Arq Bras CardiolabcArquivos Brasileiros de CardiologiaArq. Bras. Cardiol.0066-782X1678-4170Sociedade Brasileira de Cardiologia - SBCCbcWjjDkD5QGTHVNXCjjg4rS0066-782X202000010003310.36660/abc.20190741Short EditorialQuality of Life in Heart Failure: An Important Goal in Treatment0000-0002-2801-5525GomesBrenno Rizerio1BocchiEdimar Alcides12Universidade de São PauloFaculdade de MedicinaHospital das ClínicasSão PauloSPBrazilUnidade de Insuficiência Cardíaca e Dispositivos de Assistência Circulatória Mecânica do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor HCFMUSP), São Paulo, SP - BrazilUniversidade de São PauloFaculdade de MedicinaDepartamento de CardiopneumologiaSão PauloSPBrazilDepartamento de Cardiopneumologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - BrazilMailing Address: Edimar Alcides Bocchi, Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da USP - Rua Melo Alves, 690 - 4º andar. Postal Code 01417-010, Cerqueira Cesar, São Paulo, SP - Brazil. E-mail: dcledimar@incor.usp.br1002202001202011413334This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.KeywordsHeart FailureAnxiety/diagnosisHospitalizationQuality of LifeAgedStroke Volume
Brazil is the country with the highest prevalence of anxiety disorders, according to the World Health Organization and ranks 5th regarding the prevalence of depression.1 Mood disorders, which include anxiety and depression, are often neglected in clinical practice,2,3 and their diagnosis in patients with heart failure (HF) is even more challenging, given the overlap of several symptoms, such as fatigue, weight loss and sleep disorders.4,5
In this issue of the Archives, the cross-sectional study by Figueiredo et al.6 evaluated, in a population of 99 patients with HF and reduced ejection fraction, which clinical, sociodemographic and psychological variables most correlated with the quality of life assessed by the Minnesota Living with Heart Failure Questionnaire. The main factors associated with poorer quality of life were dyspnea advanced functional class (New York Heart Association III and IV), previous hospitalization and anxiety symptoms. Depression was not independently associated with reduced quality of life, but several other studies have found this association.7,8 The study also shows an alarming prevalence of anxiety symptoms in these patients, of 50%, when compared to 9.3% in the overall population.1
The interaction between cardiovascular disease and mood disorders occurs in a bi-direction manner.9 Recently, it was described that optimism is associated with lower risk of cardiovascular events and mortality from any cause.10 The risk of developing HF in patients with depression is 1.5 to 2.6-fold higher than in the overall population.11 In individuals diagnosed with HF, depression indicates a worse prognosis and is associated with higher hospitalization and mortality rates.11 Possible mechanisms to explain this association involve lower adherence to pharmacological and non-pharmacological treatment in patients with depression and greater tendency towards having unhealthy lifestyles.12,13 The more advanced the dyspnea functional class, the worse the symptoms of depression and the quality of life.8,11
Regarding anxiety disorders, affected individuals also seem to have a higher risk of developing HF throughout life.14 In those diagnosed with HF, the presence of anxiety is associated with poorer quality of life;15 however, the correlation with increased mortality is not as well established.16,17
Evidence is limited for the treatment of mood disorders in HF patients. Cognitive behavioral therapy was tested in a randomized study of 158 patients diagnosed with major depression and heart failure.18 Psychotherapy was associated with remission of depression (46% vs. 19%, NNT = 3.8), in addition to improvement in quality of life, anxiety and fatigue.
The pharmacological treatment of choice for mood disorders consists in selective serotonin reuptake inhibitors.19,20 For patients with HF and reduced ejection fraction, two prominent randomized trials tested these therapies in individuals with major depression: 1) MOOD-HF,21 which included 372 patients to receive escitalopram or placebo for 3 months, and 2) SADHART-CHF,22 which included 469 patients to receive sertraline or placebo for 18 months. Both were negative for the primary outcome, showing no benefit of pharmacological therapies in the treatment of depression in HF patients.
