The effectiveness of cognitive-behavioral therapy for heart failure patients: a narrative review

Abstract

Heart failure (HF) remains a major cause of morbidity, mortality and healthcare costs, despite available treatments. Psychological issues such as depression, anxiety and poor self-care are prevalent in HF patients. Such issues adversely affect patients’ daily lives and increase hospitalization and mortality rates; therefore, effective approaches to address these are needed. Cognitive-behavioral therapy (CBT) has been proposed as potentially useful for psychological comorbidities in HF patients, but its efficacy is not well-established. This narrative review aimed to summarize the evidence on the effectiveness of CBT for HF patients. A search was conducted using PubMed and Google Scholar for randomized controlled trials (RCTs) on CBT for HF patients. Ten studies (nine RCTs and one case study) were included in the review. CBT was found to be an effective intervention for managing depression, anxiety, low quality of life, and impaired social and physical functioning in HF patients. The results suggest that CBT can improve psychological well-being and enhance the benefits of rehabilitation programs. Face-to-face CBT appears to be superior to conventional therapy and can be implemented in cardiac rehabilitation settings. Further research is needed to evaluate the efficacy of internet-based CBT for cardiac patients and identify factors that promote treatment adherence.

Keywords

Psychotherapy heart failure cognitive-behavioral therapy depression anxiety quality of life narrative review

Introduction

Heart failure (HF) is a progressive, debilitating syndrome resulting from a structural or functional heart problem that causes a decrease in cardiac output or an increase in intracardiac pressure. HF is often classified into three main categories according to the ejection fraction: preserved (50%), mid-range (40%–49%), or reduced (40%).¹ HF continues to be a leading cause of mortality, morbidity and high healthcare expenditure despite the availability of several treatments. Population aging is associated with an increased incidence and prevalence of HF. HF can be regarded as a global pandemic as it affects approximately 64.3 million individuals worldwide, with 50% of HF patients dying within 5 years of diagnosis.^2,3

Depression, anxiety and poor health-related quality of life (HRQoL) are prevalent comorbidities in patients with HF, and have detrimental effects on daily life, hospitalizations and mortality rates.^4–6 Therefore, it is essential to effectively and promptly manage these issues. Insufficient self-care is also common in HF.⁷ Self-care involves activities that preserve physical functioning and prevent acute exacerbations, such as adhering to a low-sodium diet, engaging in physical activity, complying with medication-taking and monitoring edema.⁸ Self-care in HF patients reduces the likelihood of hospitalization and improves the quality of life (QoL) associated with HF.^9,10 Depression hinders self-care in HF patients, and poor self-care is associated with depression.^9,10 The main treatments for depression include psychotherapy and medications such as selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors. However, few studies have evaluated the efficacy of antidepressant medication in individuals with HF, and no conclusive results have been reported. In one clinical trial of the use of sertraline (a selective serotonin reuptake inhibitor) for depression and heart disease in chronic HF patients, sertraline did not produce an increased reduction in depression or improvement in the cardiovascular endpoint compared with placebo.¹¹ Furthermore, the addition of an antidepressant to the existing complex medical treatment for HF (angiotensin-converting enzyme inhibitors, beta-blockers, diuretics and mineralocorticoid receptor antagonists) may be perceived as burdensome because it increases regimen complexity and the risk of side effects and non-compliance. Other treatments for depression include lifestyle changes, social support, electroconvulsive therapy and transcranial magnetic stimulation; however the benefits of these treatments for depression in HF patients have not been tested.

Cognitive-behavioral therapy (CBT) is a promising treatment for various psychological issues associated with HF, including depression, anxiety and sleep disorders.^12–14 CBT may offer substantial advantages over pharmacological therapy, such as fewer drug interactions and side effects and greater patient engagement in self-care. In addition, individuals with HF are counseled to make dietary and lifestyle modifications. However, altering long-standing habits and lifestyles can be challenging. People with HF frequently have low motivation and diminished confidence as a result of previous attempts at change, stress, minimal support, anxiety and frequent alterations in symptoms and everyday functioning. CBT has been consistently shown to improve cardiac outcomes by addressing these barriers to change, improving compliance with medication and dietary/exercise recommendations, and providing better management of related psychological disorders.^15,16

The purpose of this study was to conduct a comprehensive examination of the association between HF and psychological comorbidities, particularly depression, anxiety and poor HRQoL. A review was conducted with the following aims: to explore the detrimental effects of these issues on daily life, hospitalizations and mortality rates; to investigate the potential benefits of CBT as a therapeutic treatment for psychological issues linked with HF (including depression, anxiety and sleep disorders); to highlight the advantages of CBT compared with pharmacological therapy (e.g., fewer drug interactions and side effects, greater patient engagement in self-care); to address the challenges experienced by HF patients in making dietary and lifestyle modifications; and to explore how CBT could address these barriers and improve compliance.

