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

Pain, Return to Community Status, and 90-Day Mortality Among Hospitalized Patients With Heart Failure

BACKGROUND

Pain is common among patients with heart failure but has not been examined with short-term discharge outcomes. The purpose was to examine whether pain at discharge predicts return to community status and 90-day mortality among hospitalized patients with heart failure.

METHODS

Data from medical records of 2169 patients hospitalized with heart failure were analyzed in this retrospective cohort study. The independent variable was a diagnosis of pain at discharge. Outcomes were return to community status (yes/no) and 90-day mortality. Logistic regression was used to address aims. Covariates included age, gender, race, vital signs, comorbid symptoms, comorbid conditions, cardiac devices, and length of stay.

RESULTS

The sample had a mean age of 66.53 years, and was 57.4% women and 55.9% Black. Of 2169 patients, 1601 (73.8%) returned to community, and 117 (5.4%) died at or before 90 days. Patients with pain returned to community less frequently (69.6%) compared with patients without pain (75.2%), which was a statistically significant relationship (odds ratio, 0.74; 95% confidence interval, 0.57-0.97; P = .028). Other variables that predicted return to community status included age, comorbid conditions, dyspnea, fatigue, systolic blood pressure, and length of stay. Pain did not predict increased 90-day mortality. Variables that predicted mortality included age, liver disease, and systolic blood pressure.

CONCLUSION

Patients with pain were less likely to return to community but did not have higher 90-day mortality. Pain in combination with other symptoms and comorbid conditions may play a role in mortality if acute pain versus chronic pain can be stratified in a future study.

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.

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.

Differential Gene Expression Among Patients With Heart Failure Experiencing Pain

BACKGROUND

Chronic pain is frequently experienced by patients with heart failure (HF) and is associated with higher mortality, higher symptom burden, and worsened health-related quality of life. However, the genomic mechanisms underlying chronic pain in HF are understudied. Building an understanding of the mechanistic underpinnings of pain may inform novel interventions.

OBJECTIVE

The objective was to identify genes associated with pain from messenger RNA sequence data collected from patients with HF with and without pain.

METHODS

The current study analyzed data from 40 patients with HF previously enrolled in a clinical trial. Pain presence was measured using the Health Utilities Index Mark-3. Genes were tested for differential expression using DESeq2, and differentially expressed genes were analyzed for protein-protein interaction (PPI) and relevant ontological pathways using Metascape. Genes located within the core of the PPI network were considered key in disease-relevant biological pathways. Differentially expressed genes within this PPI network were reviewed in existing literature to narrow down candidate genes of interest. These target genes of interest were reanalyzed in a second sample of 24 patients with HF using validation quantitative polymerase chain reaction.

RESULTS

A total of 334 genes (279 upregulated, 55 downregulated) were differentially expressed between patients with and without pain in the primary sample of 40. These genes were largely aligned with neutrophil degranulation pathways. Seven genes of interest were identified from a core network of 15 co-expressed genes in the PPI network and existing literature. Three of these seven genes, matrix metallopeptidase 8 ( MMP8 ), proprotein convertase subtilisin/kexin type 9 ( PCSK9 ), and neutrophil defensin 3 ( DEFA3 ), were upregulated in patients with pain versus without pain in both the primary and validation samples. All seven genes of interest are involved in immune, inflammatory, and atherosclerotic processes.

DISCUSSION

These results identify potential genes that may play a mechanistic role in chronic pain in HF. Further research is needed to evaluate these potential genes among clearly delineated pain phenotypes.

Effect of Regular Electrotherapy on Spinal Flexibility and Pain Sensitivity in Patients with Chronic Non-Specific Neck Pain and Low Back Pain: A Randomized Controlled Double-Blinded Pilot Trial

Background and Objectives: Chronic neck pain and low back pain are common conditions in high-income countries leading to social and medical problems such as invalidity and decreased quality of life. The aim of this study was to investigate the effect of supra-threshold electrotherapy on pain level, subjective feeling of disability, and spinal mobility in patients with chronic pain in the spinal cord. Materials and Methods: 11 men and 24 women with a mean age of 49 years were randomly divided into three groups: group 1, "therapy": supra-threshold electrotherapy was applied on the whole back after electrical calibration; group 2, "control": electrical calibration without successive electrotherapy; group 3, "control of control": no stimulation. Sessions were performed once a week and six times in total, each lasting 30 min. The numeric pain rating scale (NRS), cervical and lumbar range of motion (ROM), as well as disability in daily live were investigated before and after the sessions using questionnaires (Neck Disability Index, Roland Morris Questionnaire, Short-form Mc Gill Pain Questionnaire (SF-MPQ)). Results: Spinal mobility improved significantly in the lumbar anteflexion (baseline mean, 20.34 ± SD 1.46; post session mean, 21.43 ± SD 1.95; p = 0.003) and retroflexion (baseline mean, 13.68 ± SD 1.46; post session mean, 12.05 ± SD 1.37; p = 0.006) in the group receiving electrotherapy. Pain levels measured by the NRS and disability-questionnaire scores did not differ significantly before and after treatment in any of the groups. Conclusions: Our data indicate that regular supra-threshold electrotherapy for six times has a positive effect on lumbar flexibility in chronic neck pain and low back pain patients, whereas pain sensation or subjective feeling of disability remained unchanged.

