Pain and heart failure: unrecognized and untreated

Pain and Heart Failure During Transport by Emergency Medical Services and Its Associated Outcomes: Hospitalization, Mortality, and Length of Stay

BACKGROUND

Over 22% of patients with heart failure (HF) are transported by emergency medical services (EMSs) for a primary complaint of pain. The relationship between a primary complaint of pain on hospitalization status, mortality, or length of stay following transport by EMS is understudied.

OBJECTIVES

The objective of this study was to determine whether a primary complaint of pain during EMS transport predicted hospitalization status, mortality, or inpatient length of stay.

METHODS

In this retrospective longitudinal cohort study, data were analyzed from electronic health records of 3539 patients with HF. Descriptive statistics and multivariate logistic and linear regression analyses were used to achieve study objectives.

RESULTS

Demographics were mean age 64.83 years (standard deviation [SD] = 14.58); gender 57.3% women, 42.7% men; self-reported race 56.2% black, 43.2% white, and 0.7% other. Of 3539 patients, 2346 (66.3%) were hospitalized, 149 (4.2%) died, and the mean length of stay was 6.02 (SD = 7.55) days. A primary complaint of pain did not predict increased odds of in-hospital mortality but did predict 39% lower odds of hospitalization (p < .001), and 26.7% shorter length of stay (p < .001). Chest pain predicted 49% lower odds of hospitalization (p < .001) and 34.1% (p < .001) shorter length of stay, whereas generalized pain predicted 45% lower odds of hospitalization (p = .044) following post-hoc analysis.

CONCLUSIONS

A primary complaint of chest pain predicted lower odds of hospitalization and shorter length of stay, possibly due to established treatment regimens. Additional research is needed to examine chronic pain rather than a primary complaint of pain.

Correlates of musculoskeletal pain and kinesiophobia in older adults with heart failure: A structural equation model

The study aimed to study the influence of musculoskeletal pain on kinesiophobia in patients with heart failure. This cross-sectional study recruited 107 heart failure patients aged 73.18±12.68 years (57% men) from an outpatient setting. Participants self-reported pain using the Musculoskeletal System Assessment Inventory and the Cornell Musculoskeletal Discomfort Questionnaire. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia-11. About 62% reported musculoskeletal pain, with knees (16.8%) and lower back (12.%) being the most painful locations. About 31% reported moderate levels and 24% indicated high levels of kinesiophobia. There were positive and significant associations between the indicators of pain and kinesiophobia. Results showed an adequate structural equation model fit to the data with musculoskeletal pain factors explaining 22.09% of the variance in kinesiophobia. Assessment of kinesiophobia in patients with heart failure with musculoskeletal pain is essential to improve self-care and overall quality of life.

Pain sensation and gut microbiota profiles in older adults with heart failure

Objectives

Patients with heart failure (HF) experience severe pain and may have altered pain sensation; however, the underlying mechanisms of these symptoms are not yet fully understood. Identifying pain sensation and genomic biomarkers of pain in older adults with HF is a critical step toward developing personalized interventions to improve pain management and outcomes. This study aimed to investigate the differences in pain sensation, gut microbiota, self-reported pain, and symptoms in older adults with and without HF.

Methods

Twenty older adults with HF and age-matched healthy controls (HCs) were recruited in the Northeastern United States. Quantitative sensory testing and conditioned pain modulation were performed on the nondominant upper arm to detect the mechanical, thermal, and pressure pain thresholds and pain modulations. Stool samples were collected, and the 16S rRNA V4 gene region of stool samples was sequenced and processed using the Mothur 1.42.3 pipeline. Self-reported pain and symptoms were measured by the Brief Pain Inventory and the NIH Patient-reported Outcomes Measurement Information System. The associations between pain sensation, gut microbiota α-diversity indices, and pain and symptoms were explored using the Spearman correlations.

Results

The HF and HC subjects' mean ages were 73.50 (SD = 8.33) and 67.10 (SD = 7.64), respectively. The HF subjects reported significantly higher pain intensity and interference, sleep disturbance, fatigue, anxiety, and depression than the HCs. The HF subjects also had a significantly lower level of physical function and participation in social roles and activities. Compared with the HCs, the HF subjects had significantly altered conditioned pain modulation heat effect and gut microbiota compositions and predicted metabolic functions. The Statistical Analysis Of Metagenomic Profiles indicated that the HF subjects had a significantly decreased cardiac muscle contraction pathway compared with the HCs. The correlation analysis showed that the quantitative sensory testing profiles and gut microbiota diversity index were significantly associated with pain and symptoms in older adults with HF.

Conclusions

Older adults with HF had more severe self-reported pain and symptoms, altered pain sensation, and different gut microbiota composition and function compared with age-matched HCs. Pain sensation and gut microbiota may contribute to pain and symptoms in older adults with HF and could serve as biomarkers of pain and symptoms of HF. Further research with a larger sample size is warranted to confirm these findings.

Factors Associated With Depression and Anxiety for Community-Dwelling Patients With Heart Failure

BACKGROUND

Depression and anxiety are common comorbidities in heart failure (HF) and are associated with adverse outcomes including unplanned hospitalization. However, there is insufficient evidence on the factors associated with depression and anxiety for community patients with HF to inform optimal assessment and treatment in this population.

