Does heart failure always lead to chest pain. How common is chest pain in chronic heart failure patients. What factors influence the occurrence of chest pain in heart failure. Can heart failure patients experience angina without underlying coronary heart disease. How does chest pain in heart failure differ from typical angina.

The Prevalence of Chest Pain in Chronic Heart Failure Patients

Chest pain is often associated with heart problems, but its prevalence and significance in chronic heart failure patients have been subjects of debate. A study conducted by Andrew L. Clark and Kevin M. Goode aimed to investigate this issue, particularly in patients with a history of myocardial infarction.

The research involved a questionnaire survey of 1,786 patients with heart failure due to left ventricular systolic dysfunction. The average age of participants was 70.1 years, with 73% being male. The mean left ventricular ejection fraction (LVEF) was 35.3%, and 65.6% of the patients had underlying ischemic heart disease (IHD).

Key Findings on Chest Pain Prevalence

• 73% of patients with IHD and 84% without IHD reported no angina in the previous week
• 79% of IHD patients and 82% of non-IHD patients experienced at most “little” chest pain at rest
• 67% of IHD patients and 76% of non-IHD patients had at most “little” chest pain during exertion

These findings suggest that chest pain, particularly angina, is less common in chronic heart failure patients than might be expected, even among those with underlying coronary heart disease.

Factors Influencing Chest Pain in Heart Failure

The study revealed several interesting insights into the factors that may influence the occurrence of chest pain in heart failure patients:

NYHA Class and Chest Pain

Angina frequency increased with higher New York Heart Association (NYHA) functional classes. This suggests that patients with more severe heart failure symptoms are more likely to experience chest pain.

Age, Sex, and LVEF

Interestingly, the study found no significant relationship between angina and the patient’s sex, age, or left ventricular ejection fraction. This indicates that these factors may not be reliable predictors of chest pain in heart failure patients.

Ischemic Heart Disease and Outcomes

For patients with ischemic heart disease, there was a weak correlation between chest pain and adverse outcomes. This suggests that while chest pain might not be as common as expected, its presence could still be clinically relevant in certain patient groups.

Differentiating Chest Pain in Heart Failure from Typical Angina

The study’s findings raise important questions about the nature of chest pain in heart failure patients. Is the pain experienced by these patients different from typical angina? How can healthcare providers distinguish between heart failure-related chest pain and other cardiac conditions?

To address these questions, it’s crucial to consider the following points:

• Mechanism of pain: Heart failure-related chest pain may have different underlying causes compared to typical angina
• Pain characteristics: The quality, duration, and triggers of chest pain in heart failure patients might differ from classic angina symptoms
• Associated symptoms: Heart failure patients may experience other symptoms alongside chest pain that could help in differential diagnosis

Implications for Clinical Practice and Patient Management

The findings of this study have several important implications for the management of chronic heart failure patients:

Diagnostic Considerations

Healthcare providers should be aware that chest pain, particularly angina, may not be as prevalent in heart failure patients as previously thought. This knowledge can help in avoiding unnecessary diagnostic procedures and treatments focused solely on addressing chest pain.

Treatment Approaches

The lower prevalence of chest pain in heart failure patients, even those with underlying coronary heart disease, suggests that standard anti-anginal treatments may not always be necessary or effective in this population. Tailored treatment approaches that address the specific needs of heart failure patients may be more appropriate.

Patient Education

Educating patients about the varied presentations of heart failure symptoms, including the potential absence of chest pain, can help improve symptom recognition and timely reporting to healthcare providers.

The Role of Non-Cardiac Pain in Heart Failure Patients

Given that the study found a lower prevalence of angina-like chest pain in heart failure patients, it’s important to consider other potential sources of pain reported by these individuals. Non-cardiac causes of chest pain or discomfort may include:

• Musculoskeletal issues
• Gastrointestinal problems
• Pulmonary conditions
• Psychological factors, such as anxiety or depression

Healthcare providers should be prepared to investigate and address these alternative sources of pain to improve the overall quality of life for heart failure patients.

Future Research Directions in Heart Failure and Chest Pain

While this study provides valuable insights into the prevalence of chest pain in chronic heart failure patients, several questions remain unanswered and warrant further investigation:

Mechanisms of Pain in Heart Failure

What are the underlying mechanisms responsible for chest pain in heart failure patients, particularly those without significant coronary artery disease? Understanding these mechanisms could lead to more targeted treatments and improved symptom management.

Long-Term Outcomes

How does the presence or absence of chest pain in heart failure patients affect long-term outcomes and quality of life? Longitudinal studies could provide valuable information on the prognostic significance of chest pain in this population.