Association of the quality of life parameters with the indicators of chronic heart failure severity in patients with rheumatoid arthritis

Background: The quality of life of patients is one of determining factors in assessing the effectiveness of treatment and prognosis. A search for possible associations of the quality of life parameters with basic clinical indicators provides a possibility of a more detailed and comprehensive assessment of the patients condition, correction of therapy and an improvement in the prognosis. Aim: To carry out a comparative analysis of the quality of life parameters in patients with chronic heart failure (CHF) with preserved and moderately reduced left ventricular ejection fraction against the background of rheumatoid arthritis (RA) and without RA, as well as to identify possible associations of the quality of life indicators with the parameters of the CHF course. Methods: 134 CHF patients with an RA diagnosis were examined, as well as 122 CHF patients without RA. The functional class of CHF in patients participated in the study was I -II by NYHA. The diagnosis of RA was made on the basis of radiological and serological studies. The radiological stage of RA in patients included in the study was I -III, according to Steinbrocker. Methotrexate was the basic anti-inflammatory drug for the RA treatment. A comparative analysis of the CHF symptoms, morphofunctional parameters and their possible association with the quality of life indicators in patients with and without RA was performed. The processing was carried out using the Statistica 10.0 program. Results: In the group of patients with CHF and RA, in addition to the statistically significant differences in the standard clinical laboratory parameters, statistically significant differences were also revealed in the severity of pain syndrome, deterioration of role, physical and emotional functioning as compared to the CHF patients without RA. Besides, in the CHF/RA group, statistically significant associations were revealed between the severity of pain syndrome and the level of the left ventricular ejection fraction and left ventricular mass index. Conclusion: The severity of pain syndrome caused by RA in patients with CHF can negatively affect some morphological and functional parameters of the myocardium, which must be taken into account when managing this group of patients.

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.

A longitudinal analysis of the relationships between depression, fatigue, and pain in patients with heart failure

OBJECTIVES

Depression, pain, and fatigue are common and bothersome symptoms in heart failure, a serious illness in older adults. Understanding longitudinal pathways among depression, pain, and fatigue in heart failure could inform treatment and improve quality of life.

METHODS

We completed secondary, longitudinal data analyses of a sample of older adults with heart failure (baseline N = 317). Bootstrapped mediation was used to examine two longitudinal models of pain and depression, with fatigue at 6-months as the mediator. The outcome variables were 12-month pain and depression.

RESULTS

Depressive symptoms were associated with new onset of pain symptoms; however, this association was mediated by fatigue. Pain was not associated with new depression or fatigue symptoms in this sample.

DISCUSSION

In patients with heart-failure, worsening pain symptoms appear to be directly related to levels of depression and fatigue. These findings demonstrate that depression and fatigue may be key to reducing pain symptoms in this population.

Pain in Homebound Older Adults with Heart Failure after Hospital Discharge

Pain is not uncommon in older adult patients with heart failure (HF) and has been identified as a risk factor for rehospitalization of homebound patients with HF. Little is known about the pain experiences and management of older adults with HF after hospital discharge. We sought to describe pain and other symptoms among homebound older adults with HF using a qualitative and descriptive approach. We conducted semistructured interviews to obtain qualitative data and used the Brief Pain Instrument-Short Form and the Edmonton Symptom Assessment Scale to obtain descriptive data on symptom burden. We interviewed 18 participants within 10 days after hospital discharge. Participants' mean age was 75.8 ± 9.0 years; 78% were White. The mean pain score at its worst was 5.2 ± 3.1, and for pain interfering with sleep was 4.3 ± 3.41. Most participants managed pain with medications. Using thematic analysis of qualitative data, we identified three distinct categories: (1) the diversity of patients' pain experiences, (2) the diversity of pain management routines, and (3) patients' experiences with healthcare providers' pain assessment and management practices. Our findings show that homebound older adults with HF experience various pain symptoms and receive inconsistent education about how to manage pain from healthcare providers. This study supports the need for better pain assessment and education about the appropriate use of pain medications and nonpharmacologic approaches to pain control for homebound older adults with HF.

Back pain and heart failure in community-dwelling older adults: Findings from the Health ABC study

This study explored the association of back pain and heart failure (HF) with health outcomes among community-dwelling older adults. Older adults who completed a follow-up in the 11th year (2007-2008) of the Health, Aging, and Body Composition (Health ABC) study were included. The mean age was 83.4 ± 2.78 years. Back pain and heart failure were reported by 55.40% (n = 657) and 8.09 % (n = 96) of the total subjects (N = 1186), respectively. Regression analysis indicated that older adults with back pain reported worse depressive symptoms, fatigue, and physical performance and function compared with those without back pain (p < 0.05), and HF presence increased fatigue levels and decreased physical function (p < 0.05) among older adults with back pain. The high incidence and negative impact of back pain highlight the need to develop strategies for pain management among older adults with and without HF.

Pain Management in Patients with Heart Failure: A Survey of Nurses' Perception

BACKGROUND

Over 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses' perception.

AIMS

To investigate nurses' perception of pain management in HF patients.

METHODS

Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.

RESULTS

A total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.

CONCLUSIONS

The impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.