AIM

The aim of this study was to examine the prevalence of and factors associated with depression and anxiety in community-dwelling patients with HF.

METHODS

A retrospective cohort study of 302 adult patients given a diagnosis of HF referred to United Kingdom's largest specialist cardiac rehabilitation center, from June 2013 to November 2020. Main study outcomes were symptoms of depression using Patient Health Questionnaire-9 and anxiety using the General Anxiety Disorder 7-item scale. Explanatory variables included demographic and clinical characteristics and functional status from the Dartmouth COOP questionnaire: quality of life, pain, level of social activity and daily activities, and being bothered by emotional problems (feelings). Logistic regressions were performed to evaluate the association between demographic and clinical characteristics and depression and anxiety.

RESULTS

Of the sample, 26.2% reported depression and 20.2% had anxiety. Higher depression and anxiety were associated with difficulty in performing daily activities (95% confidence interval, 1.11-6.46 and 1.13-8.09, respectively) and being bothered by feelings (95% confidence interval, 4.06-21.77 and 4.25-22.46, respectively). Depression was associated with limitations in social activity (95% confidence interval, 1.06-6.34) and anxiety with distressing pain (95% confidence interval, 1.38-7.23).

CONCLUSION

Findings indicate the importance of psychosocial interventions for patients with HF to minimize and manage depression and anxiety. Patients with HF may benefit from interventions targeted to maintain independence, promote participation in social activities, and optimally manage pain.

Inpatient palliative care encounter and 30-day readmission among hospitalizations for heart failure

Aim: To determine the association between inpatient palliative care encounter (PCE) and 30-day rehospitalization. Materials & methods: The Nationwide Readmission Database was used in a cross-sectional design study. Comorbidities and a palliative care encounter (PCE; V66.7) were defined using ICD-9 codes. Results: Overall, 21.28% of 3,534,480 index hospitalizations were readmitted. PCE occurred in 1.66% of index hospitalizations and was associated with a lower odds of 30-day rehospitalization (adjusted odds ratio, 0.38; 95% CI: 0.35-0.40). This association remained significant when assessed by discharge destination. Conclusion: PCE was associated with a lower relative odds of 30-day rehospitalization. A 73% decrease in the relative odds of 30-day rehospitalization among discharges to a facility, 64% for home with home health, and 22% for discharges to home.

Characterizing Pain Leading to Emergency Medical Services Activation in Heart Failure

BACKGROUND

Pain is a common but understudied symptom among patients with heart failure (HF) transported by emergency medical services (EMS). The aims were to determine explanatory factors of a primary complaint of pain and pain severity, and characterize pain among patients with HF transported by EMS.

METHODS

Data from electronic health records of patients with HF transported by EMS within a midwestern United States county from 2009 to 2017 were analyzed. Descriptive statistics, χ 2 , analysis of variance, and logistic and multiple linear regression analyses were used.

RESULTS

The sample (N = 4663) was predominantly women (58.1%) with self-reported race as Black (57.7%). The mean age was 64.2 ± 14.3 years. Pain was the primary complaint in 22.2% of the sample, with an average pain score of 6.8 ± 3.1 out of 10. The most common pain complaint was chest pain (68.1%). Factors associated with a primary pain complaint were younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.96-0.97), history of myocardial infarction (OR, 1.96; 95% CI, 1.55-2.49), and absence of shortness of breath (OR, 0.67; 95% CI, 0.58-0.77). Factors associated with higher pain severity were younger age ( b = -0.05, SE = 0.013), being a woman ( b = 1.17, SE = 0.357), and White race ( b = -1.11, SE = 0.349).

CONCLUSIONS

Clinical and demographic factors need consideration in understanding pain in HF during EMS transport. Additional research is needed to examine these factors to improve pain management and reduce transports due to pain.

Palliative Care for People Living With Heart Disease-Does Sex Make a Difference?

The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.

End-of-life care in patients with advanced heart failure

PURPOSE OF REVIEW

With an aging population with heart failure, there is a growing need for end-of-life care in this population, including a focus on symptom management and quality-of-life considerations.

RECENT FINDINGS

Targeted therapies focusing on symptom control and improving quality of life is the cornerstone of providing care in patients with heart failure near the end of life. Such therapies, including the use of inotropes for palliative purposes, have been shown to improve symptoms without an increase in mortality. In addition, recent evidence shows that implementing certain strategies in planning for end of life, including advance care planning and palliative care involvement, can significantly improve symptoms and quality of life, reduce hospitalizations, and ensure care respects patient values and preferences.

SUMMARY

Shifting focus from prolonging life to enhancing quality of life in heart failure patients approaching the end of life can be achieved by recognizing and managing end-stage heart failure-related symptoms, advanced care planning, and a multidisciplinary care approach.