Methodology

Search strategy

A narrative review was performed by conducting a comprehensive search on PubMed and Google Scholar to identify relevant studies on the efficacy of CBT for HF patients. The search strategy included keywords such as “heart failure,” “CBT,” “depression,” “anxiety,” “quality of life,” and “randomized controlled trial.” The search was limited to articles published in English up to the date of the search (September 2022).

Study selection

The identified studies were screened using their titles and abstracts to assess their relevance to the research topic. The inclusion criteria for the studies were as follows: (a) randomized controlled trials (RCTs) or case studies, (b) studies that focused on the use of CBT for psychological comorbidities in HF patients, (c) studies that assessed the effects of CBT on depression, anxiety, sleep or QoL in HF patients. Studies that met the inclusion criteria were selected for further analysis.

Data extraction

Data from the selected studies were extracted and summarized. The extracted data included study author, year, country, study design, CBT program details, and the results of the interventions on depression, anxiety, sleep and QoL in HF patients. The data were organized in a tabular format for clear presentation and comparison of the study findings.

Limitations

Potential limitations of the included studies, such as small sample size or lack of long-term follow-up, were identified and discussed. The limitations were taken into consideration when interpreting the results and drawing conclusions.

Ethical considerations

As this study involved a narrative review of previously published studies, no ethical approval was required. However, the review followed ethical guidelines such as proper citation and acknowledgment of the original authors’ work.

Author consensus

The studies selected for analysis were chosen according to author consensus. The authors collectively agreed on the inclusion of studies that provided insights into psychological issues and comorbidities in HF patients.

Results and discussion

Ten studies (nine RCTs and one case report) were identified in which the role of CBT in patients with HF was evaluated. The study characteristics and results are summarized in Table 1.^17–26 Gary et al.¹⁷ conducted an RCT in stable New York Heart Association (NYHA) class II to III HF patients with depression. The effectiveness of a combined 12-week home-based exercise/CBT program was compared with CBT alone, exercise alone, and usual care. The Hamilton Depression Rating Scale (HAM-D) for depression, the 6-minute walk test (6MWT) for physical function, and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) for HRQoL were used as outcome variables. Data were collected initially within 2 weeks of assigning control/intervention (considered as baseline), at 12 weeks, and at 3 months using telephone follow-up. CBT was provided by psychiatric nurses and psychology students. Initially, 60 minute/week face-to-face sessions for 12 weeks were conducted, followed by bimonthly (5- to 10-minute) telephone sessions. The study conclusion was that a combined approach using CBT and exercise was superior to either therapy alone in reducing depression, increasing physical function and improving HRQoL in patients with NYHA Class II and III HF. This combined exercise and CBT group was the only group that showed sustained improvement on all primary outcome variables at 12 and 24 weeks, and stronger intervention effects were found in patients with moderate-to-major depression (i.e., HAM-D scores of 15 or higher). Cully et al.¹⁸ conducted an open trial to examine the effectiveness of tailored CBT for veterans with congestive HF and/or chronic obstructive pulmonary disease with comorbid depression and/or anxiety. All 23 veteran patients received CBT, mostly from advanced psychology trainees, consisting of six weekly sessions and three telephone booster calls. The study demonstrated improvement in both depression and anxiety at 8 weeks, and the improvement was maintained at a 3-month follow-up. Improvement was also observed in congestive HF and/or chronic obstructive pulmonary disease symptoms, measured using the Kansas City Cardiomyopathy Questionnaire [KCCQ] and Chronic Respiratory Questionnaire [CRQ], respectively.

Table 1.

Cognitive-behavioral therapy in patients with heart failure.