A structured and multidisciplinary HF management education and care program implemented in 350 patients in our service has shown a reduction in unplanned hospitalizations23 and improved quality of life, especially in the emotional domain,23,24 suggesting that this approach may be beneficial for patients with mood disorders.
The study by Figueiredo et al.,6 suffers from the usual limitations of a single-center, cross-sectional and observational assessment, and the small number of patients prevents more robust conclusions. The assessed primary outcome was quality of life, but it remains to be prospectively seen whether anxiety has an impact on clinical outcomes, such as hospital admissions or mortality.
In conclusion, the present article by Figueiredo et al.6 reinforces the importance of a holistic approach for HF patients, by demonstrating that neglected factors such as anxiety disorders are very prevalent in this population and may have an impact on quality of life. The field of treatment for mood disorders has been little explored and deserves further attention in future randomized trials.
Short Editorial related to the article: Synergistic Effect of Disease Severity, Anxiety Symptoms and Elderly Age on the Quality of Life of Outpatients with Heart Failure
References1 World Health Organization. (WHO). Depression and other common mental disorders: global health estimates. Geneva;2017.World Health Organization. (WHO)Depression and other common mental disorders: global health estimatesGeneva20172 Ziegelstein RC, Kim SY, Kao D, Fauerbach JA, Thombs BD, McCann U, et al. Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening? Psychosom Med. 2005;67(3):393-7.ZiegelsteinRCKimSYKaoDFauerbachJAThombsBDMcCannUCan doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening?Psychosom Med20056733933973 Huffman JC, Smith FA, Blais MA, Beiser ME, Januzzi JL, Fricchione GL. Recognition and treatment of depression and anxiety in patients with acute myocardial infarction. Am J Cardiol. 2006;98(3):319-24.HuffmanJCSmithFABlaisMABeiserMEJanuzziJLFricchioneGLRecognition and treatment of depression and anxiety in patients with acute myocardial infarctionAm J Cardiol20069833193244 Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70.ZigmondASSnaithRPThe hospital anxiety and depression scaleActa Psychiatr Scand19836763613705 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). Washington; 2013.American Psychiatric AssociationDiagnostic and statistical manual of mental disorders (DSM-5®)Washington20136 Figueiredo JHC, Oliveira GMMd, Pereira BB, Figueiredo AEB, Nascimento EM, Garcia MI, et al. Efeito Sinérgico da Gravidade da Doença, de Sintomas de Ansiedade e da Idade Avançada sobre a Qualidade de Vida de Pacientes Ambulatoriais com Insuficiência Cardíaca. Arq Bras Cardiol. 2020; 114(1):25-32.FigueiredoJHCOliveiraGMMdPereiraBBFigueiredoAEBNascimentoEMGarciaMIEfeito Sinérgico da Gravidade da Doença, de Sintomas de Ansiedade e da Idade Avançada sobre a Qualidade de Vida de Pacientes Ambulatoriais com Insuficiência CardíacaArq Bras Cardiol2020114125327 Rumsfeld JS, Havranek E, Masoudi FA, Peterson ED, Jones P, Tooley JF, et al. Depressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failure. J Am Coll Cardiol. 2003;42(10):1811-7.RumsfeldJSHavranekEMasoudiFAPetersonEDJonesPTooleyJFDepressive symptoms are the strongest predictors of short-term declines in health status in patients with heart failureJ Am Coll Cardiol20034210181118178 Gottlieb SS, Khatta M, Friedmann E, Einbinder L, Katzen S, Baker B, et al. The influence of age, gender, and race on the prevalence of depression in heart failure patients.J Am Coll Cardiol. 