Humanistic burden and economic impact of heart failure – a systematic review of the literature

Background: Heart failure (HF) is increasing in prevalence worldwide. This systematic review was conducted to inform understanding of its humanistic and economic burden. Methods: Electronic databases (Embase, MEDLINE®, and Cochrane Library) were searched in May 2017. Data were extracted from studies reporting health-related quality of life (HRQoL) in 200 patients or more (published 2007–2017), or costs and resource use in 100 patients or more (published 2012–2017). Relevant HRQoL studies were those that used the 12- or 36-item Short-Form Health Surveys, EuroQol Group 5-dimensions measure of health status, Minnesota Living with Heart Failure Questionnaire or Kansas City Cardiomyopathy Questionnaire. Results: In total, 124 studies were identified: 54 for HRQoL and 71 for costs and resource use (Europe: 25/15; North America: 24/50; rest of world/multinational: 5/6). Overall, individuals with HF reported worse HRQoL than the general population and patients with other chronic diseases. Some evidence identified supports a correlation between increasing disease severity and worse HRQoL. Patients with HF incurred higher costs and resource use than the general population and patients with other chronic conditions. Inpatient care and hospitalizations were identified as major cost drivers in HF. Conclusions: Our findings indicate that patients with HF experience worse HRQoL and incur higher costs than individuals without HF or patients with other chronic diseases. Early treatment of HF and careful disease management to slow progression and to limit the requirement for hospital admission are likely to reduce both the humanistic burden and economic impact of HF.

Daytime and Nighttime Sleep Characteristics and Pain Among Adults With Stable Heart Failure

BACKGROUND

Pain and sleep disturbance are common among patients with heart failure (HF) and are associated with symptom burden, disability, and poor quality of life. Little is known about the associations between specific sleep characteristics and pain in people with HF.

OBJECTIVE

The aim of this study was to describe the relationships between nocturnal sleep characteristics, use of sleep medication, and daytime sleep characteristics and pain among people with HF.

METHODS

We conducted a cross-sectional study of stable participants with HF. We administered the SF36 Bodily Pain Scale, Pittsburgh Sleep Quality Index, and Sleep Habits Questionnaire and obtained 3 days of wrist actigraphy and 1 night of home unattended polysomnography. We conducted bivariate analyses and generalized linear models.

RESULTS

The sample included 173 participants (mean [SD] age, 60 [16.1] years; 65.3% [n = 113] male). Insomnia symptoms (P = .0010), sleep duration (P = .0010), poor sleep quality (P = .0153), use of sleep medications (P = .0170), napping (P = .0029), and daytime sleepiness (P = .0094) were associated with increased pain. Patients with the longest sleep duration, who also had insomnia, had more pain (P = .0004), fatigue (P = .0028), daytime sleepiness (P = .0136), and poorer sleep quality (P < .0001) and took more sleep medications (P = .0029) than did those without insomnia.

CONCLUSIONS

Pain is associated with self-reported poor sleep quality, napping, daytime sleepiness, and use of sleep medication. The relationship between pain and sleep characteristics differs based on the presence of insomnia and sleep duration. Studies are needed to evaluate the causal relationships between sleep and pain and test interventions for these cooccurring symptoms.

Patterns of Opioid Prescribing among Medicare Advantage Beneficiaries with Pain and Cardiopulmonary Conditions

Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p < 0.001) and both conditions (17%; p < 0.001) but higher than patients with neither condition (13.1%; p < 0.001). There was no difference in time to initiation of opioids at follow-up among patients with cardiopulmonary conditions only, relative to cancer only (adjusted hazard ratio 1.03; 95% confidence interval 0.88-1.21). Conclusions: Opioid use is lower among patients with pain and cardiopulmonary conditions relative to patients with cancer. Findings emphasize the importance of pain assessment and management for patients with cardiopulmonary conditions.

The Association Between Patient-reported Clinical Factors and 30-day Acute Care Utilization in Chronic Heart Failure

BACKGROUND

Heart failure patients have high rates of repeat acute care use. Current efforts for risk prediction often ignore postdischarge data.

OBJECTIVE

To identify postdischarge patient-reported clinical factors associated with repeat acute care use.

RESEARCH DESIGN

In a prospective cohort study that followed patients with chronic heart failure for 30 days postdischarge, for 7 days after discharge (or fewer days if patients used acute care within 7 days postdischarge), patients reported health status, heart failure symptoms, medication management, knowledge of follow-up plans, and other issues using a daily interactive automatic phone call.

SUBJECTS

A total of 156 patients who had responded to phone surveys.

MEASURES

The outcome variable was dichotomous 30-day acute care use (rehospitalization or emergency department visit). We examined the association between each patient-reported issue and the outcome, using multivariable logistic regression to adjust for confounders.

RESULTS

Patients were 63 years old (SD=12.4), with 51% African-American and 53% women. Within 30 days postdischarge, 30 (19%) patients used acute care. After adjustment, poor health status [odds ratio (OR)=3.53; 95% confidence interval (CI), 1.06-11.76], pain (OR=2.44; 95% CI, 1.02-5.84), and poor appetite (OR=3.05; 95% CI, 1.13-8.23) were positively associated with 30-day acute care utilization. Among 58 reports of pain in follow-up nursing notes, 39 (67%) were noncardiac, 2 (3%) were cardiac, and 17 (29%) were indeterminate.