Study author, year, country	Nature of the study	CBT program	Provided by	Results
Gary et al. 2010USA	RCT(n = 74)	60 minutes/week for 12 weeks of face-to-face sessions, followed by bimonthly telephone sessions lasting 5–10 minutes eachCBT according to Beck’s model of depression	Psychiatric nurses and psychology students	Three questionnaires were evaluated at baseline, after the 12-week intervention relative to the control, and at a 3-month telephone follow-upThe questionnaires were: Depressive symptom severity (HAM-D) Physical function (6MWT) Health-related quality of life (MLHFQ)
				Among all patients diagnosed with moderate and major depression, only those in the CBT and exercise groups had maintained lower HAM-D scores at 12 and 24 weeks
Cully et al. 2010USA	RCT(n = 23)	A 12-week program (face-to-face or by phone) was divided into Core module session Elective module sessions Wrap-up sessions	Psychologists and advanced psychology trainees	Symptoms of depression and anxiety improved at 8 weeks and were maintained at a 3-month follow-up. Congestive HF physical disease outcomes also improved
		Consisted of psychoeducation, physical health management and constant review of treatment and patient’s progress
Lundgren et al. 2016Sweden	RCT(n = 50)	The RCT aimed to evaluate the effect of a 9-week internet-based CBT program on depressive symptoms in patients with HF	Mental health specialist nurses were supervised by a clinical psychologist, cardiologist and nurses specializing in HF care if needed	A significant and moderate correlation between improvement in symptoms of depression (mean change score 0.9, SD 4.0) and improvement in HF self-care (mean change score 1.2, SD 22.4) was found (r = 0.34, p = 0.03)
Dekker et al. 2012USA	RCT(n = 41)	One, 30-minute, face-to-face CBT session plus one additional telephone session	Nurse	Depressive symptoms and health-related quality of life improved significantly The control group had more than double the risk of experiencing a cardiac event
Tully et al. 2015Australia and Italy	RCT(n = 29)	CBT for 60 minutes, once a week for 12 weeks	Psychologist	There was a significant time and treatment interaction effect on reduction in PHQ-9 symptoms that favored the CBT group The average number of cardiac hospital readmissions was reduced for the CBT group
Freedland et al.2015USA	RCT(n = 158)	6 months of weekly 60-minute meetings followed by biweekly and then monthly sessionsFollowed by up to four 20–30-minutes relapse prevention telephone sessions provided as needed between 6 and 12 months	Therapists	Six-month depression scores (BDI-II) were lower in the CBT group than in the control groupAfter 6 months of CBT, anxiety and fatigue scores were lower and mental- and HF-related quality of life and social functioning scores were higher. There were fewer hospitalizations during the intervention
Turner et al. 2012Australia	RCT(n = 57)	Six weekly sessions of CBT of 60–90 minutes, with an extra hour at weeks 1 and 6	Trained psychologists	Significant improvements in BDI-II and HADS-A scores for the total group from baseline to 12 months: reduction in BDI-II scores (95% CI) = 9.9 (7.4–12.4), p < 0.0001; reduction in HADS-A scores (95% CI) = 3.6 (2.5–4.8), p < 0.0001, with adjustment for clusters) No difference was found in the rate of CBT or “no further intervention” participants in the “minimal” symptom severity category across the study timeline
Redeker et al. 2017USA	RCT(n = 51)	Four biweekly sessions over an 8-week period with telephone calls in the intervening weeks. CBT-I included sleep hygiene, cognitive therapy, stimulus control, sleep restriction, progressive muscle relaxation and optional advice on hypnotic tapering	A clinical psychologist certified in sleep medicine	Both DBAS and SDQ scores improved in the CBT-I group compared with the control group
Slaughter and Allen 2020UK	Case report (n = 1)	The patient received six sessions of CBT, approximately weekly, including an assessment. The time of the session differed across weeks. A 3-month follow-up was included	An assistant psychologist trained to deliver transdiagnostic CBT, supervised by a consultant clinical psychologist	A combination of measures was used: The GAD-7 to measure anxiety The PHQ-9 to measure depression The CSRI to measure use of clinical services
Cajanding 2016Philippines	RCT(n = 100)	60–120 minutes/week for 12 weeks of face-to-face sessions	CBT-trained nurses	There was considerable improvement in the CBT intervention group relative to the control group in scores on three questionnaires used at baseline and post-intervention: MLHFQ to measure quality of life Rosenberg Self-Esteem Scale to measure self-esteem Cardiac depression scores to measure mood