2004;43(9):1542-9.GottliebSSKhattaMFriedmannEEinbinderLKatzenSBakerBThe influence of age, gender, and race on the prevalence of depression in heart failure patientsJ Am Coll Cardiol2004439154215499 Riba M, Wulsin L, Rubenfire M, Ravindranath D. Psychiatry and heart disease: the mind, brain, and heart. Philadelphia: John Wiley & Sons; 2012.RibaMWulsinLRubenfireMRavindranathDPsychiatry and heart disease: the mind, brain, and heart2012PhiladelphiaJohn Wiley & Sons10 Rozanski A, Bavishi C, Kubzansky LD, Cohen R. Association of Optimism With Cardiovascular Events and All-Cause Mortality: A Systematic Review and Meta-analysis. JAMA Network Open. 2019;2(9):e1912200-e.RozanskiABavishiCKubzanskyLDCohenRAssociation of Optimism With Cardiovascular Events and All-Cause Mortality: A Systematic Review and Meta-analysisJAMA Network Open201929e1912200-e11 Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48(8):1527-37.RutledgeTReisVALinkeSEGreenbergBHMillsPJDepression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomesJ Am Coll Cardiol20064881527153712 Strine TW, Mokdad AH, Dube SR, Balluz LS, Gonzalez O, Berry JT, et al. The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults. Gen Hosp Psychiatry. 2008;30(2):127-37.StrineTWMokdadAHDubeSRBalluzLSGonzalezOBerryJTThe association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adultsGen Hosp Psychiatry200830212713713 Whooley MA, de Jonge P, Vittinghoff E, Otte C, Moos R, Carney RM, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA. 2008;300(20):2379-88.WhooleyMAde JongePVittinghoffEOtteCMoosRCarneyRMDepressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart diseaseJAMA2008300202379238814 Roy SS, Foraker RE, Girton RA, Mansfield AJ. Posttraumatic stress disorder and incident heart failure among a community-based sample of US veterans. Am J Public Health. 2015;105(4):757-63.RoySSForakerREGirtonRAMansfieldAJPosttraumatic stress disorder and incident heart failure among a community-based sample of US veteransAm J Public Health2015105475776315 Heo S, Doering LV, Widener J, Moser DK. Predictors and effect of physical symptom status on health-related quality of life in patients with heart failure. Am J Crit Care. 2008;17(2):124-32.HeoSDoeringLVWidenerJMoserDKPredictors and effect of physical symptom status on health-related quality of life in patients with heart failureAm J Crit Care200817212413216 Friedmann E, Thomas SA, Liu F, Morton PG, Chapa D, Gottlieb SS, et al. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J. 2006;152(5):940. e1-e8.FriedmannEThomasSALiuFMortonPGChapaDGottliebSSRelationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortalityAm Heart J20061525940. e1940. e817 Jiang W, Kuchibhatla M, Cuffe MS, Christopher EJ, Alexander JD, Clary GL, et al. Prognostic value of anxiety and depression in patients with chronic heart failure. Circulation. 2004;110(22):3452-6.JiangWKuchibhatlaMCuffeMSChristopherEJAlexanderJDClaryGLPrognostic value of anxiety and depression in patients with chronic heart failureCirculation2004110223452345618 Freedland KE, Carney RM, Rich MW, Steinmeyer BC, Rubin EH. Cognitive behavior therapy for depression and self-care in heart failure patients: a randomized clinical trial. JAMA Intern Med. 2015;175(11):1773-82.FreedlandKECarneyRMRichMWSteinmeyerBCRubinEHCognitive behavior therapy for depression and self-care in heart failure patients: a randomized clinical trialJAMA Intern Med2015175111773178219 Gelenberg A, Freeman M, Markowitz J, Rosenbaum J, Thase M, Trivedi M, et al. Work Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd ed. Arlington, VA: American Psychiatric Association;2010.GelenbergAFreemanMMarkowitzJRosenbaumJThaseMTrivediMWork Group on Major Depressive Disorder. Practice Guideline for the Treatment of Patients With Major Depressive Disorder20103rd ed.Arlington, VAAmerican Psychiatric Association20 Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, et al. