Journal of Pain and Symptom Management
Volume 36, Issue 5 , Pages 497-504, November 2008

Pain and Quality of Life in Hospitalized Patients with Heart Failure

  • Tone Rustøen, RN, PhD

      Affiliations

    • Faculty of Nursing, Oslo University College, Oslo
    • Centre for Shared Decision Making and Nursing Research, Rikshospitalet University Hospital, Oslo
    • Corresponding Author InformationAddress correspondence to: Tone Rustøen, RN, PhD, Faculty of Nursing, Oslo University College, Postbox 4, St. Olav's Place, 0131 Oslo, Norway.
    • ,
  • Audun Stubhaug, MD, PhD

      Affiliations

    • Faculty of Nursing, Oslo University College, Oslo
    • Department of Anesthesia, Rikshospitalet University Hospital, Oslo
    • ,
  • Ingrid Eidsmo, RN

      Affiliations

    • Ullevaal University Hospital, Oslo, Norway
    • ,
  • Arne Westheim, MD, PhD

      Affiliations

    • Ullevaal University Hospital, Oslo, Norway
    • ,
  • Steven M. Paul, PhD

      Affiliations

    • Department of Physiological Nursing, University of California at San Francisco, San Francisco, California, USA
    • ,
  • Christine Miaskowski, RN, PhD

      Affiliations

    • Centre for Shared Decision Making and Nursing Research, Rikshospitalet University Hospital, Oslo
    • Department of Physiological Nursing, University of California at San Francisco, San Francisco, California, USA

Accepted 4 December 2007. published online 11 July 2008.

Article Outline

Abstract 

The pain experience of patients with heart failure (HF) and its impact on their quality of life (QOL) has not been described in sufficient detail. This study sampled patients hospitalized with HF to describe the prevalence and severity of bodily pain; evaluate differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effect of selected demographic, disease-specific characteristics, bodily pain, and mental health on QOL. Two items from the Medical Outcomes Study—Short Form (SF-36) were used to measure pain, and one subscale of the SF-36 was used to evaluate mental health. The Minnesota Living With Heart Failure Questionnaire was used to measure QOL. Patients with HF (n=93) had a mean age of 75 years, were predominantly male (65%), and lived alone (47.3%). Lung diseases and diabetes were the most common comorbidities; 58% were categorized as New York Heart Association (NYHA) Class III, whereas 58% of the sample was diagnosed with HF in the past four years. Of note, 85% of the patients reported pain and 42.5% said that it was in the severe or very severe range. No demographic variables were associated with pain, whereas a higher number of chronic conditions were associated with pain. SF-36 mental health and pain scores, as well as NYHA class, explained 34.1% of the variance in QOL in patients with HF. These data suggest that pain is highly prevalent and has a significant impact on the QOL of patients with HF. However, additional research is warranted to determine the specific causes and characteristics of pain in these patients.

Key Words: Quality of life, pain, congestive heart failure

 

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Introduction 

Heart failure (HF) has become one of the most important chronic medical conditions worldwide.1, 2 The clinical course of HF is characterized by acute exacerbations that require emergency department visits or hospitalizations followed by periods of stable disease. HF is a chronic medical condition that affects all aspects of patients' lives and has a tremendous impact on quality of life (QOL).3, 4 Studies have shown that patients with HF report a poorer QOL when compared to the general population.5, 6, 7, 8 In most of these studies, which used either a disease-specific instrument or a general QOL questionnaire, patients with HF reported lower scores in all domains of QOL (e.g., lower levels of physical functioning, and worse mental health). In addition, patients with HF compared to the general population5 reported significant limitations in mobility and self-care activities. Most recently, scores on a disease-specific measure of QOL were shown to be strongly associated with decreased survival in patients with HF.9

Several studies5, 10, 11, 12, 13, 14 have found that a variety of symptoms are associated with decreases in QOL in patients with HF. For example, Calvert et al.5 found that pain, anxiety, and depression were associated with decreased QOL. In this study, 68% of patients with HF reported pain/discomfort, compared to only 33% of the general population. Goodlin et al.11 found that the most common causes of symptom distress in advanced HF were lack of energy, weakness or fatigue, pain, dyspnea, insomnia, and depression. In addition, Levenson et al.14 found that the percentage of patients with HF with severe pain increased significantly during the last six months of life. Finally, in a study by Sullivan and O'Meara,13 patients who died from cardiovascular disease with concomitant HF reported significantly more symptoms, including chest and abdominal pain, worse functional status, and poorer self-rated health near the end of life than patients who died from cardiovascular disease alone.