BDI-II, Beck Depression Inventory; CBT, cognitive-behavioral therapy; CBT-I, CBT for insomnia; CI, confidence interval; CSRI, Client Service Receipt Inventory; DBAS, Dysfunctional Beliefs and Attitudes about Sleep scale; GAD-7, Generalized Anxiety Disorder Assessment; HADS-A, Hospital Anxiety and Depression Scale-Anxiety; HAM-D, Hamilton Depression Rating Scale; HF, heart failure; MLHFQ, Minnesota Living with Heart Failure Questionnaire; PHQ-9, Patient Health Questionnaire; RCT, randomized controlled trial; SD, standard deviation; SDQ, Sleep Disturbance Questionnaire; 6MWT, 6-minute walk test.

Lundgren et al.¹⁹ conducted a pilot RCT to evaluate the effect of guided internet-based CBT (iCBT) on HF patients with depressive symptoms and cardiac-related anxiety. After 9 weeks of CBT, depression and fear significantly decreased. A significant and moderate correlation between improvement in symptoms of depression (mean change score 0.9, standard deviation [SD] 4.0) and improvement in HF self-care (mean change score 1.2, SD 22.4) was also found (r = 0.34, p = 0.03). Depression was measured using the Patient Health Questionnaire (PHQ-9), and fear was assessed using the subscale of the Cardiac Anxiety Questionnaire (CAQ), which is used to measure anxiety in cardiac patients. Dekker et al.²⁰ conducted an RCT to evaluate the effect of CBT on depressive symptoms, negative thinking, HRQoL and cardiac event-free survival among hospitalized HF patients. CBT comprised a brief, 30-minute face-to-face session and was delivered by a nurse during hospitalization, followed by a 1-week booster phone call. Significant improvements in depressive symptoms and HRQoL were seen on assessment after 1 week of CBT in both study and control groups, with no obvious interaction between groups and time. However, the 3-month cardiac event-free survival was shorter (40% versus 80%, p < 0.05) in the control group, and control group patients had a 3.5 greater hazard of experiencing a cardiac event (p = 0.04) than those in the intervention group. The study showed that even brief CBT may improve short-term, event-free survival in hospitalized patients with HF. However the effect of CBT was inconclusive regarding reductions in depressive symptoms and HRQoL, probably owing to the small sample size.

A multicenter study was conducted by Tully et al.²¹ to evaluate the effect of CBT on depression and anxiety in chronic HF patients. CBT was provided by a psychologist and consisted of a 1-hour session provided once per week for 12 weeks. Of 29 HF patients under psychiatric management, 15 received CBT for primary depression, whereas 14 received it for primary generalized anxiety disorder. The patients also participated in a community exercise program and simultaneously received standard physician care. The PHQ-9 and the Generalized Anxiety Disorder Assessment (GAD-7) were used for psychological assessment and a sensitivity analysis was conducted using repeated measures analysis of variance. There was a significant time and treatment interaction effect of CBT in reducing PHQ-9 symptoms in patients with primary generalized anxiety disorder (F (1, 24) = 4.52, p = 0.04). Similarly, both the exercise programs (F (1, 24) = 4.21, p = 0.05) and the anxiolytic intervention (F (1, 24) = 3.98, p = 0.05) were helpful. The study highlights the role of multifaceted interventions in the rehabilitation of HF patients with psychiatric needs. Freedland et al.²² conducted an RCT to evaluate the efficacy of CBT on depression and HF self-care among 158 outpatients in NYHA classes I, II, and III with comorbid major depression. The study group (n = 79) was provided with CBT by experienced therapists with simultaneous continuation of usual care; the control group (n = 79) received only usual care. After 6 months of randomization, mean (SD) Beck Depression Inventory (BDI-II) scores were lower in the study group (12.8 (10.6)) than in the controls (17.3 (10.7)), p = 0.008. Anxiety and fatigue scores were also lower in study group patients, who also had lower hospitalization rates.

