hematocrit (%)	41 +- 5.9	39 +- 3.9	.31	41.2 +- 5.7	38.9 +- 4.0	.18
White cell count (x10-3 per mm3)	7.13 +- 3.01	7.17 +- 2.50	.97	7.83 +- 1.84	6.25 +- 3.45	.08
Albumin (g/dL)	3.5 +- 0.51	3.5 +- 0.38	.85	3.5 +- 0.5	3.5 +- 0.39	.59
Creatinine (mg/dL)	1.3 +- 0.42	1.22 +- 0.32	.48	1.2 +- 0.31	1.4 +- 0.42	.07
TSH (mIU/L)	3.78 +- 4.22	6.47 +- 8.92	.24	4.86 +- 5.50	5.32 +- 8.66	.84
Sodium (mmol/L)	139.3 +- 2.1	138.3 +- 3.2	.14	138.9 +- 2.28	139 +- 3.43	.86
Potassium (mmol/L)	4.5 +- 0.6	4.4 +- 0.7	.73	4.3 +- 0.5	4.7 +- 0.7	.63
Urea nitrogen (mg/dL)	62.9 +- 15.1	57.6 +- 19.7	.36	59.1 +- 15	61.9 +- 20.7	.63
ACE inhibitor use (%) b	94.7	61.1	.01	90.5	62.5	.05
?-Blocker use (%) b	57.4	33.3	.13	38.1	56.3	.33
Spironolactone use (%) b	15.8	27.8	.37	23.8	18.8	.71
Digoxin use (%) b	26.3	33.3	.64	33.3	25	.58
Furosemide use (%) b	68.4	66.7	.90	66.7	68.8	.89
ARB use (%) b	5.3	11.1	.51	4.8	12.5	.59

NYHA indicates New York Heart Association; COPD, chronic obstructive pulmonary disease; TSH, thyroid stimulating hormone; ACE, angiotensin- converting enzyme; ARB, angiotensin receptor blocker.

^a Evaluated in ED admission.

^b Drugs used before ED admission.

Results

Thirty-seven patients with decompensated HF and pleural effusion were assessed at the ED during the study period (January 2010-August 2010). The mean left ventricular

ejection fraction was 36% +- 15%, and 49% of the patients were male. Fifty-seven percent of the patients had right or predominantly right-sided pleural effusion; these patients more often presented with high jugular venous pressure, had significantly more HF admissions in previous year, and used

P = .049

Table 2 The pleural effusion laterality in the study population

n (%)
Right	13	(35.1)
Bilateral with right predominance	8	(21.6)
Bilateral without predominance	7	(18.9)
Bilateral with left predominance	7	(18.9)
Left	2	(5.4)

70

Patients with right-sided predominant pleural effusion (%)

60

50

40

30

angiotensin-converting enzyme inhibitors more frequently; but there were no other relevant differences according to the dominant side of pleural effusion or the presence of trepopnea (Tables 1 and 2).

The pleural effusion laterality in the study population is shown in Table 2.

Nineteen patients (51%) reported trepopnea. In this subgroup, 14 (73.7%) presented with predominantly right- sided pleural effusion; and only 5 (26.3%) did not have right- sided pleural effusion (P b .05) (Table 3). In the group of 21 patients who presented with predominantly right-sided pleural effusion, 13 (62%) reported that they preferred a right lateral recumbent decubitus position; and 8 (38%) reported that they preferred a decubitus position other than on their right side (P = .065). Similarly, the right lateral decubitus position was preferred over all others in the group of patients who reported trepopnea (68.4% vs 27.8%; P b

.05). The association between trepopnea and right-sided dominant pleural effusion is illustrated in Fig. 2. The association between trepopnea and left-sided dominant pleural effusion is illustrated in Fig. 3.

Thus, although the presence of trepopnea in a patient with decompensated HF roughly doubled the chances that the patient had predominantly right-sided pleural effusion, its absence significantly decreased the chances of finding right- sided pleural effusion by 60%. The diagnostic performance of having trepopnea or preferring a right recumbent decubitus position or both for predicting predominant right-sided pleural effusion is shown in Table 4.