CONCLUSIONS

Patient-reported poor health status, pain, and poor appetite were positively associated with 30-day acute care utilization. These novel postdischarge markers require further study before incorporation into risk prediction to drive quality improvement efforts.

Palliative Care in Patients with Advanced Heart Failure

The heart failure (HF) guidelines recommend palliative care; however, it can often be difficult to determine the timing of palliative care referral. Because HF with fluid retention and low-cardiac output may trigger several unpleasant symptoms, continuous HF treatment is required to alleviate these symptoms in advanced HF. The patients with HF often suffer from total pain; therefore, the support from a multidisciplinary team plays a crucial role to improve quality of life of the patients and their families not only in the terminal phase but also from the early stage.

Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.

Symptom cluster among patients with advanced heart failure: a review of its manifestations and impacts on health outcomes

PURPOSE OF REVIEW

Assessment of symptom clustering is effective in enhancing care planning for symptom palliation in life-limiting disease. This review was aimed at identifying symptom cluster manifestation among advanced heart failure patients and to investigate the prognostic impact of the identified symptom clusters.

RECENT FINDINGS

A systematic search of the literature identified 10 relevant articles. Two approaches were undertaken based on: correlations between symptoms and shared characteristics of patients' symptom profiles, to identify the symptom clusters. By comparing the findings for heart failure patients at an advanced disease stage and those who were not, the symptom clusters of advanced heart failure were found to have unique characteristics. In particular, the typical symptoms associated with cardiac decompensation are not clustered together. Instead, dyspnoea is clustered with emotional symptoms indicating that a distressing dyspnoeic attack may reinforce awareness of the life-limiting nature of the disease and arouse negative emotions. In addition, the debilitating heart failure-specific symptoms share the cause of the life-limiting aspects in compromising patient vitality. The strong positive association between symptom burden and cardiac event prompts the need for effective intervention to palliate not only typical but also atypical and emotional symptoms of advanced heart failure.

SUMMARY

This review provides insight on potentially effective interventions for symptom palliation in advanced heart failure.

Palliative and end-of-life care for heart failure patients in an aging society

The populations of Asian countries are expected to age rapidly in the near future, with a dramatic increase in the number of heart failure (HF) patients also anticipated. The need for palliative and end-of-life care for elderly patients with advanced HF is currently recognized in aging societies. However, palliative care and active treatment for HF are not mutually exclusive, and palliative care should be provided to reduce suffering occurring at any stage of symptomatic HF after the point of diagnosis. HF patients are at high risk of sudden cardiac death from the early stages of the disease onwards. The decision of whether to perform cardiopulmonary resuscitation in the event of an emergency is challenging, especially in elderly HF patients, because of the difficulty in accurately predicting the prognosis of the condition. Furthermore, advanced HF patients are often fitted with a device, and device deactivation at the end of life is a complicated process. Treatment strategies should thus be discussed by multi-disciplinary teams, including palliative experts, and should consider patient directives to address the problems discussed above. Open communication with the HF patient regarding the expected prognosis, course, and treatment options will serve to support the patient and aid in future planning.

The Association Between HIV Infection and the Use of Palliative Care in Patients Hospitalized With Heart Failure

BACKGROUND

The number of adults with heart failure (HF) and HIV infection is increasing. These patients may benefit from palliative care (PC).

OBJECTIVES

Determine the association between HIV infection, other HIV characteristics, and PC among hospitalized patients with HF in the Veterans Health Administration (VHA).

DESIGN

Nested case-control study of patients with HF hospitalized from 2003 to 2015 and enrolled in the Veterans Aging Cohort Study.

SETTING/PATIENTS

Two hundred and ten hospitalized patients with HF who received PC matched to 1042 patients with HF who did not receive PC, by age, discharge date, and left ventricular ejection fraction.

MEASUREMENTS

Palliative care use was the primary outcome. Independent variables included HIV infection identified by International Classification of Diseases Ninth Revision code and further characterized as the primary diagnosis for hospitalization, unsuppressed HIV-1 RNA, CD4 counts <200 cells/mm³, and other covariates. We examined associations between independent variables and PC using conditional logistic regression.

RESULTS

The sample was 99% male, mean age was 64 years (standard deviation ±10), 54% of cases and 59% of controls were black, and 30% of cases and 31% of controls were HIV-infected. In adjusted models, HIV as the primary diagnosis for hospitalization (odds ratio [OR]: 3.69, 95% confidence interval [CI]: 1.30-10.52), unsuppressed HIV-1 RNA (OR: 2.62, 95% CI: 1.31-5.24), and CD4 counts <200 cells/mm³ (OR: 3.47; 1.78-6.77), but not HIV infection (OR: 0.79, 95% CI: 0.55-1.13), were associated with PC.

CONCLUSIONS

HIV characteristics indicative of severe disease are associated with PC for hospitalized VHA patients with HF. Increasing access to PC for patients with HF and HIV is warranted.

