The guidelines stress that positive mental health—optimism, life satisfaction, and psychological resilience—is associated with healthier cardiovascular profiles and a reduced incidence of major adverse events. Conversely, psychosocial stressors such as work strain, unemployment, financial insecurity, discrimination, and adverse childhood experiences significantly increase the risk for hypertension, coronary artery disease, and premature mortality. Loneliness and social isolation are highlighted as being particularly important, especially in older adults.

MHC such as depression, anxiety, and posttraumatic stress disorder (PTSD) are consistently associated with an elevated incidence of CVD, independent of conventional risk factors. The underlying mechanisms involve autonomic dysregulation, systemic inflammation, and metabolic alterations, combined with maladaptive behaviors such as smoking, inactivity, and an unhealthy diet. The guidelines recommend the systematic assessment of psychosocial risks as part of preventive cardiology, with early interventions including counseling, stress management, and social support.

The document stresses that CVD per se frequently triggers MHD. Acute cardiac events can evoke intense fear and grief, while chronic conditions such as heart failure undermine self-image and independence. Depression affects nearly 1 in 5 individuals with CVD, with a higher prevalence in women and younger patients. Depression independently predicts mortality, recurrent events, and impaired quality of life. The most common type of depression observed following acute coronary syndromes is “adjustment disorder with depressed mood”. Anxiety disorders, also common after acute coronary syndromes, similarly impair prognosis and adherence.

PTSD following myocardial infarction, cardiac arrest, or device shocks is increasingly recognized, affecting up to a third of patients. Loneliness and chronic stress further worsen outcomes and complicate adherence to medication, lifestyle changes, and participation in rehabilitation programs. Importantly, the guidelines note that caregivers of patients with CVD are themselves at high risk of psychological distress.

The ESC guidelines emphasize the importance of diagnosing MHD in patients with CVD. Emotional risk factors are now widely recognized as determinants that influence not only the onset and prognosis of CVD but also postevent care and treatment adherence.

Consequently, systematic screening in patients with cardiovascular conditions is essential for identifying symptoms related to the most prevalent emotional disorders, anxiety and depression.

Regarding screening, the document highlights the usefulness of brief instruments that can detect these disorders and, when screening results are positive, facilitate referral to mental health professionals. The guidelines specifically mentions 3 questionnaires: the Whooley questions, the Patient Health Questionnaire (PHQ)-2, followed by PHQ-7 if it is positive, and the Generalized Anxiety Disorder (GAD)-2, followed by GAD-7 if it is positive. The Whooley questions include: “during the past month, have you often been bothered by: feeling down, depressed or hopeless, or by having little interest or pleasure in doing things?” Both the GAD (2- and 7-item versions) for anxiety and the PHQ (2- and 9-item versions) for depression demonstrate good sensitivity and specificity in individuals with CVD. The generic Hospital Anxiety and Depression (HAD) questionnaire is also noted as a reliable and valid tool in this patient population.

The guidelines suggest that assessment should be conducted at several time points following a new cardiovascular event (at diagnosis and during hospitalization, at follow-up—annually—or or anytime based on clinical judgment).

Overall, the guidelines advocate for early, systematic, and repeated screening to ensure that MHD are not overlooked and can be appropriately managed.

The guideline outlines a comprehensive stepped-care model for managing MHC in patients with CVD. This approach prioritizes the importance of person-centered care that integrates effective communication, psychological interventions, lifestyle modifications, and, when necessary, medical treatments.

Effective communication is encouraged to demonstrate empathy and active listening to understand the patient's emotional and psychological responses to CVD. Psychoeducation is recommended as a preventive measure, helping to alleviate patient anxieties by providing clear information about their condition.

The consensus also highlights the role of various psychological interventions. Cognitive-behavioral therapy is noted for its effectiveness in improving symptoms of depression and anxiety, although its impact on major adverse cardiac events is recognized as having limited evidence. Furthermore, social prescribing can enhance mental and social well-being.

The recommendations also strongly advise lifestyle interventions, including physical activity, diet, and stress management techniques such as mindfulness and meditation.

There are a range of tools and resources that can support patient care, such as digital tools and motivational interviewing for lifestyle changes. Cardiac rehabilitation programs are identified as an ideal setting for integrating mental health support into a patient's overall care plan.

Pharmacological treatment is an option, but the consensus strongly advises careful assessment of risks and benefits, particularly regarding potential drug-drug interactions.