20

10

0

Trepopnea No trepopnea

Fig. 2 Association between trepopnea and right-sided pleural effusion.

We observed that patients who complained of trepopnea had significantly smaller left ventricular systolic (54 +- 9.5 vs 63 +- 11 mm; P = .03) and diastolic (43 +- 10 vs 53 +- 13 mm; P = .01) diameters than patients without this complaint and that significantly more patients with trepopnea had preserved left ventricular ejection fraction (42% vs 11%; P = .03) (Table 5).

Discussion

This is the first study to investigate whether the greater incidence of right-sided pleural effusion observed in patients with decompensated HF is related to the patients’ preferred decubitus position. We showed that patients who present with trepopnea have right-sided pleural effusion significantly

P = .049

70

Table 3 Thoracic radiographic findings according to trepopnea presence

Patients with left-sided predominant pleural effusion (%)

60

50

Trepopnea (n = 19)		No trepopnea (n = 18)	P
Cardiomegaly (%)	88.2	100	.12
Kerley B lines (%)	64.7	53.3	.51
Pulmonary interstitial edema	75.0	57.1	.3
cephalization (%)
Pulmonary interstitial	100	100	1
edema (%)
Evidence of primary lung	0	5.9	.48
disease (%)
Predominantly right-sided	73.7	38.9	.05
pleural effusion (%)

40

30

20

10

0

Trepopnea No trepopnea

Fig. 3 Association between trepopnea and left-sided pleural effusion.

Table 4 Accuracy of trepopnea and right lateral decubitus position preference in predicting right-sided predominant pleural effusion
	Sensitivity (%)	Specificity (%)	Likelihood ratio
			Present	Absent
Trepopnea	66.6	68.7	2.1 (0.97-4.68)	0.4 (0.24-0.96)
Right lateral decubitus position preference	62	69	1.98 (0.89-4.41)	0.55 (0.29-1.05)
Trepopnea or right lateral decubitus position	81	56	1.85 (1.02-3.35)	0.34 (0.13-0.90)
preference (or both) Likelihood ratio if finding present, positive likelihood ratio; likelihood ratio if finding absent, negative LR.

more frequently than any other pleural effusion presentation. We believe that these data support the hypothesis that the right-sided predominance is due to patient avoidance of the left lateral decubitus position when in bed.

It is well known that patients with HF prefer the right lateral decubitus position over any other recumbent position and spend 2-fold more time in this position than in the supine or left lateral decubitus positions [9]. There have been several proposed explanations for this: the uncomfortable sensation of the apex beat [5], increased norepinephrine spill [10], a worsened left ventricular filling pattern [11], and facilitated gastric emptying [10] that results in an increase in vagal activity and increased preload [12]. However, the prevalence of trepopnea and its relation to pleural effusion laterality in patients who present to the ED because of decompensated HF has yet to be investigated.

Some researchers and physicians consider trepopnea to be a rare form of orthopnea [13]. Challenging this notion, we found that, in a group of patients with decompensated HF, half presented with trepopnea and stated that they avoided the left lateral decubitus position. Moreover, most of these patients had predominantly right-sided pleural effusion. Our findings of increased prevalence of tre- popnea in patients with higher jugular venous pressure are in accordance with other authors’ findings of increased pulmonary capillary wedge pressure in patients who avoid the left lateral decubitus position [9]. These observa- tions are also concordant with the notion that congestive status underlies all 3 findings, that is, trepopnea, avoi- dance of the left lateral decubitus position, and right-sided plural effusion.

