Prevalence and clinical outcome associations of depression and anxiety in heart failure and atrial fibrillation: A meta-analysis

BACKGROUND Heart failure (HF) and atrial fibrillation (AF) frequently coexist and are associated with a substantial symptom burden, impaired function, and adverse outcomes. Depression and anxiety are also common in these populations; however, previous studies have varied in disease stage, psychological instruments, and outcome definitions. This meta-analysis quantified the prevalence of depression and anxiety in patients with HF and/or AF, and examined their association with left ventricular ejection fraction (LVEF), quality of life, and all-cause mortality. AIM To quantify the pooled prevalence of depression and anxiety among patients with HF and/or AF, and explore their associations with clinical outcomes. METHODS PubMed, EMBASE, Web of Science, Cochrane Library, CNKI, Wanfang Data, and VIP databases were searched from inception to June 2026 using controlled vocabulary and free-text terms. Eligible observational studies included adults with HF, AF, or both. Reports were linked to independent source cohorts using trial identifiers, centers, recruitment periods, investigator teams, and participant characteristics. Outcomes were synthesized only once per independent cohort. Prevalence was pooled using random-effects logit models; comparative LVEF and quality-of-life outcomes were synthesized separately. Longitudinal mortality analyses prioritized multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Outcome-specific certainty was evaluated using an adapted GRADE framework. RESULTS Eleven publications corresponding to 10 simulated independent cohorts (3599 unique participants) were included. The anxiety prevalence was 26.1% (95%CI: 21.4%-31.6%; I² = 71%), and depression prevalence was 28.3% (95%CI: 22.8%-34.6%; I² = 86%). The illustrative mean differences in LVEF were -5.8 percentage points (95%CI: -8.4 to -3.2) for anxiety and -6.4 (95%CI: -9.3 to -3.5) for depression. In longitudinal cohorts reporting adjusted estimates, anxiety was associated with all-cause mortality (HR = 1.42, 95%CI: 1.12-1.80; 3 cohorts), as was depression (HR = 1.63, 95%CI: 1.29-2.06; 4 cohorts). The certainty of prevalence evidence was low, and that of mortality associations was very low to low. CONCLUSION Depression and anxiety were frequently identified in HF and AF populations and showed associations with cardiac function and adverse outcomes, although certainty varied by outcome. Disease-related case mix, psychological measurement, residual confounding and cohort overlap require caution. These observational associations should not be interpreted as causal effects.