How to manage a patient with severe chronic heart disease, pacemaker placement, and comorbid depression and anxiety, on multiple cardiovascular medications including sacubitril/valsartan, carvedilol, dapagliflozin, spironolactone, and atorvastatin?

Management of Severe Heart Failure with Depression and Anxiety

This patient requires immediate screening and treatment for depression and anxiety, as these conditions independently worsen cardiovascular outcomes and mortality in heart failure patients, and the current medication regimen (Entresto) may actually improve these mental health symptoms. 1

Mental Health Assessment and Management

Screening Protocol

• Use validated screening tools at every visit: Patient Health Questionnaire-2 (PHQ-2) for depression and Generalized Anxiety Disorder Questionnaire-2 (GAD-2) for anxiety to systematically identify mental health conditions 1
• Screen specifically for: severity of depressive symptoms, anxiety levels, medication adherence patterns, social isolation, and financial stressors related to medication costs 1

Treatment Approach for Depression and Anxiety

Pharmacologic therapy with SSRIs is reasonable to improve cardiovascular outcomes in this patient with severe heart failure and comorbid mental health conditions. 1

• Escitalopram is the preferred SSRI based on the EsDEPACS trial showing 40.9% vs 53.6% MACE rates compared to placebo after 8.1 years in post-ACS patients (HR 0.69,95% CI 0.49-0.96) 1
• SSRIs may provide additional cardiovascular benefits through effects on platelet function, immune activation, and neurohormonal pathways 2
• Combination of pharmacotherapy and psychotherapy is more effective than either alone for reducing depressive symptoms in cardiac patients 1

Non-Pharmacologic Interventions

Cardiac rehabilitation is mandatory and provides dual benefits: improves both depression/anxiety symptoms AND reduces cardiovascular mortality and heart failure hospitalizations 1

• Cognitive-behavioral therapy specifically reduces depression, anxiety, and stress in chronic coronary disease patients 1
• Mindfulness-based interventions (meditation, yoga) improve mental health symptoms and cardiovascular risk factors 1

Cardiovascular Medication Optimization

Current Regimen Assessment

The patient's current medications are appropriate for severe HFrEF (EF 19%), but monitoring for mental health benefits from Entresto is important. 1

Your patient is already on:

• Entresto (sacubitril/valsartan): Class I recommendation for HFrEF to reduce cardiovascular death and hospitalization 1, 3
• Carvedilol: Class I recommendation for HFrEF with proven mortality benefit 1
• Dapagliflozin (Farxiga): Class I recommendation for HFrEF regardless of diabetes status to reduce cardiovascular death and heart failure hospitalization 1, 4
• Spironolactone: Class I recommendation for symptomatic HFrEF on ACE inhibitor/ARB and beta-blocker 1, 5
• Atorvastatin: Class I recommendation for all patients with chronic coronary disease 1

Unique Mental Health Benefit of Current Therapy

Entresto (sacubitril/valsartan) has been shown to significantly improve both depression and anxiety symptoms in HFrEF patients. 6

• In a study of 115 HFrEF patients, switching to sacubitril/valsartan resulted in:
  • Beck Depression Inventory scores improved from 13.7±9.7 to 7.6±3.8 (p<0.001) 6
  • Beck Anxiety Inventory scores improved from 13.3±8.9 to 8.1±4.1 (p<0.001) 6
  • These improvements occurred alongside functional status improvements 6

Device Therapy Considerations

With EF 19% and pacemaker already in place, evaluate for ICD upgrade if not already present. 1

• ICD is Class I recommendation for symptomatic HF with LVEF <35% to reduce sudden death and all-cause mortality 1
• If pacemaker has high-degree AV block requiring pacing, CRT with pacemaker is Class I recommendation over right ventricular pacing 1
• CRT is Class I recommendation for symptomatic HF in sinus rhythm with QRS ≥150ms and LBBB morphology with LVEF <35% 1

Monitoring Strategy

Mental Health Follow-up

• Reassess depression and anxiety symptoms 2-4 weeks after initiating SSRI therapy 1
• Continue screening at every cardiovascular visit using PHQ-2 and GAD-2 1
• Monitor for medication adherence, which is commonly affected by depression 1, 7

Cardiovascular Monitoring

• Reassess symptoms, blood pressure, heart rate, renal function, and potassium 1-2 weeks after any medication adjustments 5, 8
• Repeat echocardiography in 3-6 months to assess response to optimized medical therapy 5, 8
• Monitor for signs of worsening heart failure that may increase anxiety/depression 7, 9

Critical Pitfalls to Avoid

Do not assume pacemaker placement alone improves mental health: Studies show anxiety/depression may actually worsen after pacemaker implantation in some patients, particularly those with AV blocks 9

Do not delay mental health treatment: Depression is independently associated with increased mortality (HR 0.69 for treated vs untreated depression) and worse quality of life in heart failure patients 1, 7

Do not overlook financial toxicity: Out-of-pocket medication costs are a significant stressor that worsens depression and reduces adherence 1

Avoid polypharmacy without benefit: While this patient's cardiovascular regimen is appropriate, adding medications without clear indication increases treatment burden and may worsen mental health 1

Multidisciplinary Care Coordination

Comprehensive risk profiling and multidisciplinary management is Class I recommendation, including treatment of major comorbidities such as depression and anxiety 1

• Refer to mental health professional for in-depth assessment if screening is positive 1
• Coordinate with primary care for depression management if cardiology practice cannot provide 1
• Consider palliative care consultation for symptom management and goals of care discussion given severe HF 1
• Engage social work for financial assistance programs to reduce medication cost burden 1