A recent systematic review on the symptom of pain with HF15 found only nine studies that reported minimal data on pain in these patients. In the five studies that reported data specifically on patients with HF, the prevalence of pain ranged from 23% to 75%. In a more recent study of outpatients with chronic HF,16 52% reported pain and 42% categorized it as extremely distressing. However, data on pain prevalence were obtained using dichotomous yes/no questions or researcher-developed single items, and not with a validated pain measure. None of these studies reported on the severity of pain or on the level of interference of pain with activities.

Although recent data suggest that pain occurs in a significant percentage of patients with HF and that pain and other symptoms are associated with decreases in QOL in this population, additional studies are warranted to determine the prevalence and severity of pain; factors associated with increased pain; and the impact of pain on QOL in patients with HF. Therefore, the purposes of this study, in a sample of patients who were hospitalized for HF, were to describe the prevalence and severity of bodily pain; evaluate for differences in bodily pain related to selected demographic and disease-specific characteristics; and evaluate the effects of selected demographic (e.g., age, gender, and living situation) and disease-specific (e.g., ejection fraction [EF]) characteristics, bodily pain, and mental health on QOL.

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Materials and Methods 

Participants and Data Collection Procedures 

This study was part of a larger descriptive study that evaluated the relationship between hope and QOL in patients with HF. Patients were diagnosed with HF using the 1995 European Society of Cardiology Criteria for HF.17 Patients were recruited from two acute care hospitals in Norway. Consecutive patients, who were hospitalized for HF over a period of 24 months and met the study's inclusion criteria, were asked to participate several days after admission to the hospital, when their condition had stabilized. Patients were included if they were able to read and write Norwegian and had a normal mental status as judged by the nurse who was caring for the patients. The main reasons why patients declined to participate were previous involvement in another research study or severe fatigue. This study was approved by the Norwegian Committee on Human Research. All patients signed a written informed consent before participation in the study.

Instruments 

Demographic Characteristics 

Data on age, gender, marital status, living situation, and educational level were obtained for all patients. Marital status was categorized as married or not married (i.e., widowed, divorced, or not married). Living situation was categorized as living with spouse/another adult or children, or living alone. Educational level was categorized as primary school, secondary school, or university/college education.

Comorbidities and Disease-Specific Characteristics 

Patients were asked if they currently had or had a history of cancer; diabetes; musculoskeletal, skin, lung, or gastrointestinal diseases; or psychiatric disorders. Length of time since HF diagnosis, New York Heart Association (NYHA) classification, EF value, and medications were obtained from the medical record. EF values were categorized as preserved left ventricular systolic function (EF>40%) or reduced left ventricular systolic function (EF≤40%).18

Pain 

Two items from the Medical Outcomes Study—Short Form (SF-36) were used to measure pain. The SF-36 consists of 36 items of self-reported aspects of health.19, 20, 21, 22 The Norwegian version of the SF-36 has acceptable psychometric properties.23, 24, 25

The first pain question asks, “How much bodily pain have you had during the past 4 weeks?” The responses are “none,” “very mild,” “mild,” “moderate,” “severe,” or “very severe.” The second question asks, “During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?” The choices are “not at all,” “a little bit,” “moderately,” “quite a bit,” or “extremely.” The responses to the first item were used to determine pain prevalence and severity. Responses to the second item were used to determine pain interference. For the various correlational analyses, the two pain items were summarized into a subscale of the SF-36 called “bodily pain,” with scores that could range from 0 to 100, and with lower scores indicating more pain.

Mental Health 

The mental health subscale of the SF-36 was used to evaluate the impact of anxiety and depression on pain and QOL.

Quality of Life 

The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used to measure QOL because it is a disease-specific QOL questionnaire. This 21-item questionnaire measures patients' perceptions of the effects of HF on life satisfaction.26, 27, 28 Patients were asked to rank how each of the impairments associated with HF prevented them from living as they wanted to live. Each item is scored on a Likert scale that ranges from 0 (“no”) to 5 (“very much”). Individual items are summed to create two subscale scores (i.e., emotional and physical) and a total score that can range from 0 to 105. Lower subscale and total scores indicate a better QOL. The MLHFQ has demonstrated adequate validity and reliability internationally,29, 30 but had not been used in a Norwegian sample before this study. It was translated into Norwegian using the forward and backward procedure.31 In this study, the Cronbach's alpha for the total score was 0.88.

Statistical Analyses 

Data were analyzed using SPSS Version 14.0 (Chicago, IL). Descriptive statistics were generated to characterize the sample, the prevalence, and severity of bodily pain.