Novel Diagnostic Tools

Are there new diagnostic tools or biomarkers that could help differentiate between cardiac and non-cardiac causes of chest pain in heart failure patients? Developing such tools could improve diagnostic accuracy and guide more appropriate treatment decisions.

Personalized Approaches to Heart Failure Management

The findings of this study highlight the importance of personalized approaches to heart failure management. Given the variability in chest pain presentation among heart failure patients, healthcare providers should consider:

Comprehensive Symptom Assessment

Regularly assessing a wide range of symptoms, not just chest pain, to get a complete picture of a patient’s heart failure status and overall health.

Individualized Treatment Plans

Developing treatment plans that address each patient’s unique symptom profile, taking into account the presence or absence of chest pain and other comorbidities.

Risk Stratification

Using a combination of clinical factors, including the presence of chest pain, to stratify patients according to their risk of adverse outcomes and tailor follow-up care accordingly.

By adopting these personalized approaches, healthcare providers can optimize the management of chronic heart failure patients and potentially improve their quality of life and long-term outcomes.

Do patients with chronic heart failure have chest pain?

. 2013 Jul 15;167(1):185-9.

doi: 10.1016/j.ijcard.2011.12.042.

Epub 2012 Jan 12.

Andrew L Clark 
¹
, Kevin M Goode

Affiliations

Affiliation

• ¹ Department of Academic Cardiology, Castle Hill Hospital, Castle Road, Cottingham, Hull HU16 5JQ UK. [email protected]

• PMID:

  22243939

• DOI:

  10.1016/j.ijcard.2011.12.042

Andrew L Clark et al.

Int J Cardiol.

2013.

. 2013 Jul 15;167(1):185-9.

doi: 10.1016/j.ijcard.2011.12.042.

Epub 2012 Jan 12.

Authors

Andrew L Clark 
¹
, Kevin M Goode

Affiliation

• ¹ Department of Academic Cardiology, Castle Hill Hospital, Castle Road, Cottingham, Hull HU16 5JQ UK. [email protected]

• PMID:

  22243939

• DOI:

  10.1016/j.ijcard.2011.12.042

Abstract

Objective:

In questionnaire surveys, patients with chronic heart failure frequently report “pain” as a symptom. We investigated the prevalence of chest pain as a possible cause for pain, particularly in patients with prior myocardial infarction.

Design:

Questionnaire survey.

Setting:

Community heart failure clinic.

Patients:

1 786 patients with heart failure due to left ventricular systolic dysfunction (mean ± SD age 70.1 ± 11.0 years; 73% male; left ventricular ejection fraction (LVEF) 35.3 ± 9.9%; 65.6 with underlying ischaemic heart disease (IHD)).

Intervention:

Patients with chronic heart failure completed a questionnaire.

Main outcome measures:

Answers to the questions: (1) “In the last week, how many days did you get angina chest pain?”; and “In the last month, how much did the following affect you:” (2) “chest pains at rest”; (3) “chest pains during normal activity”.

Results:

73% of those with IHD, and 84% of those without had had no angina in the previous week; 79% and 82%, respectively, had at most “little” chest pain at rest; 67% and 76%, respectively, had at most “little” chest pain during exertion. Angina increased with NYHA class, but there was no relation between angina and sex of patient, age or LVEF. There was a weak relation between chest pain and an adverse outcome in the patients with ischaemic heart disease.

Conclusions:

Although pain is commonly reported in patients with chronic heart failure, it seems unlikely that the pain is due to angina, even in patients with underlying coronary heart disease.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

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MeSH terms

Angina (Chest Pain) | American Heart Association

Angina is chest pain or discomfort caused when your heart muscle doesn’t get enough oxygen-rich blood. It may feel like pressure or squeezing in your chest. The discomfort also can occur in your shoulders, arms, neck, jaw, abdomen or back. Angina pain may even feel like indigestion. In addition, some people don’t feel any pain but have other symptoms like shortness of breath or fatigue. If these symptoms are due to a lack of oxygen to the heart muscle, it’s called an “anginal equivalent.”

But angina is not a disease. It’s a symptom of an underlying heart problem, usually coronary heart disease (CHD), also known as coronary artery disease (CAD).There are many types of angina, including stable, unstable, microvascular, and angina caused by a spasm in the coronary arteries (vasospastic or variant). View an animation of angina(link opens in new window)(link opens in new window).

Angina usually happens because one or more of the coronary arteries is narrowed or blocked, also called ischemia.

