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2021 ESC Guidelines on cardiovascular disease prevention in clinical practice

2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapyDeveloped by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) With the special contribution of the European Heart Rhythm Association (EHRA)

See the editorial comment for this article ‘Treating depression in patients with heart failure: what is (not) recommended?’, by Christoph Herrmann-Lingen, https://doi.org/10.1093/eurjpc/zwac092. We read with interest ESC guidelines on cardiovascular disease prevention in clinical practice including a new recommendation for not using SSRI, SNRI, and TCA (Class III, Level B).1 The guideline refers to recent metanalysis2 including eight studies, among which there were two randomized controlled trials (RCTs)3,4 and six observational studies. The two analyzed RCTs3,4 have shown safety of sertraline (although this study was not designed to evaluate mortality) and escitalopram, but no benefit over placebo was observed. The metanalytic outcome provides evidence that the use of antidepressants in patients with heart failure (HF) is associated with an increased risk of all-cause death, regardless of whether they had clinical depression or the type of antidepressants they used.3 Such recommendation should be treated with caution as the evidence from randomized studies is limited and the clinical consequences of untreated depression in patients with HF must be taken into consideration. Major depression disorder (MDD) is a chronic and recurrent condition associated with substantial comorbidity of substance use, metabolic disorders, and cognitive impairment which all contribute to the negative prognosis in HF. The pathophysiology of MDD includes dysregulation in hypothalamic–pituitary–adrenal axis, autonomous system overdrive, and low-grade systemic inflammation. Depression appears in 20–30% of HF cases and results in increased mortality and morbidity.5 There is a need for head-to-head randomized studies investigating both, the change in depressive symptom severity and the use of antidepressant. One study in the metanalysis6 was based on the prescription of antidepressants in a National Danish Cohort and did not include data on the clinical diagnosis and the severity of depressive symptoms which is a methodological consideration. Measuring of the severity of depression is necessary to answer if antidepressants are harmful because it is possible that ineffectively treated depression increases mortality and not the antidepressants used. In another study from this metanalysis,7 the correlation with higher mortality risk was observed only in case of fluoxetine, but not with other antidepressants and fluoxetine has specific metabolism and can cause more interactions than other SSRIs. Moreover, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic HF guideline8 state that adequate conventional treatment of depression should be offered and that there is still no consensus on the best therapy for patients with HF. If it does not recommend pharmacological treatment it can lead to diminishing the significance of this comorbidity in clinical practice. Why bother with diagnosis if the treatment is harmful? The guideline should be placed in context of treatment adherence and rehabilitation of patients with HF. 

Commentary concerning treatment of depression in patients with heart failure according to 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.

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2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension.

2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death.

/pdf/2021-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-4pqhe8c49t.pdf

Jelena Čelutkienė

Papers

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.