Dear Editor,

Heart failure (HF) is a chronic cardiovascular disease affecting more than 23 million people worldwide. In the elderly population, HF frequently causes hospital readmission, and it is specified that a mood disorder such as depression is one of the modifiable risk factors for rehospitalization in this population.1 The prevalence of depression in HF has been estimated to be between 24% and 42%. Comorbid depression with HF is associated with medication nonadherence, significant morbidity, poor quality of life, and poor prognosis, as well as significant healthcare resource utilization.2 In addition, depression can adversely affect the clinical outcomes in elderly patients with HF.3 On the other hand, the evidence shows that sufficient treatment of depression may be associated with better functional status of patients with HF.4 Given that depression can pose numerous challenges in the management of HF, it must be treated effectively in the early course of the illness.

Several noninvasive options have been suggested for treatment of depression in patients with HF such as pharmacotherapy, psychotherapy, and exercise. However, research results are controversial about the effectiveness of these approaches in elderly patients, and there is no published guideline addressing these approaches. Antidepressants fail to show a significant benefit in depression in HF, and many of these drugs either interact with cardiac medications or have adverse cardiovascular effects (eg, orthostatic hypotension, hypertension, dysrhythmias).3 For these reasons, their use is limited in elderly patients with HF.

It is believed that exercise and physical activity can keep patients with HF more active and improve their self-esteem. A recent meta-analysis showed that aerobic exercise could improve depressive symptoms in patients with HF by increasing the release of neurotransmitters such as norepinephrine, dopamine, and serotonin.5 However, the use of many types of exercise is limited in HF because of impaired cardiac function. Among exercise options, yoga is shown to have beneficial effects on both HF patient outcomes and depression. A meta-analysis of 4 trials that examined the effects of mind-body interventions on the outcomes of patients with HF found that yoga could moderately improve physiological parameters, enhance exercise tolerance, decrease levels of inflammatory markers, and, consequently, improve the quality of life of patients with HF.6 However, in this meta-analysis, the safety, physical, and psychological effects of yoga in elderly patients with HF undergoing depression were not examined. In another review, when yoga was compared with usual care, it appeared to produce short-term emotional, psychological, and biological benefits for persons undergoing depression.7 On the basis of these results, it seems that yoga, as a safe and cost-effective modality, may play a positive role in the depression associated with HF. If true, yoga could be part of the cardiac rehabilitation plans for elderly patients with HF and depression. However, because of limited evidence, yoga cannot yet be advocated, and further research is needed. Well-designed clinical trials are warranted to determine the efficacy of yoga in elderly patients with HF and depression. Future research should consider the frequency and duration of yoga sessions, the skills and knowledge of the yoga instructor, the adherence of patients to yoga sessions, and the patients' outcomes related to HF and depression.

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