Angina can also be a symptom of coronary microvascular disease (MVD). This is heart disease that affects the heart’s smallest coronary arteries and is more likely to affect women than men. Learn more about angina in women.

Depending on the type of angina you have, there are many factors that can trigger angina pain. The symptoms also vary based on the type of angina you have.

Types of Angina

Knowing the types of angina and how they differ is important.

• Stable angina
• Unstable angina
• Microvascular Angina
• Vasospastic or variant angina

Understand Your Risk for Angina

If you’re at risk for heart disease or coronary artery disease, you’re also at risk for angina. The major risk factors for heart disease and coronary artery disease include:

• Unhealthy cholesterol levels
• High blood pressure
• Smoking
• Diabetes
• Overweight or obesity
• Metabolic syndrome
• Physical inactivity
• Unhealthy diet
• Older age (The risk increases for men after 45 years of age and for women after 55 years of age.)
• Family history of early heart disease

Diagnosis

All chest pain should be checked out by a health care professional. He or she will want to find out if it’s angina and if it is, whether the angina is stable or unstable. If it’s unstable, you may need emergency medical treatment to try to prevent a heart attack.

Your health care professional will most likely perform a physical exam, ask about your symptoms, and ask about your risk factors for and your family history of heart disease and other cardiovascular conditions. 

Your health care professional will also ask you a series of questions to rule out the most critical or life-threatening possibilities. Think ahead so you can provide as much information as possible. Here are some questions you might be asked:

• How long have you had this condition?
• On a scale of 1 (mild) to 10 (critical), what is your level of discomfort?
• What behavior(s) provoke the pain? Physical activity? Eating?
• What relieves the discomfort?

Print our Angina Log to keep track of your angina symptoms.

Angina Treatment

If your health care professional thinks that you have unstable angina or that your angina is related to a serious heart condition, they may recommend the following tests and procedures:

• EKG (Electrocardiogram)
• Stress Test
• Blood Tests
• Chest X-rays
• Coronary Angiography
• Cardiac Catheterization
• Computed Tomography Angiography

Treatment of angina includes:

• Determining the cause
• Cardiac procedures to open blocked arteries
• Medicines to help keep the arteries open
• Medicines to treat other medical conditions and risk factors like high blood pressure, high cholesterol and diabetes
• Lifestyle changes including healthy diet and physical activity
• Cardiac rehabilitation (if you qualify)

These treatments will help reduce pain and discomfort and how often the angina pain occurs. They will also prevent or lower your risk for heart attack and death by treating the underlying cardiovascular condition you may have.

Not all chest pain is a sign of heart disease.

Other conditions also can cause chest pain, such as:

• Pulmonary embolism (a blockage in a lung artery)
• Aortic dissection (tearing of a major artery)
• A lung infection
• Aortic stenosis (narrowing of the heart’s aortic valve)
• Hypertrophic cardiomyopathy (heart muscle disease)
• Pericarditis (inflammation in the tissues that surround the heart)
• A panic attack

Learn more:

• Print our downloadable sheet: What is Angina? (PDF)

Written by American Heart Association editorial staff and reviewed by science and medicine advisors. See our editorial policies and staff.

Last Reviewed: Nov 8, 2021

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European Society of Cardiology (ESC) guidelines for the diagnosis and treatment of heart failure

What patients need to know

This European Society of Cardiology (ESC) patient guide is a summary of the most current evidence-based recommendations for the diagnosis and treatment of heart failure.

In particular, it is designed to help patients understand:

• what are the main types of heart failure;
• what medicines are used to treat heart failure;
• which devices can be used;
• why full rehabilitation is important;
• how important is treatment by medical specialists of different profiles;
• how important it is to take care of yourself and control your condition.

To learn more

Download recommendations

ANIMATED JOURNEY OF HEART FAILURE

A series of simple yet entertaining animated videos explaining heart failure and its treatment

These videos explain how a healthy heart works, what happens in heart failure and how various treatments can help improve your health

How a healthy heart works

What happens in heart failure

How the heart and other organs adapt to heart failure

How heart failure causes fluid retention

How myocardial infarction can cause heart failure

How valve dysfunction causes heart failure

How vasodilators work in heart failure

How diuretics work in heart failure

How the auxiliary circulatory systems work in cardiac

VIDEOS OF PATIENTS AND STAFF

In this section you can see, hear or read interviews with other heart failure patients or caregivers

Fitness patient

Implantable cardioverter-defibrillator (ICD) patient

BLI as preparation for transplantation

Changing lifestyle and staying optimistic

Living with heart failure devices

Difficulty in making a diagnosis

Life with an artificial left ventricle (LVV)

VISIT OUR FACEBOOK PAGE

And share your opinions and experiences with other patients, their families and carers.