Table 5 Echocardiographic parameters according to trepopnea presence

Impact of ventricular diameters on the symptom of trepopnea

We verified that patients who complained of trepopnea had significantly smaller diastolic and systolic left ventricle measurements (and probably impaired diastolic function) compared with patients without this symptom (Table 4). Despite the fact that others have shown that patients with larger cardiac chambers tend to avoid the left lateral decubitus position [9], our results clearly showed the association of trepopnea with smaller, noncompliant ventri- cles. In support of our findings, there are reports of documented worsening diastolic function while in left lateral decubitus position according to left ventricular filling patterns as assessed by Doppler echocardiogram in patients with HF [11]. Berensztein et al [11] have shown that patients with severe HF who are similar to our study population have a smaller mitral time-velocity integral, shorter deceleration time, greater E velocity and E/A ratio, and lower A velocity in the left lateral decubitus position. This evidence of diastolic dysfunction was reversed when patients were examined in right lateral decubitus. We suggest that the lower the compliance of the left ventricle, the greater the impact of compressing it by external pressure, as may occur when the left lateral decubitus position is assumed. The discrepancy between our findings and those of Leung et al

[9] might be due to the study populations: they compared patients with HF to healthy controls, whereas we only included patients with severe HF. Thus, our observations support the findings of Berensztein et al, linking the

Trepopnea		No trepopnea	P
End-diastolic left ventricular diameter (mm)	54 +- 9.5	63 +- 11	.03
End-systolic left ventricular diameter (mm)	43 +- 10	53 +- 13	.01
left atrium diameter (mm)	50 +- 6	49 +- 7	.69
End-diastolic septum diameter (mm)	11 +- 2.5	10 +- 2.1	.18
End-diastolic posterior wall diameter (mm)	10 +- 1.7	9.8 +- 1.5	.83
Left ventricular mass (g)	272 +- 83	306 +- 99	.25
Ejection fraction >=45% (%)	42	11	.03
Relative wall thickness (mm) a	0.38 +- 0.12	0.32 +- 0.08	.15
Systolic pulmonary artery pressure (mm Hg)	52 +- 13	49 +- 11	.47
a For the relative wall thickness of the left ventricle, the following formula was used: relative wall thickness = 2 x posterior wall thickness/end-diastolic diameter.

symptom of trepopnea with smaller ventricles through the plausible mechanism that diastolic function worsens in the left lateral decubitus position.

Limitations

We designed a prospective cross-sectional study to investigate an association between right-sided pleural effusion and trepopnea. By definition, we could not determine a causal relationship between trepopnea and predominant right-sided pleural effusions. We can only present the hypothesis that trepopnea may explain the greater predominance of right-sided pleural effusion seen in HF. Another possible limitation is that the patients’ preferred decubitus position was based on information from the patients. Patients were not subjected to polysomnography. However, we took care to prepare unbiased questions about patients’ sleep preferences.

Conclusions

Trepopnea is a common symptom in patients with decompensated HF that is significantly associated with predominant right-sided pleural effusion in this population. Our results indicate that trepopnea may be a contributory factor for pleural effusion laterality in patients with decompensated HF. We suggest mechanisms that may underlie this finding.

References

1. Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA 2005;294:1944-56.
2. Beck da Silva L, Mielniczuk L, Laberge M, et al. Persistent orthopnea and the prognosis of patients in the heart failure clinic. Congest Heart Fail 2004;10:177-80.
3. Ekman I, Cleland JG, Swedberg K, et al. Symptoms in patients with heart failure are prognostic predictors: insights from COMET. J Card Fail 2005;11:288-92.
4. Kataoka H. Pericardial and pleural effusions in decompensated chronic heart failure. Am Heart J 2000;139:918-23.
5. Dock W. The anatomical and hydrostatic basis of orthopnea and of right hydrothorax in cardiac failure. Am Heart J 1935;10:1047-55.
6. Bedford DE, Lovibond JL. Hidrothorax in heart failure. Br Heart J 1941;3:93-111.
7. Natanzon A, Kronzon I. Pericardial and pleural effusions in congestive heart failure-anatomical, pathophysiologic, and clinical consider- ations. Am J Med Sci 2009;338:211-6.
8. Fujita M, Miyamoto S, Sekiguchi H, et al. Effects of posture on sympathetic nervous modulation in patients with chronic heart failure. Lancet 2000;356:1822-3.
9. Leung RS, Bowman ME, Parker JD, et al. Avoidance of the left lateral decubitus position during sleep in patients with heart failure: relationship to cardiac size and function. J Am Coll Cardiol 2003;41:227-30.
10. Miyamoto S, Fujita M, Sekiguchi H, et al. Effects of posture on cardiac autonomic nervous activity in patients with congestive heart failure. J Am Coll Cardiol 2001;37:1788-93.
11. Berensztein CS, Pineiro D, Luis JF, et al. Effect of left and right lateral decubitus positions on Doppler mitral flow patterns in patients with severe congestive heart failure. J Am Soc Echocardiogr 1996;9:86-90.
12. Miyamoto S, Tambara K, Tamaki S, et al. Effects of right lateral decubitus position on plasma norepinephrine and plasma atrial natriuretic peptide levels in patients with chronic congestive heart failure. Am J Cardiol 2002;89:240-2.
13. Fujita M, Miyamoto S, Tambara K, et al. Trepopnea in patients with chronic heart failure. Int J Cardiol 2002;84:115-8.

