Shortness of breath without chest pain can signify the presence of high risk heart disease

http://www.eurekalert.org/

Public release date: 2-Nov-2005

Contact: Simi Singer
simi.singer@xxxxxxxx
310-423-3674
Cedars-Sinai Medical Center
Shortness of breath without chest pain can signify the presence of high
risk heart disease

LOS ANGELES (Nov. 2, 2005) While most people know that chest pain can
signify the presence of heart disease, it is less well known that
shortness of breath can also be a serious cardiac symptom.
Now, researchers at Cedars-Sinai Medical Center have found that patients
with shortness of breath can have a higher risk of dying from cardiac
disease than patients without symptoms, and even than patients with
typical cardiac pain.
Authors of a study published in the November 3 issue of the New England
Journal of Medicine reported that shortness of breath was a significant
predictor of death from cardiac causes, as well as death from any cause.
The study was based on a retrospective evaluation of medical records of
nearly 18,000 patients referred for cardiac stress testing who were then
followed-up later. Researchers found that when compared to patients
without shortness of breath, those with shortness of breath were
significantly more likely to experience death from cardiac cause than
patients without shortness of breath. More than 1,000 of the patients
denied having chest pain but answered "yes" to the question, "Do you
experience shortness of breath?"
"Patients often do not interpret shortness of breath as a serious
symptom, but particularly in patients who have cardiac risk factors and
in patients without lung disease, it may be the only sign of the
presence of serious coronary artery disease that may need treatment,"
said Daniel Berman, M.D., senior author of the study and the Director of
Cardiac Imaging at Cedars-Sinai Medical Center. "If we can identify
patients with coronary disease before an event occurs, then the vast
majority of the cardiac events could be prevented by modern therapies.
The problem is identifying the patient at risk," he added.
In the retrospective study, patients without known coronary artery
disease who had shortness of breath were four times more likely to
suffer death from a cardiac cause than asymptomatic patients and twice
as likely as patients who had chest pain that is considered to be
typical cardiac pain.
"These findings may in part be due to the fact that doctors are more
likely to send patients with chest pain to bypass surgery or angioplasty
than patients with shortness of breath," explained Berman.
Coronary artery disease, usually associated with the presence of plaque
build-up in the arteries surrounding the heart, is one the main causes
of death in both men and women. While it often is associated with chest
pain, about half of the patients with this serious disease either die
suddenly without prior symptoms or have a heart attack as the first
manifestation of the disease.
The New England Journal paper authored by Aiden Abidov, M.D. and
associates described the retrospective study of the medical records of
17,991 patients referred for stress testing by their physicians who knew
or suspected they had coronary artery disease based on their symptoms or
their cardiac risk factors. The stress testing was done with myocardial
perfusion imaging, the most widely used noninvasive approach to detect
blocked coronary arteries. During the test, patients exercise on a
treadmill or, if they can't, are given medication that causes the
heart's arteries to dilate. Once the patient reaches "peak" stress, a
small amount of radioactive imaging agent is given that concentrates in
the heart according to blood flow, emitting signals that are captured by
a special type of camera. The cardiac images show the parts of the heart
which do not get enough blood flow during stress and is very effective
in predicting short-term risk of a cardiac event and determining whether
it is necessary to consider angioplasty or surgery at that time.
Approximately 8 million stress myocardial perfusion scans were performed
in the United States in 2004.
The mechanism explaining why patients with shortness of breath without
chest pain were more likely to die was not entirely clear. While some of
the patients had underlying abnormalities of pumping function of the
heart that could explain increased risk, most did not. Yet in the
patients without abnormality of pumping function, there was a tripling
of cardiac events rates in those who had shortness of breath. One
possibility is that shortness of breath in the patients sent for testing
is related to ischemia--to little blood flow to the heart muscle.
However, even after adjusting for the amount of ischemia statistically,
shortness of breath remained predictive of an adverse outcome. The
authors speculated that possibly inflammatory proteins that are
associated with the development of coronary artery disease--proteins
that have been associated with malaise and fatigue--may be responsible
for the breathing symptom.
When the investigators used statistical techniques to adjust for other
significant factors between patient groups, shortness of breath remained
an independent predictor of the risk of death from cardiac causes and
from any cause. In an accompanying editorial, Thomas Marwick, M.D. from
the University of Queensland noted "Because the absence of chest pain
has traditionally been interpreted to indicate a low likelihood of
coronary disease--and indeed a low long-term risk--functional [stress]
testing has been thought to contribute little to the evaluation of
patients without angina [exertional chest pain]?.These results should
remind us that symptoms other than chest pain are of value in
identifying patients with suspected coronary artery disease who should
undergo functional testing."
Marwick also noted that in the patients with shortness of breath, the
study results showed that the myocardial perfusion test was effective in
distinguishing the degree of risk of cardiac death--the risk was more
than five times as high in the patients with very abnormal scans than in
the patients with normal scans.
"Our findings are important for the public as well as for doctors," said
Berman. "Knowledge of these findings may lead doctors to refer patients
with shortness of breath for testing, and then more readily send those
who are found to be at serious risk for a life-saving revascularization
procedure. For patients, increased awareness of shortness of breath as a
possible cardiac symptom will hopefully prompt those with unexplained
shortness of breath to see their doctor sooner rather than later."

###
One of only five hospitals in California whose nurses have been honored
with the prestigious Magnet designation, Cedars-Sinai Medical Center is
one of the largest nonprofit academic medical centers in the Western
United States. For 17 consecutive years, it has been named Los Angeles'
most preferred hospital for all health needs in an independent survey of
area residents. Cedars-Sinai is internationally renowned for its
diagnostic and treatment capabilities and its broad spectrum of programs
and services, as well as breakthroughs in biomedical research and
superlative medical education. It ranks among the top 10 non-university
hospitals in the nation for its research activities and was recently
fully accredited by the Association for the Accreditation of Human
Research Protection Programs, Inc. (AAHRPP). Additional information is
available at www.cedars-sinai.edu.



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