Symptom Clusters and Their Impacts on Hospital Readmission in Patients With Heart Failure: A Cross-Sectional Study

Background and Purpose:

Readmissions after hospitalization due to multiple symptoms in heart failure (HF) are common and costly. Patients have difficulty differentiating HF symptoms from comorbid illness or aging. Therefore, early identification of symptom clusters could improve symptom recognition and reduce hospital readmission. However, little is known about the relationship between symptom clusters and readmission in HF patients. This study aimed to identify symptom clusters among Korean patients with HF and the relationship between symptom clusters and hospital readmission.

Methods:

This cross-sectional study included 306 HF outpatients within 12 months after discharge. Exploratory factor analysis was used to identify the symptom clusters. Multiple logistic regression analysis was used to examine the effect of symptom clusters on readmission, after adjusting for sociodemographic and clinical characteristics.

Results:

Three symptom clusters were identified in HF patients: the “respiratory distress” cluster, “bodily pain and energy insufficiency” cluster, and “circulatory and gastrointestinal distress” cluster. Patients with class III or IV of HF functional class experienced three symptom clusters at a higher level. This study showed that the “bodily pain and energy insufficiency” cluster was the strongest predictor of hospital readmission in HF patients (adjusted odds ratio = 6.59, 95% confidence interval (CI) [1.29, 32.79]).

Implications for Practice:

A higher level of “bodily pain and energy insufficiency” cluster was associated with hospital readmission in Korean HF patients. Health-care providers should be encouraged to consider patients’ cultural backgrounds to recognize differences in symptom clusters. Further studies are needed to evaluate symptom clusters across international cohorts and their impacts on patients’ outcomes.

The Relationships Among Pain, Depression, and Physical Activity in Patients With Heart Failure

INTRODUCTION

Increasing patients' physical activity levels holds many opportunities to facilitate health and well-being among those with heart failure (HF) by improving HF symptoms and decreasing depression and pain. Given low exercise participation rates, an essential first step to increase exercise rates is to evaluate how pain and depression may further influence engagement in exercise programs.

AIMS

The aims of this study were to describe the level of physical activity and exercise that patients with HF with depression achieve and to investigate the relationships among pain, depression, total activity time, and sitting time.

METHODS

In this correlational cross-sectional study, we analyzed data from 61 participants with depression and New York Heart Association class II to IV HF.

RESULTS AND CONCLUSIONS

The total time spent being active was less than 1 hour per day. Depressed patients with HF have much lower physical activity levels than the general public. Decreasing sitting time and increasing light activity levels hold promise to improve pain and depression symptoms.

Symptom burden in heart failure: assessment, impact on outcomes, and management

Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.

Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities

Patients with heart failure (HF) and their families experience stress and suffering from a variety of sources over the course of the HF experience. Palliative care is an interdisciplinary service and an overall approach to care that improves quality of life and alleviates suffering for those living with serious illness, regardless of prognosis. In this review, we synthesize the evidence from randomized clinical trials of palliative care interventions in HF. While the evidence base for palliative care in HF is promising, it is still in its infancy and requires additional high-quality, methodologically sound studies to clearly elucidate the role of palliative care for patients and families living with the burdens of HF. Yet, an increase in attention to primary palliative care (e.g., basic physical and emotional symptom management, advance care planning), provided by primary care and cardiology clinicians, may be a vehicle to address unmet palliative needs earlier and throughout the illness course.

Primary palliative care for heart failure: what is it? How do we implement it?

Heart failure (HF) is a chronic and progressive illness, which affects a growing number of adults, and is associated with a high morbidity and mortality, as well as significant physical and psychological symptom burden on both patients with HF and their families. Palliative care is the multidisciplinary specialty focused on optimizing quality of life and reducing suffering for patients and families facing serious illness, regardless of prognosis. Palliative care can be delivered as (1) specialist palliative care in which a palliative care specialist with subspecialty palliative care training consults or co-manages patients to address palliative needs alongside clinicians who manage the underlying illness or (2) as primary palliative care in which the primary clinician (such as the internist, cardiologist, cardiology nurse, or HF specialist) caring for the patient with HF provides the essential palliative domains. In this paper, we describe the key domains of primary palliative care for patients with HF and offer some specific ways in which primary palliative care and specialist palliative care can be offered in this population. Although there is little research on HF primary palliative care, primary palliative care in HF offers a key opportunity to ensure that this population receives high-quality palliative care in spite of the growing numbers of patients with HF as well as the limited number of specialist palliative care providers.

The Characteristics of Pain in Patients Diagnosed with Depression and Heart Failure

Heart failure (HF) is a costly and growing health problem that is routinely complicated by chronic pain and depression. The purpose of this paper is to describe the characteristics of pain and pain management in depressed HF patients. In this descriptive cross-sectional study, we analyzed data from 62 participants with depression and class II-IV HF. Study variables of interest were collected from the Brief Pain Inventory, Beck Depression Inventory, and Rand-36. Almost all participants (98%) had some pain in the past month and most had pain in the last 24 hours (66%). The median pain score was 4 (0-10 scale) with the majority reporting moderate to severe pain. The median pain interference score was 4.42 (0-10 scale) with the majority reporting moderate to extreme interference. Medication to treat pain was used by all participants who reported pain, with only 5% also using nonpharmacologic treatment. The majority of participants reported moderate or severe pain while also having moderate to extreme pain interference. Nonpharmacologic pain treatments were severely underused. Women were more likely to have higher levels of pain intensity and more pain interference than men, suggesting that additional screening for the impact of pain is especially important in women. The wide variety of body areas affected, along with moderate to high intensity pain and considerable interference scores reported, indicate that pain was ineffectively treated. Nonpharmacologic treatments should be considered to decrease the impact of pain.