Appendix A

No ID:

Trepopneia e Derrame Pleural a Direita em Pacientes com Insuficiencia Cardiaca Descompensada

Instituicao: HCPA No. Prontuario: Data: / / Entrevistador: Nome do paciente:

Sexo: 1 = Homem; 2 = Mulher Idade (em anos):

Telefone: 1) ( ) 2) ( )

Grupo etnico:: 1 = Caucasiano; 2 = Afro-descendente; 3 = Indigena

Trepopneia: 1 = Sim; 2 = Nao

Decubito preferencial: 1 = Direito; 2 = Outro ou sem preferencia

Etiologia da IC: 1 = Isquemica; 2 = Hipertensiva; 3 = Idiopatica; 4 = Alcoolica; 5 = Antineoplasico; 6 = Peripartum; 7 = Chagasico; 8 = Outras Tempo do diagnostico de IC: anos e meses.

No de intercorrencias relacionadas a IC no ultimo ano: Tabagismo: 1 = Sim; 2 = Nao; 3 = No passado

Carga tabagica: macos-ano. Dispneia paroxistica noturna: 1 = Sim; 2 = Nao COMORBIDADES

HAS: 1 = Sim; 2 = Nao * Fibrilacao atrial 1 = Sim; 2 = Nao DM: 1 = Sim; 2 = Nao

DPOC: 1 = Sim; 2 = Nao

AVC: 1 = Sim; 2 = Nao

Neoplasia no passado: 1 = Sim; 2 = Nao HIV+: 1 = Sim; 2 = Nao

IAM: 1 = Sim; 2 = Nao *

No de IAM: *

Doenca vascular periferica: 1 = Sim; 2 = Nao

Doenca hepatica: 1 = Sim; 2 = Nao * Hipertireoidismo: 1 = Sim; 2 = Nao * Hipotireoidismo: 1 = Sim; 2 = Nao *

EXAME FISICO DA CHEGADA AO HOSPITAL

Peso (Kg): Altura(m):

FC: PA: x mmHg

Classe funcional NYHA: 1 = I; 2 = II; 3 = III; 4 = IV B3: 1 = Sim 2 = Nao Turgencia jugular: 1 = Sim 2 = Nao RHJ: 1 = Sim 2 = Nao;

Ausculta pulmonar: 1 = Sem crepitantes; 2 = Crepitantes < 1/4 inferior; 3 = Crepitantes > X e < / do pulmao; 4 = > / do pulmao; 5 = Todo o pulmao Edema periferico: 1 = 2 = 1+; 3 = 2++; 4 = 3+++; 5 = Anasarca.

RADIOGRAFIA DE TORAX

Data: / /

Lateralidade do derrame: 1 = Direito; 2 = Esquerdo; 3 = Bilateral e sem lateralidade; 4 = Bilateral e maior a E; 5 = Bilateral e maior a D

Linhas B de Kerley: 1 = Sim; 2 = Nao Inversao cranial do fluxo: 1 = Sim; 2 = Nao

Edema pulmonar intersticial: 1 = Sim; 2 = Nao Doenca pulmonar primaria: 1 = Sim; 2 = Nao Cardiomegalia: 1 = Sim; 2 = Nao

EXAMES LABORATORIAIS (Ultimos 6 meses)

