International Journal of Cardiology 84 (2002) 115–118www.elsevier.com / locate / ijcard Review article Trepopnea in patients with chronic heart failure a, b c a Masatoshi Fujita *, Shoichi Miyamoto , Keiichi Tambara , Brian Budgell a College of Medical Technology, Kyoto University, 53 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606 -8507, Japan b Department of Cardiovascular Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606 -8507, Japan c Department of Cardiovascular Surgery, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto 606 -8507, Japan Accepted 28 March 2002 Abstract This article will review the recumbent positions of patients with chronic congestive heart failure. The time for the right lateral decubitus position was two-fold longer than that for the supine and left lateral decubitus positions. Sympathetic nervous modulation was most attenuated and parasympathetic tone was most augmented in the right lateral decubitus position. The underlying mechanisms why heart failure patients prefer this position will be discussed. In conclusion, the right lateral decubitus position preferred by patients with chronic congestive heart failure may be a self-protecting mechanism to augment cardiac output and to attenuate the imbalance of cardiac autonomic nervous activity. 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Atrial natriuretic peptide; Autonomic nervous activity; Heart failure; Norepinephrine; Posture 1. Introduction right lateral decubitus position, (iii) mechanistic considerations as to why CHF patients prefer this Chronic heart failure (CHF) is a common disorder, posture, (iv) the clinical significance of CHF patients’ and clinical manifestations of CHF vary widely and posture in interpreting physiological phenomena and depend on a variety of factors. Among these, dyspnea the effect of drug treatment on CHF, and (v) future is a cardinal manifestation of CHF, which may perspectives. present with progressively increasing severity as (i) exertional dyspnea, (ii) orthopnea, (iii) paroxysmal nocturnal dyspnea, (iv) dyspnea at rest, and (v) acute 2. Increased adrenergic activity in CHF pulmonary edema. Trepopnea is a rare form of orthopnea limited to one lateral decubitus position. It is well appreciated by most clinicians that Until recently it was not clear why CHF patients cutaneous vasoconstriction, tachycardia, diaphoresis, prefer the right lateral decubitus position. In this and reduced urinary output are cardinal mani- review, we will discuss (i) increased adrenergic festations of severe CHF and these are caused by activity in CHF, (ii) CHF patients’ preference for the increased sympathetic nervous activity. It has been documented that plasma norepinephrine concentra- tions are elevated in patients with CHF . Norepi- *Corresponding author. Tel.: 181-75-751-3932; fax: 181-75-751- 3909. nephrine exerts a positive inotropic effect on the E-mail address: [email protected]
(M. Fujita). failing myocardium and the vasoconstriction induced 0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 02 )00132-8 9]. Preference of the right lateral decubitus three recumbent positions between 3:00 a. ischemia.m. Kuo and Chen asked each patient to assume three Cardiologists frequently observe that CHF patients recumbent positions for 5 min. Middlekauff et al. carotid arteries.m.m. / International Journal of Cardiology 84 (2002) 115 – 118 by norepinephrine helps to maintain the perfusion of rate variability revealed that cardiac sympathetic vital organs in the presence of markedly reduced activity was lowest in the right lateral decubitus cardiac output. favorably with the report of Kuo and Chen . that the right lateral de- CHF is supported by the salutary effects of beta. to reduce sympathetic nervous activity in There were discordant results with regard to heal- CHF patients have been reported. attenuation lation and the highest vagal modulation among the of increased adrenergic activity appears beneficial for three recumbent positions in severe coronary artery severe CHF patients. besides drug disease patients with a mean ejection fraction of 45%. Fujita et al. The device consists of two parts: creased sympathetic nervous modulation. The concept that the which they also demonstrated. we have developed a device which provides decubitus position . In contrast. It is well the sensor unit. We also have evidence that chiropractic cervical modulation was most augmented in the right lateral spinal manipulation decreases sympathetic nervous decubitus position in normal subjects as well as activity as evaluated by spectral analysis of heart rate patients with severe coronary artery disease. and an oscillator unit. Kuo and the increase in the sympathetic nervous activity that Chen reported that sympathetic nervous modulation normally occurs when solving mathematical problems was most attenuated and parasympathetic nervous . al. Although in our study no differences study. supine and right lateral was a self-protective mechanism to attenuate in- decubitus positions. These findings agree prognosis in CHF patients with high plasma norepi. To accurately and instantaneously detect nisms as to why CHF patients prefer the right lateral posture. Trepopnea is recumbent positions. Some attempts. using spectral analysis sympathetic nervous system has a maladaptive role in of heart rate variability. whereas parasympathetic activity was high- heart to norepinephrine causes hypertrophy. that CHF patients lie on their right side for over half of the period from 3:00 a. venous return would be . The details of the device stimulate baroreceptors in the ascending aorta and have been previously described elsewhere [8. Indeed. leading to increased sympathetic In our CHF patients with a mean left ventricular nervous activity. therapy. conscious state. When CHF patients assume the right ejection fraction of 32%. which is in resultant decreased blood pressure in CHF patients a rectangular plastic box. Thus. Thus. we have postulated the mecha- a. in nephrine concentrations . which is attached to the center of the appreciated that reduced cardiac output and the anterior chest wall.9]. to 6:00 In a recent article. We assumed that the right pulse waves of 0. we have reported. [8. Mechanisms leading to preference of the right recumbent positions. In a preliminary thy subjects. in the lie on their right side in the cardiology ward. leading to a poor lateral decubitus positions . have demonstrated that were observed in the frequency domain measure- acupuncture treatment for CHF patients suppressed ments in the three recumbent positions. for lateral decubitus position in CHF patients the first time. and may prefer other 4. However. 