A commentary on Bendopnea as an independent prognostic marker for adverse events in hospitalized heart failure patients: insights from a multicenter prospective cohort study By Baeza-Trinidad R. Front. Cardiovasc. Med. (2025) 12: 1659830. doi: 10.3389/fcvm.2025.1659830
I have read with great interest the article by Wu et al. entitled “Bendopnea as an independent prognostic marker for adverse events in hospitalized heart failure patients: insights from a multicenter prospective cohort study” (1). The prevalence of bendopnea in decompensated heart failure patients, notably higher in those with advanced NYHA class, was similar to previously reported findings, underscoring its importance in advanced heart failure. The authors conclude that bendopnea is an independent predictor of adverse events, including mortality, in hospitalized heart failure patients. While we appreciate their reinforcement of bendopnea's prognostic value through a multicenter prospective cohort, we would like to contextualize these findings by noting that the association between bendopnea and adverse mortality-related outcomes in heart failure patients has been demonstrated previously. Nonetheless, their discussion of the symptom's diagnostic utility and potential for risk stratification is particularly valuable, especially since it represents the largest prospective study to date assessing prognosis in this population.
Since bendopnea (initially called flexo-dyspnea) was first described in the early 2010s, several studies have been conducted to evaluate the association of this symptom with poor prognosis (2, 3). Indeed, our initial study, which included 250 hospitalized patients, was the first to evaluate this fact in acute heart failure patients (4). It described a significant association with an increased mortality rate in hospitalized patients with decompensated heart failure in six months follow-up period (in univariate analysis), also reporting an increasing trend in readmission rates. This finding highlights the importance of this symptom not only as a prevalent manifestation in patients with heart failure but also as a significant prognostic factor. This symptom was also associated with other heart failure signs and symptoms, including paroxysmal nocturnal dyspnea, elevated jugular venous pressure, abdominal fullness, oliguria and orthopnea, with the latter three specifically showing a relationship with a quicker onset of dyspnea during the maneuver. This association, as well as an advanced functional class, was similar to that observed in other studies, incluiding the study by Wu et al.
Further supporting the prognostic role of bendopnea, Thibodeau et al. described an increase in heart failure admissions at 3 months and an association with cardiovascular mortality in ambulatory patients with reduced left ventricle ejection fraction, highlighting its prognostic value during stabilization (5). More recently, in a post-hoc analysis of the FRAGILE-HF and SONIC-HF studies, Nakade et al. reported that the presence of bendopnea at discharge was associated with higher two-year mortality (6). On the other hand, in another study conducted by our group, it was observed that the absence of bendopnea at discharge in patients who presented it on admission did not result in a decrease in mortality or readmissions after six months (7). Additionally, bendopnea has been studied in other pathologies such as aortic valve stenosis, obstructive sleep apnea syndrome, pulmonary hypertension and also in general population, though an association with prognosis in these non heart failure contexts has not been described yet (8–12).
In conclusion, it is clear that the evidence base concerning bendopnea in heart failure is robust, consistently demonstrating its relationship with a worse prognosis in short, medium, and long term follow-up. The multicenter prospective data presented by Wu et al. reinforce its association with mortality. It is appreciable that their approach, which reinforces the previously known evidence of bendopnea as a crucial and identifiable sign that should be used during clinical practice as an easily risk stratification of heart failure patients. While the prognostic value of bendopnea is well established, further investigations are needed to clarify the mechanisms underlying its changes in response to therapeutic interventions. Therefore, future research should also explore the role of bendopnea resolution as a potential biomarker for treatment strategies.
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Author contributions
RB-T: Writing – original draft, Writing – review & editing.
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References
1.
Wu Y Zhu Y Liu S Hu Y Ma S . Bendopnea as an independent prognostic marker for adverse events in hospitalized heart failure patients: insights from a multicenter prospective cohort study. Front Cardiovasc Med. (2025) 12:1659830. 10.3389/fcvm.2025.1659830
2.
