Original Article

Pain and Quality of Life in Hospitalized

Patients with Heart Failure
Tone Rusten, RN, PhD, Audun Stubhaug, MD, PhD, Ingrid Eidsmo, RN,
Arne Westheim, MD, PhD, Steven M. Paul, PhD,
and Christine Miaskowski, RN, PhD
Faculty of Nursing (T.R., A.S.), Oslo University College, Oslo; Centre for Shared Decision Making and
Nursing Research (T.R., C.M.) and Department of Anesthesia (A.S.), Rikshospitalet University Hospital,
Oslo; and Ullevaal University Hospital (I.E., A.W.), Oslo, Norway; and Department of Physiological
Nursing (S.M.P., C.M.), University of California at San Francisco, San Francisco, California, USA
Abstract
The pain experience of patients with heart failure (HF) and its impact on their quality of life
(QOL) has not beendescribed insufcient 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-specic characteristics; and evaluate the effect of
selected demographic, disease-specic characteristics, bodily pain, and mental health on QOL.
Two items from the Medical Outcomes StudydShort 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 inthe
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 signicant impact on the QOL of
patients with HF. However, additional research is warranted to determine the specic causes
and characteristics of pain in these patients. J Pain Symptom Manage
2008;36:497e504. 2008 U.S. Cancer PainRelief Committee. Published by Elsevier Inc. All
rights reserved.
This study took place at Ullevaal University Hospital
and Buskerud Hospital Trust and was funded by
Oslo University College.
The data fromthe general population applied in this
publication are based on the Survey of Level of
Living 2002 in Norway. Deidentied date sets have
been made available by the Norwegian Social Sci-
ence Data Services (NSD). Statistics Norway (SSB)
was responsible for sampling and interviewing.
Neither NSD nor SSB are responsible for the analy-
ses/interpretation of data presented here.
Address correspondence to: Tone Rusten, RN, PhD,
Faculty of Nursing, Oslo University College, Postbox
4, St. Olavs Place, 0131 Oslo, Norway. E-mail:
tone.rustoen@su.hio.no
Accepted for publication: December 4, 2007.
2008 U.S. Cancer Pain Relief Committee
Published by Elsevier Inc. All rights reserved.
0885-3924/08/$esee front matter
doi:10.1016/j.jpainsymman.2007.11.014
Vol. 36 No. 5 November 2008 Journal of Pain and Symptom Management 497
Key Words
Quality of life, pain, congestive heart failure
Introduction
Heart failure (HF) has become one of the
most important chronic medical conditions
worldwide.
1,2
The clinical course of HF is char-
acterized by acute exacerbations that require
emergency department visits or hospitaliza-
tions followed by periods of stable disease.
HF is a chronic medical condition that affects
all aspects of patients lives and has a tremen-
dous impact on quality of life (QOL).
3,4
Stud-
ies have shown that patients with HF report
a poorer QOL when compared to the general
population.
5e8
In most of these studies, which
used either a disease-specic 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, pa-
tients with HF compared to the general popu-
lation
5
reported signicant limitations in
mobility and self-care activities. Most recently,
scores on a disease-specic measure of QOL
were shown to be strongly associated with de-
creased survival in patients with HF.
9
Several studies
5,10e14
have found that a vari-
ety of symptoms are associated with decreases
in QOL in patients with HF. For example, Cal-
vert et al.
5
found that pain, anxiety, and depres-
sion 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 dis-
tress in advanced HF were lack of energy, weak-
ness 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 signicantly during
the last six months of life. Finally, in a study
by Sullivan and OMeara,
13
patients who died
from cardiovascular disease with concomitant
HF reported signicantly more symptoms, in-
cluding chest and abdominal pain, worse func-
tional 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 HF
15
found only nine studies
that reported minimal data on pain in these
patients. In the ve studies that reported
data specically on patients with HF, the prev-
alence of pain ranged from 23% to 75%. In
a more recent study of outpatients with
chronic HF,
16
52% reported pain and 42% cat-
egorized 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 inter-
ference of pain with activities.
Although recent data suggest that pain oc-
curs in a signicant 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 se-
verity of bodily pain; evaluate for differences in
bodily pain related to selected demographic
and disease-specic characteristics; and evalu-
ate the effects of selected demographic (e.g.,
age, gender, and living situation) and disease-
specic (e.g., ejection fraction [EF]) character-
istics, bodily pain, and mental health on QOL.
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 Euro-
pean Society of Cardiology Criteria for HF.
17
Pa-
tients 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 studys inclusion criteria,
were askedto participate several days after admis-
sion to the hospital, when their condition had
stabilized. Patients were included if they were
able to read and write Norwegian and had
498 Vol. 36 No. 5 November 2008 Rusten et al.
a normal mental status as judged by the nurse
who was caring for the patients. The main rea-
sons why patients declined to participate were
previous involvement in another research study
or severe fatigue. This study was approved by
the Norwegian Committee onHuman Research.
All patients signed a written informed consent
before participation in the study.
Instruments
Demographic Characteristics. Data on age, gen-
der, marital status, living situation, and educa-
tional 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 catego-
rized as primary school, secondary school, or
university/college education.