One-way analyses of variance and Chi-squared analyses were performed to evaluate differences in SF-36 bodily pain and QOL scores using select demographic (i.e., age category, gender, education level, marital status, and cohabitation [yes, no]) and disease-specific characteristics (i.e., NYHA class, EF value, and different chronic diseases [yes, no]).

To determine the variables to include in the subsequent multiple regression analysis to predict QOL (i.e., total score on the MLHFQ), correlation coefficients were calculated between the total QOL score and selected demographic and disease-specific characteristics, as well as SF-36 bodily pain and mental health scores. A multiple regression analysis was performed to determine the effects of the significant variables from the univariate analyses on QOL. All significant variables from the univariate analyses were entered into the model simultaneously. To construct a model that was parsimonious, variables were systematically removed until only significant predictors remained in the final model. For all tests, a P-value of <0.05 was considered statistically significant.

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Results 

Demographic Characteristics 

Ninety-three patients with HF were recruited for this study. As shown in Table 1, the mean age was 75.1 years (SD=9.7 years) and 64.5% of the patients were male. Almost half of the sample lived alone, 20.7% had a college or university education, and 44.6% were married. Approximately 85% of the patients were either disabled or retired.

Table 1. Demographic and Disease-Specific Characteristics of the Patients with HF
Characteristicsn (%)
Age (years) [mean (SD) range]75.1 (9.7) 48–93

Gender
Male60 (64.5)
Female33 (35.5)

Living situation
Alone43 (47.3)
Spouse/children48 (52.7)

Marital status
Married41 (44.6)
Not married51 (55.4)

Education
Primary school40 (46.0)
Secondary school29 (33.3)
University/college18 (20.7)

NYHA Class
I2 (2.3)
II14 (16.7)
III47 (56.0)
IV21 (25.0)
EF value [mean (SD) range]34.5 (12.3) 7%–73%
≤40%47 (68.1)
>40%22 (31.9)

Characteristics of HF and Previous and Concurrent Medical Conditions 

More than half of the sample (58%) was diagnosed with HF in the past four years. Most patients (81%) were classified as NYHA Class III or IV and 68.1% had reduced left ventricular systolic function with EF values≤40% (Table 1). The mean EF for the patients was 34.5% (SD=12.3%).

As many as 80% of the patients reported having one or more chronic conditions in addition to HF. The most common comorbidities were lung disease (31.2%), diabetes (30.1%), musculoskeletal disease (21.5%), cancer (16.1%), skin disease (15.1%), gastrointestinal disease (14.0%), and psychiatric disorders (4.3%). In addition to HF, one condition was reported by 47.3% of the patients, two by 16.1%, three by 12.9%, and four or five by 3.3% of the patients.

Data on medications were collected for 78 (83.9%) of the patients. While in the hospital, patients were taking an average of seven medications (SD=2.5, range 2–14) for HF, other medical conditions, and pain. Of note, only one of 78 patients were taking nonsteroidal anti-inflammatory drugs, two of 78 were taking paracetamol (acetaminophen) plus an opioid, 11 of 78 were taking steroids, two of 78 were taking opioids, and eight of 78 patients were taking antidepressants. In addition, patients were prescribed low-dose aspirin (26 of 78) as treatment for coronary heart disease (CHD); long-acting nitroglycerin (21 of 78) and nitroglycerine patches (five of 78) for HF or CHD; and nitroglycerine sublingual (two of 78) for CHD-related chest pain.

Pain Prevalence, Severity, and Interference 

Based on the SF-36 item “bodily pain in last 4 weeks,” 85% of the 87 patients with HF (n=74), who answered this question, reported some pain. A total of 13 patients (14.9%) reported none, eight (9.2%) reported very mild pain, six (6.9%) reported mild pain, 23 (26.4%) reported moderate pain, 28 (32.2%) reported severe pain, and nine (10.3%) reported very severe pain.

On the “pain interference with normal work” item, of the 87 patients with HF who answered this question, 19 patients (21.8%) reported not at all, 11 (12.6%) reported a little bit, 17 (19.5%) reported moderately, 20 (23.0%) reported quite a bit, and 20 (23.0%) reported extremely.

The mean SF-36 bodily pain score for this sample was 43.0 (SD=30.1, range 0–100), with lower scores indicating higher levels of bodily pain.

