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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">The growing complexity of HF</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; has evolved from the classic understanding of a mere hemodynamic &#40;pumping&#41; failure&#44; to a far more complex clinical syndrome&#46; We know today that multiple organs and body systems are involved in the clinical presentation&#44; progression and prognosis of HF&#46; This evolution results not only from advanced scientific insight and clinical understanding of the disease&#44; but also from factors such as improved medical care for acute cardiac events and an ageing society&#46; Together this leads to a higher prevalence of the disease and greater longevity for patients with HF&#46; Heart failure is particularly prevalent among the elderly&#59; the mean patient age at initial diagnosis of HF is &#62;70 years&#46; Various morbidities can accumulate over life and HF patients often present with multiple comorbidities&#46; These&#44; however&#44; often interact and exacerbate HF &#40;such as arteriosclerosis&#44; kidney impairment&#44; chronic obstructive pulmonary disease&#44; diabetes mellitus&#44; muscle wasting&#44; anemia and others&#41; and contribute to the presentation of HF as a complex systemic clinical syndrome&#46; Among the various heart-organ interactions in HF&#44; prominence should be given to brain disorders due to the brain&#39;s central role in our biological and mental wellbeing&#46; In fact&#44; the heart and the brain are very closely connected via multiple and bidirectional links which form the basis for the concept of a &#8220;cerebral-cardiac syndrome&#8221; in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> While stroke&#44; cognitive decline&#44; depression&#44; anxiety or abnormal central reflexes derive from distinct aspects of cerebral function&#44; they can all be seen as components of the global heart-brain interaction in HF&#46; An integrated view of these multifaceted afferent and efferent links between the brain and the heart and the vascular system will be required for a deeper understanding of the significance of cerebral involvement in symptoms&#44; progression and mortality in HF&#46; Such an overview and taxonomy of heart-brain interactions was recently presented by the Heart Failure Association of the European Society of Cardiology &#40;ESC&#41; &#91;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#93;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Relevance of higher cerebral functions in heart failure</span><p id="par0010" class="elsevierStylePara elsevierViewall">Higher cognitive function and the psychological aspects of HF are increasingly in the focus of clinical studies&#46; Despite the understanding of their impact on quality of life and on outcome&#44; there is a paucity of therapeutic options&#46; Cognitive impairment is common in HF syndromes with an estimated prevalence of 25&#37;-75&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Yet&#44; an even higher prevalence may be assumed as many cases are not recognized&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Cognitive impairment is associated with a loss of independence&#44; and a significantly impaired quality of life&#44; lower treatment adherence and a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Many aspects of cognitive decline are still not fully understood&#46; The early detection of subtle decline in cognitive function and the course of these injuries may be challenging targets&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue&#44; Rigueira et al&#46; report on a prospective longitudinal study to address these issues in a single center cohort of patients after hospital admission for an acute event of HF decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The authors observed that a six-fold higher risk of HF readmission is associated with cognitive injury&#44; as assessed by the Montreal Cognitive Assessment&#46; Moreover&#44; in the follow up of these patients&#44; recovery of cognitive performance is minimal at best&#46; The latter remains an aspect of ongoing debate as previous studies reported recovery of cognitive function after acute episodes of HF decompensation&#44; as well as little change or even a continued decrease in cognitive function in HF patients over time&#46; This may underscore the diversity of disease course in individual cases and also highlight the need for careful&#44; continued individual monitoring of cognitive function in patients with HF during long-term ambulatory care&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors further assessed depression and anxiety in their study and observed&#44; in line with previous studies&#44; a high prevalence of these psychological disorders&#46; Depression in HF is common and is associated with poor quality of life&#44; lower treatment adherence and self-care efforts&#44; greater morbidity and mortality&#44; increased hospitalization and higher health care costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> The prevalence of major depression is 20-40&#37; in patients with HF&#44; which is about four to five times higher than in the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The risk of depression increases with age&#44; with advancing HF severity and is higher in women&#46; Notably&#44; despite the known significant impact of depression in HF&#44; it remains an underdiagnosed aspect of HF syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Early depressive symptoms&#44; especially&#44; may be overlooked in the routine care of HF patients&#46; Current ESC guidelines on HF advise routine screening of HF patients for depression both during hospitalization and follow-up&#46; Comprehensive care concepts to monitor changes in depression should include family members to ensure early recognition&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Therapeutic concepts to target depression and anxiety in HF remain a challenge despite the clear understanding of the significance of these mental disorders&#46; The use of a range of antidepressant medications may be limited due to unfavorable effects on blood pressure or pro-arrhythmic potential&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Two randomized controlled trials administered selective serotonin reuptake inhibitors which appear to be safe in HF &#40;SADHART-CHF and MOOD-HF&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> These studies did not demonstrate superiority over placebo in reducing depressive symptoms in patients with HF in the short- and long-term&#46; Therefore&#44; non-pharmacological therapy&#44; such as exercise training and cognitive behavioral therapy may be relevant options in HF&#44; although their sustainability in long-term clinical practice is unknown&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Key message</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Rigueira et al&#46; points out once more that cognitive impairment and depression are common comorbidities and complications in HF and they contribute to a worse symptom status&#44; decreased quality of life and increased mortality&#46; More studies are required to address these often overlooked mental aspects of HF for early diagnosis and to raise awareness of this complication among patients&#44; their social network&#44; the attending physician&#44; and health care structures&#46; Comprehensive care concepts in HF should include monitoring and targeting cognitive impairment and depression in order to slow down HF progression and to improve quality of life&#44; symptom status and patient prognosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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