Background Patients with heart failure (HF) experience multiple psychological symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. Objective To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. Method A total of 1,260 HF patients participated. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous level variables, then as categorical variables using standard published cut points. Patients were then divided into four groups based on the presence of anxiety and depression symptoms. Results When entered as a continuous variable, the interaction between anxiety and depression (HR 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in HF patients. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (versus no symptoms, or symptoms of anxiety or depression alone) independently predicted all-cause mortality (HR 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychological variables was a predictor of cardiac rehospitalization in HF patients whether using the continuous or categorical level of measurement. Conclusion To improve mortality outcomes in patient with HF, attention must be paid by healthcare providers to the assessment and management of co-morbid symptoms of depression and anxiety.

Psychological conditions such as depression can have a greater impact on morbidity and mortality outcomes than traditional risk factors for these outcomes. Despite their importance, it is rare for clinicians to assess patients for these conditions and rarer still for them to consistently and adequately manage them. Illumination of the phenomena of comorbid psychological conditions in heart failure may increase awareness of the problem, resulting in improved assessment and management.

The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.

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