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heartfailurematters.org — website of the European Society of Cardiology

The website heartfailurematters.org was created under the direction of the Association of Heart Failure Specialists of the European Society of Cardiology (ESC). ESC is a world leader in the discovery and dissemination of advanced methods of cardiovascular medicine. Our members and decision makers are medical professionals who volunteer their time and knowledge as cardiologists in Europe and beyond.

Heart failure: symptoms, causes, treatment

Heart failure is associated with decreased heart function. The heart muscle cannot generate the energy needed to pump the required amount of blood throughout the body.

Only in Russia about 7 million people suffer from heart failure. In people over 70, one in four people are affected, with men typically being affected at a much younger age than women. The risk for men is about one and a half times higher than for women. In Russia, diseases of the circulatory system are the most common cause of death.

• What is heart failure?
• What causes heart failure?
• What are the types of heart failure and what are their symptoms?
  • Left-sided heart failure
  • Right-sided heart failure
  • Global heart failure
  • Systolic heart failure
  • Diastolic heart failure
  • Chronic heart failure
  • Acute heart failure
• What are the classes of heart failure?
• How is heart failure diagnosed?
• How is heart failure treated?
• What are the chances of recovery from heart failure?

What is heart failure?

With a healthy heart, oxygen-rich blood from the left ventricle is pumped through the body to the organs, providing them with oxygen and nutrients. After supplying the organs, oxygen-poor blood returns from the body to the right side of the heart, from where it is transported to the lungs. In the lungs, the blood is enriched with oxygen so that it can again be pumped throughout the body through the left ventricle.

Heart failure is the weakening of the pumping function of the heart. Typically, either the right side of the heart (right-sided heart failure) or the left side of the heart (left-sided heart failure) is affected. In advanced heart failure, both sides of the heart may be affected (global heart failure). Heart failure can also be chronic or acute in nature. Chronic heart failure is more common than acute heart failure, which occurs suddenly and unexpectedly. Acute heart failure can occur suddenly against the background of an acute cardiovascular catastrophe and / or decompensation of heart failure.

What causes heart failure?

Heart failure is caused by diseases that affect or damage the heart muscle. The most common cause of chronic heart failure is coronary artery disease.

Coronary artery disease (CHD) is caused by narrowing of the coronary vessels (coronary arteries), most often due to atherosclerosis. The coronary arteries are blood vessels that provide the heart with oxygen and other important nutrients. The progressive narrowing (also called stenosis) of the arteries leads to poor blood flow to the heart muscle. CAD is often diagnosed when angina (chest pain and tightness) is present, but otherwise goes unnoticed.

A heart attack occurs due to a decrease in the circulation of oxygen-rich blood to the heart muscle, resulting in irreversible tissue death. This damage affects the pumping function of the heart, leading to heart failure. A large proportion of patients also suffer from high blood pressure, which further exacerbates the situation.

High blood pressure (hypertension) is the sole cause of heart failure in nearly 20% of people, making it the second most common cause of heart failure. High blood pressure makes the heart constantly work harder. The heart cannot work under additional load for a long period of time, and therefore degrades.

A similar effect may be caused by a heart valve problem. With narrowed or leaking aortic valves, the heart must work harder or beat faster, which also leads to increased workload.

Bradycardia, an abnormal heart rhythm in which the heart rate is slow, can also cause heart failure because there is too little blood circulating. A too fast heartbeat (tachycardia) is associated with a decrease in stroke volume and therefore can also lead to heart failure.

Hereditary heart disease, pregnancy, autoimmune disorders, alcohol, drug or drug abuse, overactive thyroid, and metabolic disorders (diabetes mellitus) may be causes of heart failure.

What are the types of heart failure and what are their symptoms?

Each type of heart failure has different symptoms and the symptoms can vary in intensity. However, the main symptom of heart failure is difficulty breathing during exercise or at rest. Warning signs may include sweating with mild exertion, an inability to lie flat, chest tightness, or swelling in the legs.

Left-sided heart failure

The left side of the heart is responsible for pumping oxygen-rich blood throughout the body to the organs. In left-sided heart failure, the pumping function of the left ventricle is limited, resulting in insufficient oxygenated blood to pump throughout the body. Instead, blood remains in the pulmonary circulation, which can lead to fluid in the lungs (pulmonary edema), difficulty breathing, throat irritation, a “rattling” sound when breathing, weakness, or dizziness.