Differences in SF-36 Bodily Pain Scores 

With respect to demographic characteristics, no differences in mean SF-36 bodily pain scores were found based on age, gender, marital status, cohabitation, or educational level. With respect to disease-specific characteristics, no differences were found in mean SF-36 bodily pain scores based on NYHA class, EF values, or presence of various chronic medical conditions. However, a significant negative correlation was found between mean SF-36 bodily pain score and number of chronic conditions (r=−0.21; P=0.045), which suggests that a higher number of chronic conditions was associated with more pain.

Differences in QOL Scores 

Eighty-three patients completed the MLHFQ. The mean QOL score was 54.7 (SD=21.5). QOL scores ranged from a low of 6.0 to a high of 95.1. With respect to demographic characteristics, no differences in mean QOL scores were found based on age, gender, marital status, cohabitation, or educational level. With respect to disease-specific characteristics, a significant negative correlation was found between the patients' EF values and total QOL scores (r=−0.27, P=0.03). In addition, significant differences in total QOL scores were found among the four NYHA classes (F3,70=3.3, P=0.025). Post hoc contrasts demonstrated that the patients in NYHA Class IV had significantly higher mean QOL scores (i.e., worse QOL) than patients in NYHA Class II (P=0.023).

Effect of Selected Demographic and Disease-Specific Characteristics, Bodily Pain, and Mental Health on QOL 

Table 2 lists the univariate correlations between the total score on the MLHFQ and selected demographic and disease-specific characteristics, as well as SF-36 bodily pain and mental health scores. Based on the findings from these correlational analyses, a multiple regression analysis was performed using SF-36 mental health, bodily pain scores, and NYHA class as predictors of QOL. As shown in Table 3, the overall model explained 34.1% of the variance in QOL, using the total score from the MLHFQ as the dependent variable (P<0.001). In terms of unique contributions, mental health explained 9% of the variance (P=0.005), NYHA class explained 7% of the variance (P=0.008), and pain explained 5% of the variance (P=0.03) in QOL.

Table 2. Relationships Between Total Scores on the MLHFQ and Selected Demographic, Clinical, and Miscellaneous Characteristics
CharacteristicsTotal Score on the MLHFQ
rP-value
Demographic characteristics
Age−0.090.44
Gender0.190.08
Living situation0.120.27
Marital status−0.140.20
Education−0.200.08

Clinical characteristics
NYHA class0.310.01
EF value−0.270.03
Total number of diseases0.060.63

Miscellaneous characteristics
Mental health−0.51<0.0001
Bodily pain−0.46<0.0001

Values in bold are statistically significant at the 0.05 level.

Table 3. Effect of Bodily Pain, Mental Health, and Severity of the Disease on QOL in Patients with HF (Multiple Regression Summary; Dependent Variable: QOL [total score on the MLHFQ] n=70)
SourceR2rβR2-ChangedfFP
Overall model0.341 3,6611.38<0.001
Mental health −0.48a−0.320.091,668.500.005
NYHA class 0.35b0.280.071,667.430.008
Bodily pain −0.37c−0.250.051,6650.900.027

aZero order correlation is significant at the P<0.0001 level.

bZero order correlation is significant at the 0.002 level.

cZero order correlation is significant at the 0.001 level.

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Discussion 

This study is the first to evaluate the prevalence and severity of pain in a sample of hospitalized patients with HF using a validated pain measure and to examine the relationships between various demographic and disease-specific characteristics, as well as pain, on patients' QOL. Of note, 85% of the patients with HF reported some level of pain and 42.5% reported pain in the severe to very severe range. To place these findings on pain prevalence and severity in patients with HF into context, they were compared with pain prevalence and pain severity rates reported by a sample drawn from the Norwegian general population.32 Using responses from the SF-36, approximately 70% of the Norwegian general population reported some pain. However, only 13% reported that their pain was in the severe to very severe range. In addition, whereas 80% of the patients with HF reported that pain interfered with their normal work, only 50% of the sample from the general population reported this finding. These comparisons suggest that pain is a significant problem for patients with HF.

The overall percentage of patients with HF in pain in this study is somewhat higher than the range of 23% to 75% reported in the review by Godfrey et al.15 This difference may be attributed to the fact that patients with HF in this study were hospitalized with an exacerbation of their HF. It is interesting to note that the prevalence rates and severity ratings of pain in this sample of patients with HF are comparable to those reported by patients with breast and lung cancer pain.33, 34 However, the bodily pain scores (43.0±30.1) of patients with HF are lower than those reported by patients with chronic pain who were admitted to a pain center (i.e., 26.0±16.0).35

Despite the high prevalence rates and severity scores across a number of studies,5, 11, 13, 14, 15, 16 the paucity of research on pain in patients with HF makes it difficult to draw definitive conclusions about the causes and characteristics of the pain. In one study of patients with HF,12 53.7% reported chest pain, whereas 57.4% reported pain from other causes. In another study,13 22%–37% of patients reported chest pain and 12%–18% reported abdominal pain. However, one can hypothesize that given the number of comorbid conditions that patients with HF have, as well as the fatigue and deconditioning that occurs with HF,16, 36 pain could occur from a variety of conditions or problems. Therefore, additional research with pain-specific measures (e.g., Brief Pain Inventory37 and McGill Pain Questionnaire38) is needed to determine the specific etiologies for the pain reported by patients with HF.

