The hallmark symptoms of HF are dyspnea and edema. However, patients also frequently report significant subjective symptoms such as anxiety and depression. Recent studies have shown that frailty, which includes anxiety and depression as key components, significantly impacts both the quality of life and the prognosis of individuals with HF [2-4]. Moreover, depression can affect medication adherence, which in turn may significantly influence the long-term prognosis of HF patients. Therefore, if behavioral therapies like BRT can effectively reduce anxiety and depression, as demonstrated in this study, it could be immensely beneficial from a clinical standpoint for improving the prognosis of HF patients.

This study presents several intriguing aspects worth noting. It involved a cohort of patients with relatively severe HF, characterized by an average ejection fraction (EF) of around 30% and classified as New York Heart Association Functional Class III/IV. In such cases, the likelihood of experiencing anxiety and depression is elevated. Since severe HF is associated with hyperactivity of the sympathetic nervous system, behavioral therapies like BRT could potentially mitigate this overactivity to some extent, highlighting the significance of the study's findings. However, the regimen of performing behavioral therapy twice daily for a total of 40 minutes over 8 weeks may be inadequate for eliciting significant changes in anxiety or depression levels. The study reportedly used WhatsApp to promote adherence, yet more precise data on the extent of patient compliance with the study protocol would be beneficial.

Second, it would be helpful to consider the impact of concurrent pharmacological treatments during the study period. Recent advancements in HF pharmacotherapy not only enhance survival rates but also significantly improve symptom management. An improvement in a patient's dyspnea can lead to decreased levels of anxiety and depression. Throughout the 8-week treatment period, it is essential to ensure that guideline-directed medical therapy is properly administered. Although the treatment period was relatively short, obtaining follow-up data on EF would have been advantageous for assessing any improvements in cardiac function. Adjusting for the effects of pharmacological therapy is necessary to mitigate potential confounding influences on the efficacy of BRT.

Third, an intriguing finding of this study was a negative correlation between EF levels and depression. In contrast, a previous study reported that HF with preserved EF (HFpEF) is associated with greater depression compared to HF with reduced EF [5]. Both studies were limited by their small sample sizes, which makes it challenging to draw definitive conclusions. However, the tendency for HFpEF to occur more frequently in older patients carries significant implications. Specifically, older patients with HFpEF may experience higher levels of frailty and cognitive dysfunction [6], potentially increasing their risk of anxiety and depression. Nonetheless, the participants in this study were relatively young, with an average age of 58 years. In this younger cohort, the patient's perception of the severity of their illness may play a significant role, potentially explaining the observed negative correlation between EF and depression.

In conclusion, despite certain areas requiring further investigation, this study underscores the considerable potential of BRT—a non-invasive and readily applicable behavioral therapy—for managing anxiety and depression in HF patients. Exploring modifications such as extending the duration or frequency of sessions, or integrating behavioral therapies with pharmacological treatments, could potentially amplify the effects noted in this study. It is crucial not to underestimate or sideline the role of various behavioral therapies in improving the prognosis of HF patients. Instead, these methods should be considered essential elements of a comprehensive strategy for HF management.