Comorbidities and Disease-Specic Characteristics.
Patients were asked if they currently had or had
a history of cancer; diabetes; musculoskeletal,
skin, lung, or gastrointestinal diseases; or psy-
chiatric disorders. Lengthof time since HFdiag-
nosis, New York Heart Association (NYHA)
classication, 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
StudydShort Form (SF-36) were used to mea-
sure pain. The SF-36 consists of 36 items of
self-reported aspects of health.
19e22
The Nor-
wegian version of the SF-36 has acceptable psy-
chometric properties.
23e25
The rst 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, moder-
ately, quite a bit, or extremely. The
responses to the rst item were used to deter-
mine 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-
specic QOL questionnaire. This 21-item ques-
tionnaire measures patients perceptions of
the effects of HF on life satisfaction.
26e28
Pa-
tients were asked to rank how each of the im-
pairments 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 us-
ing the forward and backward procedure.
31
In
this study, the Cronbachs alpha for the total
score was 0.88.
Statistical Analyses
Data were analyzed using SPSS Version 14.0
(Chicago, IL). Descriptive statistics were gener-
ated to characterize the sample, the preva-
lence, 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 cate-
gory, gender, education level, marital status,
and cohabitation [yes, no]) and disease-
specic 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 pre-
dict QOL (i.e., total score on the MLHFQ), cor-
relation coefcients were calculated between
the total QOL score and selected demographic
and disease-specic characteristics, as well as
SF-36 bodily pain and mental health scores. A
Vol. 36 No. 5 November 2008 499 Pain and QOL in HF
multiple regression analysis was performed to
determine the effects of the signicant vari-
ables from the univariate analyses on QOL.
All signicant variables from the univariate
analyses were entered into the model simulta-
neously. To construct a model that was parsimo-
nious, variables were systematically removed
until only signicant predictors remained in
the nal model. For all tests, a P-value of
<0.05 was considered statistically signicant.
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 (SD9.7 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 mar-
ried. Approximately 85% of the patients were
either disabled or retired.
Characteristics of HF and Previous
and Concurrent Medical Conditions
More than half of the sample (58%) was di-
agnosed with HF in the past four years. Most
patients (81%) were classied as NYHA Class
III or IV and 68.1% had reduced left ventricu-
lar systolic function with EF values #40%
(Table 1). The mean EF for the patients was
34.5% (SD12.3%).
As many as 80% of the patients reported hav-
ing one or more chronic conditions in addition
to HF. The most common comorbidities were
lung disease (31.2%), diabetes (30.1%), muscu-
loskeletal 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 ve 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 med-
ications (SD2.5, range 2e14) for HF, other
medical conditions, and pain. Of note, only
one of 78 patients were taking nonsteroidal
anti-inammatory 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 (ve 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 87patients withHF(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%) re-
ported 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 (SD30.1, range 0e100),
with lower scores indicating higher levels of
bodily pain.
Table 1
Demographic and Disease-Specic
Characteristics of the Patients with HF
Characteristics n (%)
Age (years) [mean (SD) range] 75.1 (9.7) 48e93
Gender
Male 60 (64.5)
Female 33 (35.5)
Living situation
Alone 43 (47.3)
Spouse/children 48 (52.7)
Marital status
Married 41 (44.6)
Not married 51 (55.4)
Education
Primary school 40 (46.0)
Secondary school 29 (33.3)
University/college 18 (20.7)
NYHA Class
I 2 (2.3)
II 14 (16.7)
III 47 (56.0)
IV 21 (25.0)
EF value [mean (SD) range] 34.5 (12.3) 7%e73%
#40% 47 (68.1)
>40% 22 (31.9)
500 Vol. 36 No. 5 November 2008 Rusten et al.
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, mari-
tal status, cohabitation, or educational level.
With respect to disease-specic 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 signicant negative cor-
relation 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 (SD21.5).
QOL scores ranged from a low of 6.0 to a high
of 95.1. With respect to demographic character-
istics, no differences in mean QOL scores were
found based on age, gender, marital status,
cohabitation, or educational level. With respect
to disease-specic characteristics, a signicant
negative correlation was found between the
patients EF values and total QOL scores
(r 0.27, P 0.03). In addition, signicant
differences in total QOL scores were found
among the four NYHA classes (F
3,70
3.3,
P 0.025). Post hoc contrasts demonstrated
that the patients in NYHA Class IV had signi-
cantly higher mean QOL scores (i.e., worse
QOL) thanpatients inNYHAClass II (P 0.023).
Effect of Selected Demographic and Disease-
Specic 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-specic
characteristics, as well as SF-36 bodily pain
and mental health scores. Based on the nd-
ings from these correlational analyses, a multi-
ple 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 vari-
able (P <0.001). In terms of unique contribu-
tions, mental health explained 9% of the
variance (P 0.005), NYHA class explained
7% of the variance (P 0.008), and pain ex-
plained 5% of the variance (P 0.03) in QOL.
