Anna Gawrys, Mercer University College of Pharmacy
The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of Heart Failure recognizes a high prevalence of depression in heart failure (HF) patients. 
The presence of depression or anxiety among HF patients can significantly impact quality of life, medical outcomes, and healthcare service utilization. Autonomic nervous system dysfunction, inflammation, cardiac arrhythmias, and altered platelet function are suggested as potential pathophysiologic mechanisms relating affective disorders to heart failure. 
Title: Effect of Escitalopram on All-Cause Mortality and Hospitalization in Patients With Heart Failure and Depression The MOOD-HF Randomized Clinical Trial 
|Design||Double-blind, placebo-controlled randomized clinical trial; N= 32|
|Objective||To determine whether 24 months of treatment with escitalopram improves mortality, morbidity, and mood in patients with chronic systolic heart failure and depression|
|Study Groups||Escitalopram (10-20 mg) (n= 185); placebo (n= 187)|
|Methods||Patients at outpatient clinics with New York Heart Association class II-IV heart failure and reduced left ventricular ejection fraction (<45%) were screened for depression using the 9-item Patient Health Questionnaire. Patients with suspected depression were then invited to undergo a Structured Clinical Interview based on the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) to establish the diagnosis. Patients were randomized 1:1 to receive escitalopram (10-20 mg) or matching placebo in addition to optimal heart failure therapy. Study duration was 24 months.|
|Duration||March 2009 – February 2014|
|Primary Outcome Measure||All-cause death or hospitalization
|Baseline Characteristics||Escitalopram (n= 185)||Placebo (n= 187)|
|Age over 70 years, n (%)||60 (32)||60 (32)|
|Female sex, n (%)||45 (24)||46 (25)|
|Living alone, n (%)||41 (22)||48(26)|
|New York Heart Association class III-IV, no (%)||88 948)||108 (58)|
|Hypertension, n (%)||146 (79)||148 (79)|
|Diabetes mellitus, n (%)||60 (32)||59 (32)|
|Myocardial infarction, n (%)||80 (43)||83 (44)|
|Angiotensin-converting enzyme inhibitor or angiotensinreceptor blocker, n (%)||175 (95)||176 (94)|
|Beta-blocker, n (%)||168 (91)||173 (93)|
|Diuretic, n (%)||149 (81)||151 (81)|
|Results||Escitalopram (n= 185)||Placebo (n= 187)||P-value|
|All-cause death, n (%)||18 (10)||14 (7)||0.36|
|All-cause hospitalization, n (%)||116 (63)||118 (63)||0.97|
|Adverse Events||Common Adverse Events: N/A|
|Serious Adverse Events: N/A|
|Percentage that Discontinued due to Adverse Events: 15%|
|Study Author Conclusions||In patients with chronic heart failure with reduced ejection fraction and depression, 18 months of treatment with escitalopram compared with placebo did not significantly reduce all-cause mortality or hospitalization, and there was no significant improvement in depression. These findings do not support the use of escitalopram in patients with chronic systolic heart failure and depression.|
Considering overwhelming evidence that beta blockers reduce morbidity and mortality among the heart failure patients, this class of medication became first line therapy. Unfortunately, one of the adverse effects of beta blockers is depression. Additionally, heart failure patients are said to develop depression due to their complex nature of the disease. Considering those two facts, depression treatment must become an important element in the heart failure therapy protocol. This study shows that treatment with escitalopram is not effective among heart failure patients and ongoing pursuit for the appropriate medication needs to continue.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240-327.
- York KM, Hassan M, Sheps DS. Psychobiology of depression/distress in congestive heart failure. Heart Fail Rev. 2009;14(1):35-50.
- Angermann CE, Gelbrich G, Störk S, et al. Effect of Escitalopram on All-Cause Mortality and Hospitalization in Patients With Heart Failure and Depression: The MOOD-HF Randomized Clinical Trial. JAMA. 2016;315(24):2683-93.