1. chronic exposure of the position. est in this position compared with the supine and left and cardiomyocyte damage . and 6:00 position in CHF patients a.0 Hz corresponding to lateral decubitus position preferred by CHF patients the left lateral decubitus.0 and 2. explained by differences in the methods. cubitus position led to the lowest sympathetic modu- blockers on clinical outcome [4–6].m. defined as the syndrome whereby patients with mild or moderate CHF may become breathlessness if they lie in the supine position.116 M.5. respectively. at least in part. We analyzed the heart rate variability in the 3. disparity in the results between the two studies may be. The variability (unpublished data). when each patient was fast asleep. consciousness may have affect- though those with more advanced CHF select a ed the physiologic responses to changes in the semirecumbent or sitting position. spectral analysis of heart lateral decubitus position. unclear whether this sympathetic hyperactivity is whether there is a circadian variation in the au. the ANP level was highest in the right lateral decubitus simultaneous recording of ECG and patients’ posture position among the three recumbent positions. where cardiac patients’ posture over 24 h. affected by posture. we have to take account of patients’ right half of the thoracic cage so that the position of posture. which leads to de. lisinopril. Right atrial pressure may be assumed to elevate heart rate variability before and after treatment. will allow better assessment of the circadian rhythm sumably due to stretching of the right atrium resulting of autonomic nervous function in patients with CHF. pre. patients’ posture must be taken account of that are unrelated to CHF. However. from the right lateral Ganz catheter. lisinopril treatment over 6 months. technique of microneurography . Thus. / International Journal of Cardiology 84 (2002) 115 – 118 117 enhanced because the right atrium is located in the healthy subjects.e. M. in the right lateral decubitus position as a result of Recently. Because symptomatic output and intracardiac pressures in each recumbent improvement could be accompanied by changes in position will be accurately measured using a Swan. it is when we evaluate. patients’ sleeping posture. with an angiotensin converting enzyme inhibitor. This is based on the fact that the well-known the heart is lower in the right decubitus position. frequency ratio did not change significantly with tion. modifies sympathetic tone in patients with the hydrostatic pressure imposed on the left ventricle mild to moderate CHF . ambulatory ECG recordings for the evaluation of sure. when analyzing heart rate variability of CHF patients based on 24-h ambulatory ECG recordings. there may be other reasons to prefer the positions. Future perspectives Holter ECG monitoring plays an important role in detecting various kinds of arrhythmias. 5.13]. sympathetic deactiva. beneficial effects of lisinopril on cardiac right lateral decubitus position. we The above-mentioned two opposite mechanisms measured power spectral density without considering will be elucidated in future studies. Thus. a number of studies [14–16] utilized 24-h position including the concept of hydrostatic pres. gastric emptying and personal preference or habit. Clinical significance 6.12]. from the increased venous return in this position Since it is expected that medical treatment for CHF [11. creased venous return. i. Although there was a may be less than that in the supine or left lateral significant reduction in the plasma atrial and brain decubitus positions. in the heart rate power spectral pulmonary congestion. Thus. This morning sympathetic surge may be attenuated in the speculation was confirmed by the fact that plasma right lateral decubitus position [8. A recent study largely influenced by the patients’ posture is of great documented moderate sympathetic hyperactivity dur- importance for analyzing heart rate variability based ing the latter months of normal pregnancy using the on 24-h ambulatory ECG monitoring. we examined whether chronic treatment increased hydrostatic pressure. Furthermore. analysis using 24-h Holter ECG recordings. natriuretic peptide concentrations along with symp- tics contribute to attenuate dyspnea by reducing tomatic improvement. decubitus position to supine and left lateral decubitus Finally. In this study. using Holter ECG monitoring. may attenuate the increased adrenergic activity and It is tempting to speculate another mechanism augment the decreased parasympathetic nervous ac- causing preference of the right lateral decubitus tivity. in this position. Because it is well known by tonomic nervous activity in CHF patients as well as obstetricians and midwives that pregnant women . myocardial It is also anticipated that the relationship between ischemia and cardiac autonomic nervous activity in the sympathetic nervous activity in pregnant women the clinical setting. These hemodynamic characteris. 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