End-of-Life Care in the Treatment of Heart Failure in Older Adults

Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.

Chronic Pain in Chronic Heart Failure: A Review Article

Heart failure (HF) is one of the main causes of death and disability in the world. The prevalence of HF in developed countries is between 1% and 2% of the adult population and approximately between 6% and 10% in the elderly, giving rise to high costs of care and treatment. Indeed, in the United States, the direct and indirect costs exceeded 23 billion dollars in 2002. HF is typically characterized by periods of acute symptoms followed by returns to nearly asymptomatic periods. As dyspnea and fatigue are considered the signature symptoms of HF, other symptoms such as pain go unnoticed. Awareness of the burden of pain, however, is growing in patients with chronic HF. The past 2 decades have witnessed remarkable technical headway in cardiology and many patients have survived despite the progressive impairment of their cardiovascular function. It is, therefore, of great value to investigate the prevalence and management of pain in patients with HF. To that end, we undertook a comprehensive search using the MEDLINE database for studies and guidelines on the subject of pain and HF and the complications and considerations and finally selected 65 studies for review.

Risk Factors for All-Cause Rehospitalization Among Medicare Recipients with Heart Failure Receiving Telehomecare

OBJECTIVE

To identify potential risk factors associated with rehospitalization among Medicare recipients with heart failure (HF) receiving telehomecare.

MATERIALS AND METHODS

This study is a nonexperimental, cross-sectional secondary data analysis of the Centers for Medicare and Medicaid (CMS) mandated assessment called the Outcome and Assessment Information Set (OASIS)-C, provided by a large home care company. A total of 526 patients who received telehomecare from January 1, 2011 to August 31, 2013 were included in the analyses, which used multiple logistic regression.

RESULTS

The overall rate of rehospitalization was 36% while patients were receiving telehomecare. Moderately frail health status (p = 0.01), the presence of severe pain (p = 0.01), the presence of dermatologic problems (p = 0.03), and independence in dressing one's lower body (compared to slightly dependent [p = 0.01] or mostly dependent patient groups [p = 0.02]) were identified as risk factors for rehospitalization.

CONCLUSIONS

The risk factors identified from this study may be used to drive more effective telehomecare placements, and referrals for additional services among telehomecare patients with HF.

Symptom clusters and quality of life among patients with advanced heart failure

Objectives

To identify symptom clusters among patients with advanced heart failure (HF) and the independent relationships with their quality of life (QoL).

Methods

This is the secondary data analysis of a cross-sectional study which interviewed 119 patients with advanced HF in the geriatric unit of a regional hospital in Hong Kong. The symptom profile and QoL were assessed by using the Edmonton Symptom Assessment Scale (ESAS) and the McGill QoL Questionnaire. Exploratory factor analysis was used to identify the symptom clusters. Hierarchical regression analysis was used to examine the independent relationships with their QoL, after adjusting the effects of age, gender, and comorbidities.

Results

The patients were at an advanced age (82.9 ± 6.5 years). Three distinct symptom clusters were identified: they were the distress cluster (including shortness of breath, anxiety, and depression), the decondition cluster (fatigue, drowsiness, nausea, and reduced appetite), and the discomfort cluster (pain, and sense of generalized discomfort). These three symptom clusters accounted for 63.25% of variance of the patients' symptom experience. The small to moderate correlations between these symptom clusters indicated that they were rather independent of one another. After adjusting the age, gender and comorbidities, the distress (β = −0.635, P < 0.001), the decondition (β = −0.148, P = 0.01), and the discomfort (β = −0.258, P < 0.001) symptom clusters independently predicted their QoL.

Conclusions

This study identified the distinctive symptom clusters among patients with advanced HF. The results shed light on the need to develop palliative care interventions for optimizing the symptom control for this life-limiting disease.

Pain among hospitalized older people with heart failure and their preparation to manage this symptom on discharge: a descriptive-observational study

Globally, heart failure (HF) is one of the major health issues faced by many older people. It causes significant symptom burden that requires ongoing management. This paper reports on a descriptive-observational study undertaken to: (1) describe the prevalence of pain and analgesic prescription usage in hospitalized older HF patients; (2) determine the degree to which these patients are provided with a pain self-management strategy prior to discharge; and (3) determine if the patients' pain self-management strategy has been detailed in the discharge summary. A total of 122 older HF patients were included in this study. Results indicated that moderate to severe pain (Numeric Rating Scale score ≥4) is experienced by a substantial number of older people hospitalized with HF. There is little documented evidence that older people are provided with adequate analgesic prescriptions and the instructions required to effectively manage their pain on discharge to the community.

Reporting of patient-centred outcomes in heart failure trials: are patient preferences being ignored?