Discussion
This study is the rst to evaluate the preva-
lence and severity of pain in a sample of hospi-
talized patients with HF using a validated pain
measure and to examine the relationships be-
tweenvarious demographic anddisease-specic
characteristics, as well as pain, on patients
QOL. Of note, 85% of the patients with HF re-
ported some level of pain and 42.5% reported
pain in the severe to very severe range. To place
these ndings on pain prevalence and severity
in patients with HF into context, they were com-
pared with pain prevalence and pain severity
rates reported by a sample drawn from the Nor-
wegian general population.
32
Using responses
from the SF-36, approximately 70% of the Nor-
wegiangeneral populationreported 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 popu-
lationreportedthis nding. These comparisons
suggest that pain is a signicant problem for
patients with HF.
The overall percentage of patients with HF
in pain in this study is somewhat higher than
Table 2
Relationships Between Total Scores on the
MLHFQ and Selected Demographic, Clinical,
and Miscellaneous Characteristics
Characteristics
Total Score
on the MLHFQ
r P-value
Demographic characteristics
Age 0.09 0.44
Gender 0.19 0.08
Living situation 0.12 0.27
Marital status 0.14 0.20
Education 0.20 0.08
Clinical characteristics
NYHA class 0.31 0.01
EF value L0.27 0.03
Total number
of diseases
0.06 0.63
Miscellaneous characteristics
Mental health L0.51 <0.0001
Bodily pain L0.46 <0.0001
Values in bold are statistically signicant at the 0.05 level.
Vol. 36 No. 5 November 2008 501 Pain and QOL in HF
the range of 23% to 75% reported in the re-
view by Godfrey et al.
15
This difference may
be attributed to the fact that patients with HF
in this study were hospitalized with an exacer-
bation 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
How-
ever, the bodily pain scores (43.0 30.1) of pa-
tients with HF are lower than those reported
by patients with chronic pain who were admit-
ted to a pain center (i.e., 26.0 16.0).
35
Despite the high prevalence rates and sever-
ity scores across a number of studies,
5,11,13e16
the paucity of research on pain in patients
with HF makes it difcult to draw denitive
conclusions about the causes and characteris-
tics 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 an-
other study,
13
22%e37% of patients reported
chest pain and 12%e18% reported abdominal
pain. However, one can hypothesize that given
the number of comorbid conditions that pa-
tients 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-specic measures (e.g., Brief Pain
Inventory
37
and McGill Pain Questionnaire
38
)
is needed to determine the specic 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 ed-
ucational level) or disease-specic (i.e., NYHA
class, EF values, or presence of various chronic
medical conditions) characteristics. These
ndings are in contrast with previous studies
of differences in pain intensity among the
Norwegian population based on age,
39
gen-
der,
40
or the presence of a chronic illness.
41
These inconsistent ndings 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.
5,7e9,12,16,42,43
Consistent
with the ndings from this study, previous
studies
5,7e9,42
have demonstrated that worsen-
ing HF, as measured by NYHA class, was associ-
ated 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 rst 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 dis-
ease-specic measures of QOL for patients
with HF (i.e., MLHFQ and Kansas City Cardio-
myopathy 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 ex-
plained by this model and that pains unique
contribution to the percent of explained vari-
ance was only 5%. These ndings suggest
that either the relatively small sample size or
other factors not measured in this study con-
tribute 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
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)
Source R
2
r b R
2
-Change df F P
Overall model 0.341 3,66 11.38 <0.001
Mental health 0.48
a
0.32 0.09 1,66 8.50 0.005
NYHA class 0.35
b
0.28 0.07 1,66 7.43 0.008
Bodily pain 0.37
c
0.25 0.05 1,66 50.90 0.027
a
Zero order correlation is signicant at the P <0.0001 level.
b
Zero order correlation is signicant at the 0.002 level.
c
Zero order correlation is signicant at the 0.001 level.
502 Vol. 36 No. 5 November 2008 Rusten et al.
gender, younger age, higher body mass index,
lower systolic blood pressure, greater symptom
burden, and worse functional status. In an-
other study of 60 outpatients with HF,
16
depression was associated with a greater num-
ber of symptoms, which in turn was associated
with decreased QOL. Finally, Zambroski
et al.,
12
in a convenience sample of 53 outpa-
tients with HF, found that younger age, worse
functional status, higher symptom prevalence,
and higher symptom burden were associated
with decreased QOL. Although ndings from
these three studies
12,16,44
suggest that symp-
tom 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 eval-
uate the independent contribution of the most
common symptoms on the QOL of patients
with HF. In addition, the effect of other fac-
tors, such as social support and coping strate-
gies, 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 rel-
atively small sample size that is primarily male
and older, denitive conclusions cannot be
made about the inuence of gender and age
on the pain experience of patients with HF.
Despite its limitations, the ndings from this
study provide evidence that unrelieved pain is
a signicant problem for patients with HF. In
addition, as with other chronic medical condi-
tions, unrelieved pain has a negative impact on
patients QOL. These ndings point to the
need for additional studies to characterize
the problem of chronic pain in patients with
HF. Without specic epidemiologic data, the
development of appropriate interventions for
pain in this population will not occur.
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