“Listen to your patient; he is telling you the diagnosis.”
– William Osler
Dyspnea (the sensation of breathing discomfort) is a common and vexing problem among older adults: one review of the literature found that on average, 1 in 3 adults age ≥65 reported experiencing this symptom.
In addition to being common, dyspnea may portend a worse prognosis. Over 10 years ago, a study in the New England Journal of Medicine found that patients referred for cardiac stress testing who reported dyspnea had four times the risk of sudden cardiac death (compared with those who were asymptomatic), and were twice as likely to die as those with typical chest pain on exertion (median follow-up: 2.7 years). The authors concluded that dyspnea should be routinely evaluated before stress testing. A subsequent study in the PREMIER registry of patients with acute myocardial infarction found that dyspnea was common (present in nearly half of patients 1 month after an hospital discharge), and its presence was associated with impaired quality of life, hospital readmissions, and poorer survival compared with dyspnea-free patients.
It is unclear exactly why dyspnea portends such a poor prognosis. The authors of the New England Journal paper suggested that dyspnea may represent underlying ischemia, left ventricular dysfunction, of pulmonary disease. Alternate causes may include neuromuscular disease, cancer, anemia, or deconditioning. In my own practice, there’s often no single cause – an older adult with heart failure often has concurrent atrial fibrillation, lung disease, and deconditioning.
Similarly, it’s unclear how to optimally evaluate and treat many patients reporting dyspnea. Multiple specialists (cardiologists, pulmonologists, internal medicine) are frequently involved and may have conflicting recommendations. A centralized clinic to evaluate dyspnea (examples here and here) may help to relieve some of the patient burden of coordinating their own care between specialists. In addition, with the growth of goal-oriented care, relief of dyspnea may serve as a reasonable target around which to base therapies. At the very least, it’s clear that dyspnea in older adults should be routinely assessed, and if present should prompt further evaluation. In the setting of rapidly progressing technology in medicine, taking a good history is still paramount.
By: John Dodson, MD, MPH