It is most commonly caused by coronary artery disease (CHD), high blood pressure, or a heart attack, and less commonly by a disorder of the heart muscle or heart valves.

Left-sided heart failure may present acutely or develop over time. Usually first noticed by shortness of breath from physical activity. If severe, it can even lead to hypotension (low blood pressure) at rest.

Right-sided heart failure

The right side of the heart is responsible for returning oxygen-poor blood back to the lungs. In right-sided heart failure, the right ventricle does not work properly. This causes increased pressure in the veins, forcing fluid into the surrounding tissues. This leads to swelling, especially in the feet, toes, ankles and shins. It can also lead to an urgent need to urinate at night when the kidneys get better circulation.

The most common cause is an acute or chronic increase in pulmonary circulation resistance. Caused by pulmonary disease such as pulmonary embolism, asthma, severe emphysema, chronic obstructive pulmonary disease (COPD, most commonly due to tobacco use), or left-sided heart failure. Rare causes include heart valve problems or heart muscle disease.

Global heart failure

When both the left and right sides of the heart are affected, it is called global heart failure. There are symptoms of left and right heart failure.

Systolic and diastolic heart failure

Systolic heart failure is associated with loss of normal functioning of heart muscle cells or external disturbances in pumping function. Blood enters the lungs, and the organs do not receive enough oxygen.

In diastolic heart failure, the elasticity of the ventricle is lost, which prevents it from relaxing and filling properly. One of the most common causes of diastolic dysfunction is high blood pressure. Because of the increased resistance in the arteries, the heart has to work harder. The elasticity of the heart muscle decreases, and less blood can be pumped from the ventricles into the body between contractions. This results in the body not getting enough blood and nutrients.

Heart valve disease can also cause thickening of the heart muscle. The muscles of the heart become stiffer and less elastic due to the accumulation of proteins. Symptoms range from cough to shortness of breath.

Chronic and acute heart failure

Chronic heart failure is a progressive disease that develops over months or years and is more common than acute heart failure. In chronic heart failure, the symptoms are often not taken seriously because the body is able to compensate for it over a long period of time, or the symptoms are associated with increasing age. Symptoms reflect either left or right sided heart failure.

Acute heart failure occurs suddenly, minutes or hours after a heart attack, when the body can no longer compensate. Some symptoms include:

• Severe difficulty breathing and/or coughing;
• Gurgling sound on breathing;
• Cardiac arrhythmias;
• Paleness;
• Cold sweat.

What are the classes of heart failure?

There are several classifications of heart failure:

1. Classification according to V. Kh. Vasilenko, N. D. Strazhesko, G. F. Langa;
2. Killip classification of acute heart failure;
3. And the most common, the classification of the New York Heart Association.

According to the New York Heart Association (NYHA) functional classification, heart failure is classified into classes I-IV based on the severity of symptoms and limitation of physical activity.

Heart failure is divided into four classes based on the severity of symptoms:

• NYHA I: heart disease without any limitation of physical activity. Normal activity does not cause increased fatigue, heart palpitations, or difficulty breathing.
• NYHA II: Heart disease causing moderate limitation in activities of daily living. No symptoms at rest.
• NYHA III: Heart disease causing marked limitation in daily activities. Simple activities such as brushing your teeth, eating, or talking cause fatigue, heart palpitations, or difficulty breathing. There are no symptoms at rest.
• NYHA IV: Heart disease causing symptoms at rest (and with any degree of mild physical activity).

Heart failure significantly reduces the quality of life. Patients often experience great frustration with their physical limitations and tend to withdraw from social life. For this reason, psychological disorders such as depression are often present in addition to the expected physical symptoms.

How is heart failure diagnosed?

Diagnosis begins with a comprehensive evaluation of the person’s medical history, focusing on symptoms (onset, duration, manifestation). This helps classify the severity of the symptom. The heart and lungs are examined. If a heart attack or arrhythmia is suspected, a 12-lead resting ECG is performed. In addition, echocardiography and complete blood count. The need for catheterization is determined individually.

How is heart failure treated?

Chronic heart failure is treated with medications (such as ACE inhibitors, beta-blockers, and diuretics). Medicines are used to prevent complications and improve quality of life. ACE inhibitors and beta-blockers can prolong life, but they must be taken regularly to achieve a positive effect.

In addition, rhythm therapy is used (for the treatment of cardiac arrhythmias), implantation of a three-chamber pacemaker. The latter provides timely activation of the atria and both ventricles. A defibrillator is also often implanted as part of a pacemaker to counter dangerous abnormal heart rhythms in the setting of severe heart failure. This treatment is also known as resynchronization therapy.