It is interesting to note that no differences were found in the mean SF-36 bodily pain scores based on selected demographic (i.e., age, gender, marital status, cohabitation, or educational level) or disease-specific (i.e., NYHA class, EF values, or presence of various chronic medical conditions) characteristics. These findings are in contrast with previous studies of differences in pain intensity among the Norwegian population based on age,39 gender,40 or the presence of a chronic illness.41 These inconsistent findings may be partially explained by the relatively small sample size of patients with HF in this study.

Several studies have evaluated the impact of HF on patients' QOL.5, 7, 8, 9, 12, 16, 42, 43 Consistent with the findings from this study, previous studies5, 7, 8, 9, 42 have demonstrated that worsening HF, as measured by NYHA class, was associated with a poorer QOL. In addition, as was seen in this study, higher levels of depression were associated with poorer QOL.42 It is not readily apparent why older age and female gender were not associated with decreases in QOL that were reported in previous studies.30, 42 Possible explanations for these differences are the higher percentage of men and the older age of the participants in this study.

This study is the first to demonstrate that, in conjunction with severity of disease and worse mental health, pain has a negative impact on QOL and uniquely explains 5% of the variance in QOL in patients with HF. Perhaps this association was not made previously because although the two most commonly used disease-specific measures of QOL for patients with HF (i.e., MLHFQ and Kansas City Cardiomyopathy Questionnaire) do evaluate other symptoms (e.g., dyspnea and fatigue), neither includes a pain item.

However, one needs to acknowledge that only 34.1% of the variance in QOL was explained by this model and that pain's unique contribution to the percent of explained variance was only 5%. These findings suggest that either the relatively small sample size or other factors not measured in this study contribute to the variance in QOL in patients with HF. For example, in a recent study of 2709 patients with HF,44 independent factors associated with poorer QOL were female gender, younger age, higher body mass index, lower systolic blood pressure, greater symptom burden, and worse functional status. In another study of 60 outpatients with HF,16 depression was associated with a greater number of symptoms, which in turn was associated with decreased QOL. Finally, Zambroski et al.,12 in a convenience sample of 53 outpatients with HF, found that younger age, worse functional status, higher symptom prevalence, and higher symptom burden were associated with decreased QOL. Although findings from these three studies12, 16, 44 suggest that symptom burden has a negative impact on the QOL of patients with HF, none of these studies evaluated the independent effect of pain on QOL. Additional research is warranted to evaluate the independent contribution of the most common symptoms on the QOL of patients with HF. In addition, the effect of other factors, such as social support and coping strategies, on QOL need to be evaluated in future research studies.

Several limitations of this study are worth noting. Because the primary purpose of this study was to evaluate the relationship between hope and QOL in patients with HF, a detailed pain questionnaire was not administered to the participants. Therefore, little is known about the causes and characteristics of pain in this sample. In addition, because of the relatively small sample size that is primarily male and older, definitive conclusions cannot be made about the influence of gender and age on the pain experience of patients with HF.

Despite its limitations, the findings from this study provide evidence that unrelieved pain is a significant problem for patients with HF. In addition, as with other chronic medical conditions, unrelieved pain has a negative impact on patients' QOL. These findings point to the need for additional studies to characterize the problem of chronic pain in patients with HF. Without specific epidemiologic data, the development of appropriate interventions for pain in this population will not occur.

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 This study took place at Ullevaal University Hospital and Buskerud Hospital Trust and was funded by Oslo University College.The data from the general population applied in this publication are based on the Survey of Level of Living 2002 in Norway. Deidentified date sets have been made available by the Norwegian Social Science Data Services (NSD). Statistics Norway (SSB) was responsible for sampling and interviewing. Neither NSD nor SSB are responsible for the analyses/interpretation of data presented here.

PII: S0885-3924(08)00293-5

doi:10.1016/j.jpainsymman.2007.11.014

Journal of Pain and Symptom Management
Volume 36, Issue 5 , Pages 497-504, November 2008

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