Turner et al.²³ conducted an RCT to compare the effects of six sessions of CBT with a single brief intervention session. Fifty-seven HF patients with BDI-II scores greater than 13 were initially provided with a single session of CBT. Block randomization was subsequently performed, following which 25 patients received six sessions of CBT and 32 did not receive any further intervention. On reassessing the patients at 2, 6 and 12 months using the BDS-II and the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), significant improvements were seen in both groups from baseline to 12 months. However, the group that received six CBT sessions showed no significant reductions in depression or anxiety symptoms compared with another group that received a single brief intervention session. This indicates that the quality, content and initial timing of CBT are more important than greater frequency of CBT in reducing psychiatric morbidities in HF patients. Redeker et al.²⁴ also conducted an RCT to understand the role of CBT for insomnia (CBT-I) in reducing sleep dysfunction in HF patients. Of 51 NYHA class II to III HF patients involved in the study, 30 received CBT-I from a clinical psychologist certified in sleep medicine, and 21 patients in a control group received only HF self-management education. CBT-I included sleep hygiene, cognitive therapy, stimulus control, sleep restriction, progressive muscle relaxation and optional advice on hypnotic tapering. Scores on both the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale and the Sleep Disturbance Questionnaire (SDQ) showed improvement in the CBT-I group compared with the control group. The CBT-I group also reported improvements in sleep quality, sleep latency, insomnia severity, fatigue, anxiety and depression with sustained effects at 6 months.

A case report by Slaughter and Allen²⁵ described an HF patient on a research trial for cardiac resynchronization therapy with defibrillation who had been experiencing severe anxiety and moderately severe depression. The patient received six sessions of transdiagnostic CBT, and self-report measures were collected at each session and at a 3-month follow-up. The CBT was provided by an assistant psychologist trained in transdiagnostic CBT under the supervision of a consultant clinical psychologist. The GAD-7, PHQ-9, and Client Service Receipt Inventory (CSRI) were used to monitor the patient’s anxiety, depression, and the use of clinical services, respectively. After the successful transdiagnostic CBT intervention, the patient showed non-clinical levels of depression and anxiety, which were maintained for 3 months. His use of clinical services was also reduced, and he reported fewer visits by specialist nurses and general practitioners and fewer hospital admissions. An RCT was conducted by Cajanding²⁶ to determine the effectiveness of CBT on mood, QoL and self-esteem among Filipino HF patients. Patients in the intervention group (n = 52) received face-to-face CBT sessions provided by trained nurses for 60 to 120 minutes per week for 12 weeks. The control group (n = 48) received only traditional care. Cardiac depression scores, MLHFQ scores, and Rosenberg Self-Esteem Scale scores were used to measure pre and post-intervention depression, QoL, and self-esteem, respectively. The results showed a significant improvement in mood scores, QoL and self-esteem in the intervention group compared with the control group.

Overview of CBT

CBT is an active and problem-focused treatment that attempts to reduce emotional discomfort and enhance adaptive behavior in patients with a variety of mental health and adjustment issues.^27,28 CBT combines behavioral and cognitive treatments. The behavioral therapy aspect focuses on exposure and behavioral action, whereas the cognitive therapy aspect is based on the assumption that thoughts and beliefs affect emotions and conduct. There are various types of CBT that are tailored to specific problems and groups, such as trauma-centered CBT for children and adolescents and CBT-I for military personnel and pregnant women.^29–32 CBT has been used to treat a variety of mental and somatic illnesses, including depression, anxiety disorders, chronic pain, eating disorders, schizophrenia, obsessive–compulsive disorders and post-traumatic stress disorder.^12,33–38 A range of CBT interventions and therapy studies have been conducted to address other health issues such as insomnia and stress.^39,40 Behavioral strategies in CBT focus on overcoming avoidance, engaging in prosocial behavior and achieving self-care. For example, behavioral activation for depression helps patients to become more actively engaged in their lives, whereas exposure to anxiety, obsessive–compulsive disorders, and trauma- and stress-related disorders helps patients to extinguish fear responses by having systematic contact with feared stimuli and situations. A range of strategies, such as cognitive restructuring, behavioral activation, exposure, problem-solving and promoting acceptance, are frequently used in CBT.^41–44

CBT and palliative therapy can be used as complementary therapies to manage HF patients. CBT is a type of psychotherapy that focuses on changing negative patterns of thinking and behavior. Palliative therapy is a symptom management approach that focuses on improving the QoL of patients with advanced or life-limiting illnesses. Examples of CBT techniques that may be used include relaxation training, activity pacing and cognitive restructuring. Palliative therapy can address the physical symptoms and emotional distress that are common during the advanced stages of HF. Palliative therapy involves a multidisciplinary approach that includes managing symptoms such as dyspnea, fatigue, pain and sleep disturbances. Palliative care professionals can help patients and their families to understand the disease process, establish realistic care goals and optimize symptom management.⁴⁵

iCBT is a low-cost treatment that can be administered to a large number of patients.^46–48 CBT is more accessible than some other treatments because sessions can be provided at patients’ homes to fit in with their daily routines.⁴⁹ Furthermore, healthcare professionals with minimal CBT training can administer iCBT with good therapeutic outcomes.⁵⁰

