Home-based cardiac rehabilitation in heart failure with anxiety and depression: lessons from REACH-HF

This invited commentary refers to ‘Impact of home-based cardiac rehabilitation in people with heart failure with elevated depressive and anxiety symptoms: a secondary analysis of the REACH-HF randomized trials’, by J. Lambert et al., https://doi.org/10.1093/eurjcn/zvaf196. Heart failure (HF) is a chronic, progressive syndrome that is frequently complicated with mental health issues such as anxiety and depression.1 The global prevalence of depressive symptoms of any severity among patients with HF was 41.9%,2 while the prevalence of anxiety disorders is 13.1%.3 These mental health conditions are consistently associated with adverse clinical trajectories, including poorer clinical outcomes, reduced treatment adherence, and increased mortality.4 Traditional centre-based cardiac rehabilitation (CR) programmes, while effective in improving physical and psychological outcomes, often face challenges in engaging individuals with mental health issues, potentially due to avoidance behaviours and perceived barriers.5,6 Home-based CR (HBCR) has emerged as a promising and more accessible alternative that may reduce participation barriers and improve uptake and adherence.7 The REACH-HF (Rehabilitation EnAblement in Chronic Heart Failure) programme is a facilitated, home-based self-management intervention designed to support patients with HF and their caregivers. This secondary analysis by Lambert et al.8 investigates whether elevated baseline depression and anxiety moderate the effects of the REACH-HF intervention on mental health, health-related quality of life (HRQoL), and physical activity. The study analysed pooled data from 263 participants across two randomized controlled trials (REACH-HF for HF with reduced and preserved ejection fraction). Using the Hospital Anxiety and Depression Scale (HADS) with a cut-off ≥ 8 to define elevated symptoms, the authors found that 24% had elevated depression and 33% had elevated anxiety at baseline. Moderation analyses revealed that participants with elevated depression derived significantly greater benefits from the REACH-HF intervention in terms of depressive symptoms, overall HRQoL, and disease-specific HRQoL compared with those without elevated symptoms. Similarly, those with elevated anxiety showed greater improvements in depressive symptoms, HRQoL (physical domain), inactivity, and light physical activity. Notably, no significant effects were observed for anxiety symptoms themselves, suggesting that the intervention may impact related psychological and behavioural domains without directly reducing anxiety scores. These findings challenge the assumption that depression and anxiety inherently limit engagement or benefit from HBCR. Instead, authors suggest that individuals with higher symptom burden may experience greater responsiveness to a flexible, HBCR programme that integrates behavioural activation principles, such as graded task setting and goal-oriented self-management. The results support the integration of routine mental health screening into HF care, as recommended by the 2025 ESC Clinical Consensus Statement on Mental Health and Cardiovascular Disease.9 Furthermore, to address the identified psychological needs, metacognitive therapy (MCT) presents as a particularly suitable, theory-based intervention; empirical support from a randomized controlled trial indicates that MCT significantly improves depression and anxiety symptoms beyond usual care, potentially surpass the efficacy of cognitive behavioural therapy.10 However, further research is needed to determine how best to integrate such therapies within HBCR models for patients with HF. Several limitations warrant consideration. This was a secondary analysis, and subgroup findings should therefore be interpreted cautiously. Mental health status was assessed using HADS cut-offs rather than clinical diagnoses, and analyses were based on complete cases, introducing potential selection bias. Nevertheless, the consistency of findings across multiple outcomes and HF phenotypes strengthens the overall message. From an HBCR implementation perspective, these findings are clinically invaluable. Elevated depressive or anxiety symptoms should not be viewed as a reason to exclude patients from HBCR, but rather as a signal to individualize support intensity, follow-up, and behavioural strategies. Empirical data showed that about 24% of patients still have elevated anxiety after participation in CR, and 13% have depressive symptoms,11 necessitating the integration of evidence-based psychological interventions. Moreover, anxiety and depression among cardiac patients are chronic, fluctuating conditions which require CR to be provided in a more accessible and feasible approach; harnessing technology for home-based delivery is promising.12 At the same time, broader implementation of HBCR requires transparent reporting of safety procedures, monitoring, and escalation pathways. The feasibility of these pathways in routine practice is supported by real-world examples, such as baseline cardiopulmonary testing13 and wearable devices with automated alerts.14 Evidence from remote and digital CR programmes, including those predominantly in coronary and mixed CVD populations, demonstrates very low rates of exercise-related serious adverse events15 and no reported exercise-related deaths when appropriate screening and supervision strategies are applied.16 Economic evaluations further indicate that HBCR is frequently cost-effective compared with centre-based models, supporting scalability and equitable access.17 Technology-assisted CR trials also highlight how structured platforms, self-monitoring, and clinician feedback can enhance self-efficacy and sustained lifestyle change,18 components that may be particularly relevant for HF patients with psychological distress. Taken together, the work by Lambert et al.8 suggests that HBCR can be effectively delivered to patients with HF and elevated psychological symptoms, while pointing to important areas for future programme development, particularly in addressing anxiety and improving consistency in reporting engagement, adherence, and safety. Involvement of mental health professionals is needed as they can play a crucial role as gatekeepers in the development and implementation of HBCR interventions incorporating evidence-based psychological therapies. Chong Mei Sin (Writing—original draft [lead]), Manar Eid (Writing—original draft [supporting], Writing—review & editing [equal]), Jing Jing Su (Conceptualization [supporting], Writing—review & editing [equal]), and Ladislav Batalik (Conceptualization [lead], Writing—review & editing [equal]) This research was funded by the Ministry of Health, Czech Republic, conceptual development of research organization (FNBr, 65269705). This commentary does not contain new data.