Hemoglobina: Hematocrito: VCM: Leucocitos totais: Albumina: Creatinina: TSH:

Na: Ureia

ECOCARDIOGRAMA (Data: / / ): AE: ; VEsistole: ; VEdiastole ; Septo ; PP , PSAP: FE :

MEDICAMENTOS EM USO DOMICILIAR IECA:

1. Captopril ( ) 1.Sim ( )2. Nao Dose:
2. Enalapril ( ) 1.Sim ( )2. Nao Dose:
3. Outro ( ) 1.Sim ( )2. Nao Nome: Dose:

BETA-BLOQUEADOR:

1. Metoprolol tartarato ( ) 1.Sim ( )2. Nao Dose:
2. Metoprolol Succinato ( ) 1.Sim ( )2. Nao Dose:
3. Carvedilol ( ) 1.Sim ( )2. Nao Dose:
4. Bisoprolol ( ) 1.Sim ( )2. Nao Dose:
5. Outro ( ) 1.Sim ( )2. Nao Nome: Dose:

ESPIRONOLACTONA: ( ) 1.Sim ( )2. Nao Dose: DIGOXINA: ( ) 1.Sim ( )2. Nao Dose: FUROSEMIDE: ( ) 1.Sim ( )2. Nao Dose:

HCTZ: ( ) 1.Sim ( )2. Nao Dose: HIDRALAZINA: ( )1.Sim ( )2.Nao Dose: ISOSSORBIDA: ( )1.Sim ( )2.Nao Dose:

AAS: ( )1.Sim ( )2.Nao Dose: AMIODARONA: ( )1.Sim ( )2.Nao Dose:

BRAII:

Losartan ( ) 1.Sim ( )2. Nao Dose:

Valsartan ( ) 1.Sim ( )2. Nao Dose:

Olmersartan ( ) 1.Sim ( )2. Nao Dose:

Outro ( ) 1.Sim ( )2. Nao Nome: Dose:

ESTATINA:

1. Sinvastatina ( ) 1.Sim ( )2. Nao Dose:
2. Pravastatina ( ) 1.Sim ( )2. Nao Dose:
3. Outro ( ) 1.Sim ( )2. Nao Nome: Dose:

BLOQUEADOR DE CANAL DE CALCIO:

1. Anlodipino ( ) 1.Sim ( )2. Nao Dose:
2. Verapamil ( ) 1.Sim ( )2. Nao Dose:
3. Nifedipino ( ) 1.Sim ( )2. Nao Dose:
4. Outro ( ) 1.Sim ( )2. Nao Nome: Dose:

OUTROS MEDICAMENTOS (ESCREVER DOSE):

ID number:

Trepopnea and Right-sided Pleural effusion in Patients with Decompensated Heart Failure

Hospital: HCPA Medical register: Date: / / Interviewer: Patient name:

Gender: 1 = Male; 2 = Female Age (years):

Phone number: 1) ( ) 2) ( )

Ethnic group: 1 = Caucasian; 2 = African; 3 = Native american Trepopnea: 1 = Yes; 2 = No

Preferential decubitus: 1 = Right; 2 = Left; 3 = Dorsal; 4 = Ventral; 5 = No preference

HF etiology: 1 = Ischemic; 2 = Hypertensive; 3 = Idiopathic; 4 = Alcoholic; 5 = Drugs; 6 = Peripartum; 7 = Chagas disease; 8 = Other Time from HF diagnosis: years and months.

HF admissions in previous year:

Tobacco use: 1 = Yes; 2 = No; 3 = Previous burden of smoking: cigarette-years. Paroxysmal nocturnal dyspnea: 1 = Yes ; 2 = No

COMORBIDITIES

Hypertension: 1 = Yes; 2 = No Atrial Fibrillation: 1 = Yes; 2 = No Diabetes: 1 = Yes; 2 = No

COPD: 1 = Yes; 2 = No

Stroke: 1 = Yes; 2 = No

Previous cancer: 1 = Yes; 2 = No

HIV+: 1 = Yes; 2 = No

Myocardial infarction: 1 = Yes; 2 = No Myocardial infarction events: Peripheral vascular disease: 1 = Yes; 2 = No Liver disease: 1 = Yes; 2 = No