Internet-based CBT vs. face-to-face CBT

iCBT is similar to conventional CBT but is provided via the internet. The patient is asked to complete modules and other CBT materials online. An online therapist guides the patient and provides them with appropriate support by monitoring progress, clarifying information and helping the patient to access the appropriate treatment steps.⁵¹

Various forms of iCBT have been designed by researchers worldwide. In most cases, a therapist guides the patient during the entire CBT process. Treatments are usually structured to include 15 training modules, the same number provided in face-to-face CBT sessions. iCBT and face-to-face CBT can be completely different in terms of technical support, diagnostic processes and the amount of therapist support. However, they share some characteristics, such as exposure, treatment duration of 8 to 15 weeks and psychoeducation. iCBT programs typically use text messages as the primary form of communication between the therapist and the patient. They also include an integrated assessment system and assignments.^52,53

The authors of a recent study have proposed that therapist-guided iCBT and, to some extent, digital mindfulness and acceptance-based interventions complement face-to-face therapy.⁵⁴ In terms of the current development and consolidation of traditional CBT approaches, iCBT requires considerably fewer resources and is easier to implement. However, some RCTs indicate that there is no significant difference between CBT and iCBT in improving the patient's condition, although iCBT incurs a lower cost.^55,56

In a study related to HF, an iCBT intervention was used for myocardial infarction patients.⁵⁶ Patients who were recommended iCBT were sent daily reminders via short text messages and were allotted a member of research staff, who they were able to contact by telephone. Various other techniques, such as paper-and-pencil assessment forms, were provided to patients if they were unable to be reached via telephone.⁵⁷

The treatment comprised a 14-week tailored CBT course guided by a therapist and was delivered via a secured internet-based portal.⁵⁶ It was carefully developed by a licensed psychologist and included 10 modules with different themes and tailored to the myocardial infarction patients. After completion of the introductory modules, which were compulsory, patients could choose from a range of other modules. The intervention was adapted to provide patients with more control while maintaining the quality of treatment.⁵⁸ Each module consisted of two to four steps, one to two homework assignments and information for text-based psychoeducation. The homework assignments contained skills training and self-monitoring, with exercises using CBT-based techniques. During the treatment period, patients were asked to work on one step per week. After completion of all the homework assignments, the modules were sent to the therapist, who provided feedback. Additionally, patients received iCBT, which included materials and video clips of the psychological reactions of post-myocardial infarction patients trying to cope with their situation. Patients were also encouraged to communicate with fellow patients. The results showed that iCBT did not lower levels of depression and anxiety symptoms and so was less effective than traditional CBT.⁵⁶

Conclusion

The current evidence suggests that CBT is a safe and effective treatment that lowers the severity of psychosocial comorbidities in patients with HF. We recommend additional research in the following two areas of behavioral cardiology. First, studies are needed to explore and identify strategies to improve self-care, physical and social functioning, and poor QoL in individuals with HF. Second, more comprehensive, large-scale RCTs are required to determine the potential long-term effectiveness of CBT interventions for improving psychological health in HF patients. Exploratory analyses in these two areas may ultimately help to reduce hospitalizations in clinically depressed patients with HF. Despite the considerable effect of cognitive-behavioral training, as opposed to conventional training, on promoting self-care patterns in patients with chronic illnesses, more work is needed to explore different techniques and strategies to improve self-care practices in HF patients.

Footnotes

Author contributions

SP, MRK and AT were involved with the primary conception of the idea and writing the first draft. SP, MRK and AT were involved in determining the number and type of studies included and selecting the study inclusion criteria. MRAA, SM and SP helped in the supervision and final editing of the draft.

Declaration of conflicting interests

All authors declare that they have no financial relationships at present or within the previous 3 years with any organizations that might have an interest in the submitted work. All authors declare that there are no other relationships or activities that could appear to have influenced the submitted work.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iD

Sakshi Prasad

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