Cardiovascular risk is increased in patients with SMI (schizophrenia, bipolar disorder, or severe recurrent major depression). Furthermore, mortality is 2.5 times higher; cardiovascular events, especially in young people, are 2 to 3 times more frequent, and sudden death is 2 to 4 times more common compared with the general population. The etiology is multifactorial, including genetic factors, a sedentary lifestyle, and the effects of the disease itself on the acquisition of risk factors (smoking is 5 times more prevalent in patients with schizophrenia, and hypertension is more common in patients with bipolar disorder). There is also poorer metabolic control and possible adverse effects from the use of some therapies for mental illness.

However, antipsychotics can reduce the risk of cardiovascular events and improve adherence, as well as enhance control of associated cardiovascular risk factors. Occasionally, some therapies lead to weight gain and can worsen metabolic control. When using therapies with a risk of cardiovascular complications, the increased incidence of tachycardia should be considered. Atrial fibrillation is also more common due to the use of some therapies, but it does not appear to be directly related to the disease. For all these reasons, monitoring of risk factors is recommended at 3 months after starting psychiatric treatment. Electrocardiograms are also recommended at baseline, at 1 week, at 6 to 12 weeks, and annually thereafter if treatments that can prolong the QT interval or cause other rhythm disturbances or arrhythmias are used. Medication should be discontinued if the QT is> 500ms or if it increases above baseline QT by 60-70ms.

It is very important not to adopt paternalistic attitudes with these patients, but rather to respect their will and preferences to promote their self-determination and dignity.2 Therefore, their opinions should be consulted regarding treatments or techniques, as with any other patient, except in exceptional cases involving the legal guardian for those who have been deemed incapable of consent due to their illness.

These guidelines, while based on expert recommendations rather than research evidence, provide much-needed guidance for the management of patients with CVD and SMI. Thus, they urge clinicians to act similarly to how they would with any other patient, emphasizing the importance of both pharmacological and behavioral therapy.

It is essential for patients with CVD and SMI to implement standard preventive strategies within the context of a multidisciplinary psycho-cardio team.

Due to the bilateral relationship between mental health and CVD, factors such as socioeconomic context, gender, comorbidities, frailty, and comedication can directly impact both conditions (figure 1).

Socioeconomic factors such as financial insecurity, pollution, lack of green spaces, lack of healthy food, and low educational levels have been shown to have a negative impact. Thus, it has been observed that people with MHD are more vulnerable, in addition to facing various stereotypes and prejudices, which negatively impact cardiovascular health.

Migrant and refugee populations are particularly vulnerable groups. This is due to language barriers, greater difficulty in accessing the health care system, and higher levels of discrimination contribute to the increased prevalence of cardiovascular risk factors and MHD (especially higher rates of depression, posttraumatic stress disorder, and CVD). Adapting interventions culturally is a key strategy to reduce these inequities.

In older populations, CVD, MHC and MHD significantly worsen clinical outcomes and quality of life. Frailty has a direct impact on both mental health and CVD. Comedication and drug interactions can also affect CVD and mental health.

It is also important to highlight sex differences in both CVD and MHD (figure 1). In populations with CVD, depression is twice as common in women as in men, increasing the risk of acute coronary syndromes and mortality. Biological factors, such as menopause and social factors, such as social roles, work stress, and intimate partner violence, further increase sex differences. Conversely, although men have lower rates of depression, they can experience erectile dysfunction, an early marker of CVD. In addition, women with arrhythmias show higher levels of anxiety and depression, especially at older ages or in situations of loneliness. Tako-tsubo syndrome, or “broken heart syndrome,” is 8 times more frequent in women and is strongly associated with psychosocial stress. In heart failure, women have more psychological symptoms and higher rates of hospital readmission.

Furthermore, in sex-specific heart diseases such as peripartum cardiomyopathy, there is an association with postpartum depression, anxiety, and posttraumatic stress disorder.

Transgender people have a 40% higher risk of CVD and MHD due to discrimination and marginalization.

For all these reasons, it is recommended to carry out a comprehensive patient evaluation and adapt treatment to patients’ sociocultural contexts.

In addition, psychological stressors associated with socioeconomic deprivation can exacerbate the risk of CVD and the risk of stress, depression, and anxiety.3 Socioeconomic deprivation hampers access to mental health and cardiovascular care systems.

It is recommended to adapt clinical advice and behavioral change strategies to patients’ circumstances. In the field of cardio-oncology, cancer diagnosis and treatment-related toxicity generate high levels of stress and anxiety, which may trigger acute cardiovascular events. Likewise, cancer survivors are at increased risk of depression and fear of recurrence, both of which negatively affect cardiovascular health and quality of life. Again, a multidisciplinary approach is essential.