Older people often suffer from multiple diseases. Therefore, universal cross-disease outcomes (e.g. functional status, quality of life, overall survival) are more relevant than disease-specific outcomes, and a range of potential outcomes are needed for medical decision-making. To assess how patient-relevant outcomes have penetrated randomized controlled trials (RCTs), reporting of these outcomes was reviewed in heart failure trials that included patients with multimorbidity. We systematically reviewed RCTs (Jan 2011–June 2012) and evaluated reported outcomes. Heart failure was chosen as condition of interest as this is common among older patients with multimorbidity. The main outcome was the proportion of RCTs reporting all-cause mortality, all-cause hospital admission, and outcomes in four domains of health, i.e. functional, signs and symptoms, psychological, and social domains. Of the 106 included RCTs, 50 (47 %) reported all-cause mortality and cardiovascular mortality and 29 (27 %) reported all-cause hospitalization and cardiovascular hospitalization. Of all trials, 68 (64 %) measured outcomes in the functional domain, 80 (75 %) in the domain of signs and symptoms, 65 (61 %) in the psychological domain, and 59 (56 %) in the social domain. Disease-specific instruments were more often used than non-disease-specific instruments. This review shows increasing attention for more patient-relevant outcomes; this is promising and indicates more awareness of the importance of a variety of outcomes desirable for patients. However, patients’ individual goal attainments were universally absent. For continued progress in patient-centred care, efforts are needed to develop these outcomes, study their merits and pitfalls, and intensify their use in research.

Managing comorbidities in patients with chronic heart failure: first, do no harm

Heart failure (HF) affects approximately 5.1 million adults in the USA, with expectations of a rise to nearly 8 million adults by 2030. Patients with HF are at increased risk for morbidity/mortality, and comorbidities can further complicate care for these patients. Diabetes mellitus, chronic pain, arrhythmias, and depression are diagnoses that often coexist with HF. Medications commonly used to treat these comorbidities may induce or worsen HF symptoms, so determining appropriate drug therapy is important. Healthcare providers must understand the relationship between these medications and HF in order to improve prescribing practices to increase patient safety and reduce morbidity and mortality. This manuscript discusses the association between certain medications used to treat the aforementioned diagnoses and their relationship to HF. The purpose of this article is to provide guidance on which pharmacologic options require special consideration, increased monitoring, or complete avoidance in HF patients with diabetes mellitus, chronic pain, arrhythmias, and/or depression.

The relationship between pain, fatigue, depression and functional performance in stable heart failure

OBJECTIVE

Evaluate the relationship between pain, fatigue, depression, demographic, clinical, and functional variables in stable heart failure (HF).

BACKGROUND

Pain, fatigue and depression are common in HF. Little is known about the relationship between pain, fatigue and depression and functional measures in this population.

METHODS

Secondary data analysis of a cross sectional study of 173 stable HF patients. Associations between clinical and demographic factors, pain (SF-36), depression (CES-D), and fatigue (MAF) to functional performance and capacity (SF-36 role limitations due to physical functioning and 6-Minute Walk Test) were evaluated using hierarchical multiple regressions.

RESULTS

The sample was 65% male with a mean age of 60. Fifty-seven percent (n = 100) had pain, 54% (n = 94) had fatigue, and 46% (n = 79) had depression. Pain, depression and fatigue were negatively associated with functional performance but not functional capacity when controlling for demographic and clinical covariates.

CONCLUSIONS

Pain, fatigue and depression were associated with decreased functional performance in stable HF. Symptom management interventions are needed in HF.

Brain metabolites in autonomic regulatory insular sites in heart failure

Autonomic, pain, and neuropsychologic comorbidities appear in heart failure (HF), likely resulting from brain changes, indicated as loss of structural integrity and functional deficits. Among affected brain sites, the anterior insulae are prominent in serving major regulatory roles in many of the disrupted functions commonly seen in HF. Metabolite levels, including N-acetylaspartate (NAA), creatine (Cr), choline (Cho), and myo-inositol (MI), could indicate the nature of anterior insula tissue injury in HF. The study aim was to assess anterior insular metabolites to determine processes mediating autonomic, pain, and neuropsychologic disruptions in HF. We performed magnetic resonance spectroscopy in bilateral anterior insulae in 11 HF and 53 controls, using a 3.0-Tesla magnetic resonance imaging scanner. Peaks for NAA at 2.02 ppm, Cr at 3.02 ppm, Cho at 3.2 ppm, and MI at 3.56 ppm were assigned, peak areas were calculated, and metabolites were expressed as ratios, including NAA/Cr, Cho/Cr, and MI/Cr. HF patients showed significantly increased Cho/Cr ratios, indicative of glial proliferation or injury, on the left anterior insula, and reduced NAA/Cr levels, suggesting neuronal loss/dysfunction, on the right anterior insula over controls. No differences in MI/Cr ratios appeared between groups. Right anterior insular neuronal loss and left glial alterations may contribute to distorted autonomic, pain, and neuropsychologic functions found in HF.

Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals

BACKGROUND

The requirement to meet the palliative needs of acute hospital populations has grown in recent years. With increasing numbers of frail older people needing hospital care as a result of both malignant and non-malignant conditions, emphasis is being placed upon understanding the physical, psychological and social burdens experienced by patients. This study explores the extent of burden in two large UK hospitals, focusing upon those patients who meet palliative care criteria. Furthermore, the paper explores the use of palliative services and identifies the most significant clinical diagnostic and demographic factors which determine physical and psychological burden.

METHODS

Two hospital surveys were undertaken to identify burden using the Sheffield Profile for Assessment and Referral to Care (SPARC). The Gold Standards Framework (GSF) is used to identify those patients meeting palliative care criteria. Participants were identified as being in-patients during a two-week data collection phase for each site. Data was gathered using face-to-face interviews or self-completion by patients or a proxy. Descriptive analyses highlight prevalence and use of palliative care provision. Binary logistic regression assesses clinical diagnostic predictor variables of physical and psychological burden.

RESULTS

The sample consisted of 514 patients and elevated physical, psychological and social burden is identified amongst those meeting palliative care criteria (n = 185). Tiredness (34.6%), pain (31.1%), weakness (28.8%) and psychological discomfort (low mood 19.9%; anxiety 16.1%) are noted as being prevalent. A small number of these participants accessed Specialist Palliative Care (8.2%). Dementia was identified as a predictor of physical (OR 3.94; p < .05) and psychological burden (OR 2.88; p < .05), being female was a predictor of psychological burden (OR 2.00; p < .05).

CONCLUSION

The paper highlights elevated levels of burden experienced by patients with palliative care requirements. Moreover, the paper also indicates that a large proportion of such patients are not in receipt of palliative approaches to their care. Furthermore, the paper identifies that those with non-malignant illnesses, especially dementia, may experience high levels of physical and psychological burden.

Evaluation of the prevalence and severity of pain in patients with stable chronic heart failure

AIM

To evaluate the prevalence and severity of pain in patients with chronic stable heart failure (HF) in an outpatient clinic setting.

METHODS

This is a cross-sectional study evaluating symptoms of generalized or specific pain in patients with chronic stable heart failure. A standardized questionnaire (Edmonton Symptom Assessment System) was administered during a routine outpatient clinic visit. The severity of pain and other symptoms were assessed on a 10 point scale with 10 being the worst and 0 representing no symptoms.

RESULTS

Sixty-two patients [age 56 ± 13 years, 51 males, 11 females, mean ejection fraction (EF) 33% ± 17%] completed the assessment. Thirty-two patients (52%) reported any pain of various character and location such as chest, back, abdomen or the extremities, with a mean pain score of 2.5 ± 3.1. Patients with an EF less than 40% (n = 45, 73%) reported higher pain scores than patients with an EF greater than 40% (n = 17, 27%), scores were 3.1 ± 3.3 vs 1.2 ± 1.9, P < 0.001. Most frequent symptoms were tiredness (in 75% of patients), decreased wellbeing (84%), shortness of breath (SOB, 76%), and drowsiness (70%). The most severe symptom was tiredness with a score of 4.0 ± 2.8, followed by decreased wellbeing (3.7 ± 2.7), SOB (3.6 ± 2.8), and drowsiness (2.8 ± 2.8).

CONCLUSION

Pain appears to be prevalent and significantly affects quality of life in HF patients. Adequate pain assessment and management should be an integral part of chronic heart failure management.

Unequal care for dying patients in Sweden: a comparative registry study of deaths from heart disease and cancer

BACKGROUND

The Swedish Palliative Registry is a nationwide quality registry aimed at facilitating improvement in end-of-life care. The goal is for the registry to list and report quality indicators related to care during the last week of life in all cases expected death in Sweden.

AIM

To examine the quality of care during the last week of life as reported to the registry for patients with heart disease compared to those with cancer.

METHOD

A retrospective registry study.

RESULTS

Patients dying of heart disease compared to those dying from cancer had more shortness of breath, fewer drugs prescribed as needed against the usual symptoms and often died alone. Furthermore, they and their close relatives received less information about the imminence of death and bereavement follow-up was less common. The healthcare personnel were less aware of the heart disease patients' symptoms and less often knew about where they wished to die.

CONCLUSION

Great differences were found in registered end-of-life care suggesting that the care given to patients with heart disease and cancer was unequal even after adjustment for age, sex and setting at the time of death. If our observational findings are confirmed in future studies there is obviously a need for new models for end-of-life management in order to facilitate the provision of equal care to dying patients regardless of diagnosis.

Palliative care and hospice in advanced heart failure

Advanced heart failure (HF) is a disease process that carries a high burden of symptoms, suffering, and death. Palliative care can complement traditional care to improve symptom amelioration, patient-caregiver communication, emotional support, and medical decision making. Despite a growing body of evidence supporting the integration of palliative care into the overall care of patients with HF and some recent evidence of increased use, palliative therapies remain underused in the treatment of advanced HF. Review of the literature reveals that although barriers to integrating palliative care are not fully understood, difficult prognostication combined with caregiver inexperience with end-of-life issues specific to advanced HF is likely to contribute. In this review, we have outlined the general need for palliative care in advanced HF, detailed how palliative measures can be integrated into the care of those having this disease, and explored end-of-life issues specific to these patients.