Review articleTrepopnea in patients with chronic heart failure
Introduction
Chronic heart failure (CHF) is a common disorder, and clinical manifestations of CHF vary widely and depend on a variety of factors. Among these, dyspnea is a cardinal manifestation of CHF, which may present with progressively increasing severity as (i) exertional dyspnea, (ii) orthopnea, (iii) paroxysmal nocturnal dyspnea, (iv) dyspnea at rest, and (v) acute pulmonary edema. Trepopnea is a rare form of orthopnea limited to one lateral decubitus position. Until recently it was not clear why CHF patients prefer the right lateral decubitus position. In this review, we will discuss (i) increased adrenergic activity in CHF, (ii) CHF patients’ preference for the right lateral decubitus position, (iii) mechanistic considerations as to why CHF patients prefer this posture, (iv) the clinical significance of CHF patients’ posture in interpreting physiological phenomena and the effect of drug treatment on CHF, and (v) future perspectives.
Section snippets
Increased adrenergic activity in CHF
It is well appreciated by most clinicians that cutaneous vasoconstriction, tachycardia, diaphoresis, and reduced urinary output are cardinal manifestations of severe CHF and these are caused by increased sympathetic nervous activity. It has been documented that plasma norepinephrine concentrations are elevated in patients with CHF [1]. Norepinephrine exerts a positive inotropic effect on the failing myocardium and the vasoconstriction induced by norepinephrine helps to maintain the perfusion of
Preference of the right lateral decubitus position in CHF patients
Cardiologists frequently observe that CHF patients lie on their right side in the cardiology ward, although those with more advanced CHF select a semirecumbent or sitting position. Trepopnea is defined as the syndrome whereby patients with mild or moderate CHF may become breathlessness if they lie in the supine position, and may prefer other recumbent positions. Indeed, we have reported, for the first time, that CHF patients lie on their right side for over half of the period from 3:00 a.m. to
Mechanisms leading to preference of the right lateral decubitus position in CHF patients
In a recent article, we have postulated the mechanisms as to why CHF patients prefer the right lateral decubitus position [11]. We assumed that the right lateral decubitus position preferred by CHF patients was a self-protective mechanism to attenuate increased sympathetic nervous modulation. It is well appreciated that reduced cardiac output and the resultant decreased blood pressure in CHF patients stimulate baroreceptors in the ascending aorta and carotid arteries, leading to increased
Clinical significance
Holter ECG monitoring plays an important role in detecting various kinds of arrhythmias, myocardial ischemia and cardiac autonomic nervous activity in the clinical setting. The aforementioned evidence that cardiac autonomic nervous activity in CHF patients is largely influenced by the patients’ posture is of great importance for analyzing heart rate variability based on 24-h ambulatory ECG monitoring. For example, when we evaluate, using Holter ECG monitoring, whether there is a circadian
Future perspectives
It is also anticipated that the relationship between the sympathetic nervous activity in pregnant women and their recumbent position will be elucidated by the same approach described herein. A recent study documented moderate sympathetic hyperactivity during the latter months of normal pregnancy using the technique of microneurography [17]. However, it is unclear whether this sympathetic hyperactivity is affected by posture. Because it is well known by obstetricians and midwives that pregnant
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