What is the frequency of chest pain in heart failure (congestive heart failure)?

From the Guidelines

Heart failure presents with pain in approximately 89% of patients with NYHA Class IV HF, with at least moderate pain reported by 61% of hospitalized HF patients. This is based on the most recent and highest quality study available, which emphasizes the importance of pain management in patients with heart failure 1.

Pain Prevalence and Characteristics

The prevalence of pain in heart failure patients increases with age and functional class, and can be of cardiac or non-cardiac origin. Cardiac pain is usually controlled with anti-anginal medication, while non-cardiac pain may be managed with non-pharmacologic and non-opioid pharmacologic therapy.

Management of Pain

For chronic non-cancer pain, non-pharmacologic and non-opioid pharmacologic therapy are preferred, with paracetamol appearing to be safe in HF patients 1. Topical NSAIDs might be tried, but their safety has not been studied in HF patients. Opioids should be considered if pain persists despite non-pharmacological and non-opioid pharmacologic therapy, and in the lowest dose for the shortest duration.

Key Considerations

It is essential to note that NSAIDs should be avoided in patients with HF, as they increase fluid retention and can worsen HF 1. Additionally, the risk of side effects and addiction should be carefully balanced when prescribing opioids, especially in patients with severely impaired renal function, where opioids with a safer metabolic profile are preferred.

Clinical Implications

The presence of pain in heart failure patients should prompt a thorough evaluation to determine the underlying cause, whether cardiac or non-cardiac, and guide appropriate management. This is crucial to improve the quality of life and reduce morbidity and mortality in patients with heart failure.

From the Research

Prevalence of Pain in Heart Failure

• Pain is a common symptom in patients with heart failure, with a prevalence of 67% in patients with chronic HF (New York Heart Association class I-IV) 2.
• The prevalence of pain increases as functional class worsens, with 84.4% of patients with advanced heart failure reporting pain at any site 3.
• Pain can occur at multiple sites, with the most common site being the legs below the knees (32.3% of subjects) 3.

Characteristics of Pain in Heart Failure

• Pain can be severe or very severe, with 28.6% of subjects with chest pain and 38.9% of those with other sites of pain reporting severe or very severe pain 3.
• Pain can interfere with activity, with 70% of patients reporting that pain interferes with their activity 3.
• The strongest predictors of pain in heart failure patients are degenerative joint disease, other arthritis, shortness of breath, and angina pectoris 3.

Management of Pain in Heart Failure

• Opioids are the only medication reported to provide pain relief in heart failure patients, with 34.1% of subjects prescribed opioids 3.
• Caution is recommended when using opioids in patients with sympathetic crashing acute pulmonary edema (SCAPE), a subset of acute heart failure 4.
• Non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) can improve vital signs and physiological parameters in patients with cardiogenic pulmonary edema, decreasing the need for endotracheal intubation and hospital mortality 5.