Brandon N Mehra MR . “Flexo-dyspnea”: a novel clinical observation in the heart failure syndrome. J Heart Lung Transplant. (2013) 32(8):844–5. 10.1016/j.healun.2013.06.006
3.
Thibodeau JT Turer AT Gualano SK Ayers CR Velez-Martinez M Mishkin JD et al Characterization of a novel symptom of advanced heart failure: bendopnea. JACC Heart Fail. (2014) 2(1):24–31. 10.1016/j.jchf.2013.07.009
4.
Baeza-Trinidad R Mosquera-Lozano JD El Bikri L . Assessment of bendopnea impact on decompensated heart failure. Eur J Heart Fail. (2017) 19(1):111–5. 10.1002/ejhf.610
5.
Thibodeau JT Jenny BE Maduka JO Divanji PH Ayers CR Araj F et al Bendopnea and risk of adverse clinical outcomes in ambulatory patients with systolic heart failure. Am Heart J. (2017) 183:102–7. 10.1016/j.ahj.2016.09.011
6.
Nakade T Maeda D Matsue Y Fujimoto Y Kagiyama N Sunayama T et al Bendopnea prevalence and prognostic value in older patients with heart failure: FRAGILE-HF-SONIC-HF post hoc analysis. Eur J Prev Cardiol. (2024) 31(11):1363–9. 10.1093/eurjpc/zwae128
7.
Baeza-Trinidad R Mosquera-Lozano JD Gómez-Del Mazo M Ariño-Pérez de Zabalza I . Evolution of bendopnea during admission in patients with decompensated heart failure. Eur J Intern Med. (2018) 51:e23–4. 10.1016/j.ejim.2018.02.026
8.
Dominguez-Rodriguez A Thibodeau JT Ayers CR Jimenez-Sosa A Garrido P Montoto J et al Impact of bendopnea on postoperative outcomes in patients with severe aortic stenosis undergoing aortic valve replacement. Interact Cardiovasc Thorac Surg. (2018) 27(6):808–12. 10.1093/icvts/ivy174
9.
Baeza-Trinidad R Roncero-Lazaro A Mosquera-Lozano JD Ruiz-Martinez C Brea-Hernando A . Evaluation of bendopnea in severe obstructive sleep apnea syndrome. Med Clin (Barc). (2021) 157(1):17–9. 10.1016/j.medcli.2020.05.062
10.
Akaslan D Aslanger E İsmail Basa C Öztürk RK Ataş H Mutlu B . Bendopnea predicts right ventricular energy failure in patients with pulmonary hypertension. Turk Kardiyol Dern Ars. (2023) 51(7):440–6. 10.5543/tkda.2023.47077
11.
Karauzum K Karauzum I Kilic T Sahin T Baydemir C Baris Argun S et al Bendopnea and its clinical importance in outpatient patients with pulmonary arterial hypertension. Acta Cardiol Sin. (2018) 34(6):518–25. 10.6515/ACS.201811_34(6).20180528A
12.
Baeza-Trinidad R Isaula-Jimenez O Peinado-Adiego C Mosquera-Lozano JD . Prevalence of bendopnea in general population without heart failure. Eur J Intern Med. (2018) 50:e21–2. 10.1016/j.ejim.2017.11.007
Summary
Keywords
acute heart failure, bendopnea, diagnosis, dyspnea, heart faiIure
Citation
Baeza-Trinidad R (2026) Commentary: Bendopnea as an independent prognostic marker for adverse events in hospitalized heart failure patients: insights from a multicenter prospective cohort study. Front. Cardiovasc. Med. 12:1745774. doi: 10.3389/fcvm.2025.1745774
Received
13 November 2025
Revised
23 December 2025
Accepted
25 December 2025
Published
20 January 2026
Volume
12 - 2025
Edited by
Syamal K. Bhattacharya, University of Tennessee Health Science Center (UTHSC), United States
Reviewed by
Lama A. Ammar, Mount Sinai Health System, United States
Sumeet Vaikunth, University of Pennsylvania, United States
Updates
Copyright
© 2026 Baeza-Trinidad.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Ramon Baeza-Trinidad rbaezat@riojasalud.es
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.