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am J Psychiatry. 2004;161(11 Suppl):3-31.UrsanoRJBellCEthSFriedmanMNorwoodAPfefferbaumBPractice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorderAm J Psychiatry200416111 Suppl33121 Angermann CE, Gelbrich G, Störk S, Gunold H, Edelmann F, Wachter R, et al. Effect of escitalopram on all-cause mortality and hospitalization in patients with heart failure and depression: the MOOD-HF randomized clinical trial. JAMA. 2016;315(24):2683-93.AngermannCEGelbrichGStörkSGunoldHEdelmannFWachterREffect of escitalopram on all-cause mortality and hospitalization in patients with heart failure and depression: the MOOD-HF randomized clinical trialJAMA2016315242683269322 O'Connor CM, Jiang W, Kuchibhatla M, Silva SG, Cuffe MS, Callwood DD, et al. Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial. J Am Coll Cardiol. 2010;56(9):692-9.O'ConnorCMJiangWKuchibhatlaMSilvaSGCuffeMSCallwoodDDSafety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trialJ Am Coll Cardiol201056969269923 Bocchi EA, Cruz F, Guimaraes G, Pinho Moreira LF, Issa VS, Ayub Ferreira SM, et al. Long-term prospective, randomized, controlled study using repetitive education at six-month intervals and monitoring for adherence in heart failure outpatients: the REMADHE trial. Circ Heart Fail. 2008;1(2):115-24.BocchiEACruzFGuimaraesGPinho MoreiraLFIssaVSAyub FerreiraSMLong-term prospective, randomized, controlled study using repetitive education at six-month intervals and monitoring for adherence in heart failure outpatients: the REMADHE trialCirc Heart Fail20081211512424 Cruz FdD, Issa VS, Ayub-Ferreira SM, Chizzola PR, Souza GEC, Moreira LFP, et al. Effect of a sequential education and monitoring programme on quality-of-life components in heart failure. Eur J Heart Fail. 2010;12(9):1009-15.CruzFdDIssaVSAyub-FerreiraSMChizzolaPRSouzaGECMoreiraLFPEffect of a sequential education and monitoring programme on quality-of-life components in heart failureEur J Heart Fail201012910091015MinieditorialQualidade de Vida em Insuficiência Cardíaca: Um Objetivo Importante no Tratamento0000-0002-2801-5525GomesBrenno Rizerio1BocchiEdimar Alcides12Unidade de Insuficiência Cardíaca e Dispositivos de Assistência Circulatória Mecânica do Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor HCFMUSP), São Paulo, SP - BrasilDepartamento de Cardiopneumologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - BrasilCorrespondência: Edimar Alcides Bocchi, Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da USP - Rua Melo Alves, 690 - 4º andar. CEP 01417-010, Cerqueira Cesar, São Paulo, SP - Brasil. E-mail: dcledimar@incor.usp.brPalavras-chaveInsuficiência CardíacaAnsiedade/diagnósticoHospitalizaçãoQualidade de VidaIdosoVolume Sistólico
O Brasil é o país com a maior prevalência de transtornos de ansiedade segundo a Organização Mundial da Saúde e figura em 5º lugar em relação à prevalência de depressão.1 Os transtornos de humor, que englobam ansiedade e depressão, são frequentemente negligenciados na prática clínica,2,3 e seu diagnóstico em pacientes com insuficiência cardíaca (IC) é ainda mais desafiador, tendo em vista a sobreposição de diversos sintomas, como fadiga, perda ponderal e distúrbios do sono.4,5
Nesta edição dos Arquivos, o estudo transversal de Figueiredo et al.,6 avaliou em uma população de 99 pacientes com IC de fração de ejeção reduzida, quais variáveis clínicas, sociodemográficas e psicológicas têm maior correlação com a qualidade de vida avaliada pelo Minnesota Living with Heart Failure Questionnaire. Os principais fatores associados a pior qualidade de vida foram classe funcional avançada de dispneia (New York Heart Association III e IV), internação hospitalar prévia e sintomas de ansiedade. A depressão não foi associada de forma independente à redução de qualidade de vida, porém diversos outros estudos já encontraram essa associação.7,8 O estudo revela ainda prevalência alarmante de sintomas de ansiedade nesses pacientes de 50% em comparação a 9,3% na população geral.1
