New AHA Statement Highlights Symptom Relevance in Cardiovascular Disease

The betterment of cardiovascular disease (CVD) symptoms may be an integral part of disease management, but it is crucial to understand that symptoms can vary over time in both frequency or severity.

A new scientific statement from the American Heart Association (AHA) presented the relevance of symptoms associated with CVD and the current state of the science, reviewing the genesis, manifestations, and similarities or differences between diagnoses.

Due to commonalities in symptoms across disorders, it is crucial to use established measures or develop reliable and responsive measures of CVD symptoms to track over a period of time, according to the investigators.

“Monitoring symptoms with reliable and valid measures in research and clinical practice may enhance clinical care by identifying those who may be at risk for poor outcomes more quickly (eg, lower quality of life, hospitalization, death),” wrote lead author Corrine Y. Jurgens, PhD, RN, AHA Council on Cardiovascular and Stroke Nursing.

Current research in CVD is focused on major adverse cardiovascular events, such as hospitalization or death, and less focus on symptoms, despite their noted significance. Investigators added that several caveats should be taken into consideration into the interpretation of symptoms in CVD.

These patients may experience symptoms in the absence of important changes in underlying pathogenesis, while the absence of symptoms does not necessarily confer the absecne of change in unlderying CVD, the authors added.

However, they noted that there are symptoms that have relevance in CVD, including acute coronary syndrome (ACS), heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease.

Acute Coronary Syndrome

The statement reports the most frequently reported symptoms of ACS is chest pain, with the most common co-occurring symptoms being dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness.

Challenges in interpreting symptoms in ACS include the lack of consensus on the duration of the prodromal phase, with literature defining the range as between 1 month to 48 hours before an ACS event. Additionally, more similarities in symptom presentation in ACS have been reported among women compared with men, but there are salient differences.

Women with ACS on average are significantly older than men, but the contributions of chronological and biological aging to symptoms experienced by patients with ACS remain unknown.

Due to a lack of standard measures, bias in favor of certain symptom assessments and an inability to compare symptoms across cohorts may exist. The lack of agreement of ACS symptom measurement in research makes it difficult to synthesize findings about symptoms across research and to incorporate evidence-based information about symptoms into treatment guidelines, investigators added.

Heart Failure

Dyspnea is a hallmark of heart failure and is often characterized in terms of provocation, including dyspnea at rest, dyspnea on exertion, otheropena, paroxysmal nocturnal dyspnea, and bendopnea. Early and subtle symptoms, such as gastrointestinal-related symptoms or fatigue, may be a sign of worsening heart failure and impending hospitalization or death.

The statement reported women experienced higher physical symptom burden, higher depression and anxiety, and lower quality of life compared with men. Moreover, older age is associated with issues in recognition and interpretation of dyspnea.

Quality of life and health status measures are most commonly used in heart failure, but the number of symptoms indirectly covered by these measures is limited. The current and future work in heart failure symptoms is now focused on symptom patterns and clustering over time.

Valvular Disorders

Investigators noted valvular heart disease is a frequent cause of heart failure, with symptoms indistinguishable from other heart failure causes. The staging of valvular heart disease is based on a combination of valve findings, symptoms, and ventricular function.

Symptoms differ between sexes for aortic valve disease, while aortic stenosis is generally asymptomatic. Women often report dyspnea and exercise intolerance more often than men as stenosis progresses. Symptom presence and severity remain key to determining stage of disease and timing of surgical or transcather intervention, investigators added.

Stroke

Acute symptoms after stroke help predict disability and quality of life. Thus, responding to stroke signs and symptoms quickly is essential for proper treatment. Investigators added stroke severity, physical disability, and cognitive impairments after stroke are associated with common symptoms of anxiety, depression, fatigue, and pain.

In order to better enhance public education about stroke, more research is needed to understand the presentation of stroke symptoms by other select demographic characteristics. Additionally, the statement added all individuals who experience a stroke should be screened for post stroke anxiety and depression, as well as other physical and psychological issues

Rhythm Disorders

Cardiac arrhythmias present with common symptoms, with palpitations being a characteristic symptom of many cardiac arrhythmias.

Patients with new-onset atrial fibrillation (AF) present either asymptomatically or with nonspecific symptoms, with palpatations 27%–70%), fatigue (26%–75%), and dyspnea (28%–76%) the most common symptoms reported.

Women and younger patients with AF were reported to typically present with palpitations, while men are more commonly asymptomatic. Increasing age additionally increases likelihood of a nonclassic or asymptomatic presentation of AF.

Thus, symptom monitoring and the association between symptoms and heart rate are essential components of medication titration for rate control and selection of a rate versus rhythm control management strategy. Clinicians often underrepresented AF symptom severity, thus clinical-reported measures should be avoided unless necessary, according to investigators.

Peripheral Vascular Diseases

Peripheral vascular disease and associated symptoms can occur from either arterial or venous pathology. Symptoms of peripheral arterial disease (PAD) vary with a range from none, despite disease progression, to leg pain at rest.

Symptomatic PAD has been associated with increased risk of major adverse cardiovascular events, with men at higher risk. However, women with PAD are more likely to have non-classic or absence of symptoms, as well as a more rapid decline and lower quality of life.

Similarly, peripheral venous disease (PVD) can be symptomatic or asymptomatic. The clinical classification of the disease includes symptoms such as leg pain, aching, and fatigue.

The existing measures of PVD are quality-of-life measures including symptoms, limitations of activities of daily living, and psychological impact. Limitations of PVD measures are similar to other CVD regarding minimally important differences. The existing legacy measures of PVD are centered on clinician appraisal and not patient-reported symptoms.

Overall, investigators require more information on the relationship between symptoms and clinical events and underlying CVD pathogenesis, particularly among individuals living with multiple chronic conditions.

“Despite limitations in measurement and complexities in how they are experienced, symptoms have clear relevance to the diagnosis, monitoring, and treatment of CVD,” Jurgens and colleagues concluded.

The AHA Scientific Statement, “State of the Science: The Relevance of Symptoms in Cardiovascular Disease and Research: A Scientific Statement From the American Heart Association,” was published in Circulation.