Knowing how to live with negative emotions is not easy, and developing mechanisms to overcome them can be even more challenging. The attempt to determine the physical effects of emotions and establish their profound influence on the heart has challenged physicians for centuries. Mood disorders, such as depression and anxiety, significantly impact quality of life and increase morbidity and mortality.

At least 30% of patients diagnosed with heart failure (HF) have depressive symptoms, and these numbers have progressively increased since the 1990s.¹ A meta-analysis found that the rates of mortality and cardiovascular events were twice as high in patients with HF and associated depression,² and this was often independent of functional class.^1,3 Some behavioral patterns contribute to these results, since patients with depression or anxiety often do not adhere to pharmacological treatment, are less active, have poor eating habits, and use tobacco.^1,3

However, the mutual association between depression, anxiety, and HF is more complex than it seems, involving similar pathophysiological bases that give rise to a vicious cycle,^1,4 as shown in Figure 1.

Depression increases the risk of developing HF by 18%, in addition to worsening its evolution.⁴ It is also a consequence of cardiovascular disease, which is often a limiting factor in the patient's life. Sympathetic hyperactivation, endothelial dysfunction, heart rate variability, blood pressure, platelet aggregation, and inflammation are some of the mechanisms in this connection between mood and heart disorders.^1,4.

Knowing the patient's mental status and detecting concomitant emotional disorders are fundamental for reasonable clinical control and for adapting patients to their new situation.⁵

Based on the hypothesis that HF and depression contribute to cognitive decline,¹ Soares et al.,⁵ conducted a prospective study of 71 patients diagnosed with HF in a private hospital. The objectives were to identify the presence of disturbances in cognitive function in hospitalized patients, in addition to investigating possible associations between cognitive impairment and depression and/or anxiety, as well as to observe whether they correlated with readmission within 30 days of hospital discharge.⁵ The authors found cognitive decline in 53% of the patients, and the most affected aspect was recent memory. There was a significant association between cognitive impairment and depression, but no association with hospital readmission.⁵

Today, the risk that a patient with HF will develop cognitive impairment is 4 times higher than in the general population.⁶ Chronic hypoxia, embolic events due to atrial fibrillation, and previous vasculopathy may serve as a substrate for this outcome.⁵ Thus, mental health should be tracked throughout follow-up of patients with HF⁷ and should be considered part of the clinical picture of the disease.⁵ Self-care impacts the course of treatment and has both medium- and long-term benefits.