Hypenhiroidism: 1 = Yes; 2 = No

Hypothiroidism: 1 = Yes; 2 = No

PHYSICAL EXAMINATION

Weight (Kg): Height (m):

Heart rate: Arterial pressure: x mmHg NYHA functional class: 1 = I; 2 = II; 3 = III; 4 = IV S3: 1 = Yes; 2 = No Jugular venous Turgence: 1 = Sim 2 = Nao RHJ: 1 = Sim 2 = N1o;

Pulmonary rales: 1 No; 2 = rales < 1/4 ; 3 = rales > X and < 1/2; 4 = > /; 5 = rales up to the upper lobes. Edema: 1 = without edema; 2 = 1+; 3 = 2++; 4 = 3+++; 5 = Anasarca

THORAX RADIOGRAPHY

Date:

Pleural effuson laterality: 1 = Right; 2 = Left; 3 = Bilateral and without laterality; 4 = Left-sided predominant; 5 = Right-sided predominant Kerley B lines: 1 = Yes; 2 = No

Interstitial pulmonary edema cephalization: 1 = Yes; 2 = No Interstitial pulmonary edema: 1 = Yes; 2 = No

Primary lung disease: 1 = Yes; 2 = No Cardiomegaly: 1 = Yes; 2 = No

LABORATORY EXAMS

Hemoglobin: Hematocrit: MCV: WBC: Albumin: Creatinine: Thyroid stimulating hormone:

Sodium: Potassium: Urea nitrogen

Echocardiography (Date: / / ): Left atrium: ; LV systole: ; LV diastole ; Septum ; Posterior wall ; PCWP:

Ejection fraction:

DRUGS USED PRIOR TO HF ADMISSION ACEi:

1. Captopril ( ) 1.Yes ( )2. No Dosage:
2. Enalapril ( ) 1.Yes ( )2. No Dosage:
3. Other ( ) 1.Yes ( )2. No Name of the Dosage Dose:

BETA-BLOCKER:

1. Metoprolol tartarat ( ) 1.Yes ( )2. No Dosage:
2. Metoprolol Succinate ( ) 1.Yes ( )2. No Dosage:
3. Carvedilol ( ) 1.Yes ( )2. No Dosage:
4. Bisoprolol ( ) 1.Yes ( )2. No Dosage:

S. Other ( ) 1.Yes ( )2. No Name of the drug Dosage:

SPIRONOLACTONE: ( ) 1.Yes ( )2. No Dosage: DIGOXIN: ( ) 1.Yes ( )2. No Dosage: FUROSEMIDE: ( ) 1.Yes ( )2. No Dosage:

HYDROCHLOROTHIAZIDE: ( ) 1.Yes ( )2. No Dosage: HIDRALAZINE: ( )1.Sim ( )2.Nao Dosage: ISOSSORBIDE: ( ) 1.Yes ( )2. No Dosage:

ASPIRINE: ( ) 1.Yes ( )2. No Dosage: AMIODARONE: ( ) 1.Yes ( )2. No Dosage:

ARB:

1. Losartan ( ) 1.Yes ( )2. No Dosage:
2. Valsartan ( ) 1.Yes ( )2. No Dosage:
3. Olmersartan ( ) 1.Yes ( )2. No Dosage:
4. Other ( ) 1.Yes ( )2. No Name of the drug Dosage:

STATIN:

1. Sinvastatin ( ) 1.Yes ( )2. No Dosage:
2. Pravastatin ( ) 1.Yes ( )2. No Dosage:
3. Other ( ) 1.Yes ( )2. No Name of the drug Dosage:

CALCIUM CHANEL BLOCKERS:

1. Anlodipine ( ) 1.Yes ( )2. No Dosage:
2. Verapamil ( ) 1.Yes ( )2. No Dosage:
3. Nifedipine ( ) 1.Yes ( )2. No Dosage:
4. Other ( ) 1.Yes ( )2. No Name of the drug Dosage: OTHER DRUGS (NOTE DOSAGE):