A interação entre doenças cardiovasculares e transtornos do humor ocorre de forma bidirecional.9 Recentemente, foi descrito que o otimismo está associado a menor risco de eventos cardiovasculares e mortalidade por qualquer causa.10 O risco de se desenvolver IC em pacientes com depressão é 1,5 a 2,6 vezes maior do que na população geral.11 Naqueles indivíduos com diagnóstico de IC, a depressão indica pior prognóstico, e está associada a maiores taxas de hospitalização e mortalidade.11 Possíveis mecanismos para explicar essa associação envolvem a menor aderência ao tratamento farmacológico e não farmacológico em pacientes com depressão e a maior propensão a hábitos de vida não saudáveis.12,13 Quanto mais avançada a classe funcional de dispneia, piores os sintomas de depressão e a qualidade de vida.8,11
Em relação aos transtornos de ansiedade, indivíduos acometidos também parecem ter maior risco de desenvolver IC ao longo da vida.14 Naqueles diagnosticados com IC, a presença de ansiedade está associada a pior qualidade de vida,15 entretanto a correlação com aumento de mortalidade é bem menos estabelecida.16,17
As evidências são limitadas para o tratamento dos transtornos de humor em pacientes com IC. A terapia cognitiva comportamental foi testada em um estudo randomizado com 158 pacientes com diagnósticos de depressão maior e insuficiência cardíaca.18 A psicoterapia esteve associada a remissão de depressão (46% vs. 19%, NNT = 3,8), além de melhora de qualidade de vida, ansiedade e fadiga.
O tratamento farmacológico de primeira escolha para transtornos do humor consiste nos inibidores seletivos da recaptação de serotonina.19,20 Quanto a pacientes com IC de fração de ejeção reduzida, dois estudos randomizados de destaque testaram essas terapias em indivíduos com depressão maior: 1) MOOD-HF,21 que incluiu 372 pacientes para receberem escitalopram ou placebo por 3 meses, e 2) SADHART-CHF,22 que incluiu 469 pacientes para receberem sertralina ou placebo por 18 meses. Ambos foram negativos para o desfecho primário, não demonstrando benefício de terapias farmacológicas no tratamento da depressão em pacientes com IC.
Um programa de educação e cuidados estruturados e multidisciplinares para o manejo de IC implementado em 350 pacientes em nosso serviço demonstrou redução em hospitalizações não planejadas23 e melhora da qualidade de vida principalmente no que tange ao domínio emocional,23,24 sugerindo que essa abordagem pode ser benéfica para pacientes com transtornos do humor.
O estudo de Figueiredo et al.,6 padece das limitações usuais de uma avaliação unicêntrica, transversal e observacional, e o pequeno número de pacientes impede a tomada de conclusões mais robustas. O desfecho primário avaliado foi a qualidade de vida, mas resta saber, de forma prospectiva, se a ansiedade tem impacto em desfechos clínicos como internações hospitalares ou mortalidade.
Em conclusão, o presente artigo de Figueiredo et al.,6 reforça a importância de uma abordagem holística para pacientes com IC ao demonstrar que fatores negligenciados como transtornos de ansiedade são muito prevalentes nessa população e podem impactar a qualidade de vida. O campo do tratamento dos transtornos do humor foi pouco explorado e merece maior atenção em futuros estudos randomizados.
Minieditorial referente ao artigo: Efeito Sinérgico da Gravidade da Doença, de Sintomas de Ansiedade e da Idade Avançada sobre a Qualidade de Vida de Pacientes Ambulatoriais com Insuficiência Cardíaca