Cognitive Deficits and Related Brain Lesions in Patients With Chronic Heart Failure

Long-term cognitive and brain morphologic changes in chronic heart failure: Results of the Cognition.Matters-HF study

AIMS

Cognitive impairment (CI) is a common, yet frequently unrecognized co-morbidity in chronic heart failure (HF). We quantified trajectories of cognitive performance, brain volume, and related clinical outcome over a time course of 6 years.

METHODS AND RESULTS

The Cognition.Matters-HF cohort study recruited patients with stable HF of any aetiology and severity. Beyond cardiological assessment, the workup included cognitive testing and brain magnetic resonance imaging (MRI). Of 148 recruited patients, 70% exhibited CI at baseline. During the median follow-up time of 69 months (quartiles: 68, 70), indicators of HF severity remained essentially unaltered. CI was also stable, with the exception of intensity of attention, where age-adjusted t-scores decreased from 42 (38, 46) to 38 (34, 44; P < 0.001). Complete sets of four serial brain MRI scans were available in 47 patients (32% of total sample). Total brain volume shrank by 0.4% per year, from 1103 (1060, 1143) cm3 to 1078 (1027, 1117) cm3, which was within limits observed in non-diseased ageing individuals. During follow-up, 29 study participants (20%) died, and 26 (18%) were at least once hospitalized due to worsening HF. The presence of CI was not associated with overall (P = 0.290) or hospitalization-free (P = 0.450) survival.

CONCLUSIONS

In patients with stable HF patients receiving guideline-directed pharmacologic treatment and regular medical care, the presence of CI did not affect overall and hospitalization-free 6-year survival. The loss of brain parenchyma observed in patients with stable HF did not exceed that of normal ageing.

Aberrant cortical morphology patterns are associated with cognitive impairment in patients with chronic heart failure

A mounting body of evidences suggests that patients with chronic heart failure (HF) frequently experience cognitive impairments, but the neuroanatomical mechanism underlying these impairments remains elusive. In this retrospective study, 49 chronic HF patients and 49 healthy controls (HCs) underwent brain structural MRI scans and cognitive assessments. Cortical morphology index (cortical thickness, complexity, sulcal depth and gyrification) were evaluated. Correlations between cortical morphology and cognitive scores and clinical variables were explored. Logistic regression analysis was employed to identify risk factors for predicting 3-year major adverse cardiovascular events. Compared with HCs, patients with chronic HF exhibited decreased cognitive scores (p < .001) and decreased cortical thickness, sulcal depth and gyrification in brain regions involved cognition, sensorimotor, autonomic nervous system (family-wise error correction, all p values <.05). Notably, HF duration and New York Heart Association (NYHA) demonstrated negative correlations with abnormal cortex morphology, particularly HF duration and thickness in left precentral gyrus (r = -.387, p = .006). Cortical morphology characteristics exhibited positive associations with global cognition, particularly cortical thickness in left pars opercularis (r = .476, p < .001). NYHA class is an independent risk factor for adverse outcome (p = .001). The observed correlation between abnormal cortical morphology and global cognition suggested that cortical morphology may serve as a promising imaging biomarker and provide insights into neuroanatomical underpinnings of cognitive impairment in patients with chronic HF.

Statins and risks of dementia among patients with heart failure: a population-based retrospective cohort study in Hong Kong

Background

Heart failure (HF) and dementia frequently co-exist with shared pathological mechanisms and risk factors. Our study aims to investigate the association between statin therapy and the risks of dementia and its subtypes among patients with HF.

Methods

The Hong Kong Clinical Data Analysis and Reporting System database was interrogated to identify patients with incident HF diagnosis from 2004 to 2018, using ICD 9/ICD 10 codes. Inverse probability of treatment weighting (IPTW) was used to balance baseline covariates between statin users (N = 54,004) and non-users (N = 50,291). The primary outcomes were incident all-cause dementia, including subtypes of Alzheimer's disease, vascular dementia, and unspecified dementia. Cox proportional-hazard model with competing risk regression was performed to estimate the sub-distribution hazards ratio (SHR) with corresponding 95% confidence intervals (CI) of the risks of all-cause dementia and its subtypes that are associated with statin use.

Findings

Of all eligible patients with HF (N = 104,295), the mean age was 74.2 ± 13.6 years old and 52,511 (50.3%) were male. Over a median follow-up of 9.9 years (interquartile range [IQR]: 6.4-13.0), 10,031 (9.6%) patients were diagnosed with dementia, among which Alzheimer's disease (N = 2250), vascular dementia (N = 1831), and unspecified dementia (N = 5950) were quantified separately. After IPTW, statin use was associated with a 20% lower risk of incident dementia compared with non-use (multivariable-adjusted SHR 0.80, 95% CI 0.76-0.84). Stratified by subtypes of dementia, statin use was associated with a 28% lower risk of Alzheimer's disease (SHR 0.72, 95% CI 0.63-0.82), 18% lower risk of vascular dementia (SHR 0.82, 95% CI 0.70-0.95), and a 20% lower risk of unspecified dementia (SHR 0.80, 95% CI 0.75-0.85).

Interpretation

In patients with HF, statin use was associated with a significantly lower risk of all-cause dementia and its subtypes, including Alzheimer's disease, vascular dementia, and unspecified dementia. Both randomized trials and experimental studies to validate the potential neuroprotective effect of statin are warranted.

Funding

No funding was provided for this study.

Cognitive impairment in heart failure patients: association with abnormal circadian blood pressure rhythm: a review from the HOPE Asia Network

Cognitive impairment (CI) is frequently a comorbid condition in heart failure (HF) patients, and is associated with increased cardiovascular events and death. Numerous factors contribute to CI in HF patients. Decreased cerebral blood flow, inflammation, and activation of neurohumoral factors are all thought to be factors that exacerbate CI. Hypoperfusion of the brain due to decreased systemic blood flow, cerebral venous congestion, and atherosclerosis are the main mechanism of CI in HF patients. Abnormal circadian BP rhythm is one of the other conditions associated with CI. The conditions in which BP does not decrease sufficiently or increases during the night are called non-dipper or riser BP patterns. Abnormal circadian BP rhythm worsens CI in HF patients through cerebral congestion during sleep and atherosclerosis due to pressure overload. Interventions for CI in HF patients include treatment for HF itself using cardiovascular drugs, and treatment for fluid retention, one of the causes of abnormal circadian rhythms. Proposed pathways of cognitive impairment in heart failure through abnormal circadian blood pressure rhythm.

Associations of dietary patterns and perceived stress with memory deficits in patients with heart failure

This study aimed to examine the relationships between dietary patterns and perceived stress with memory deficits in 291 patients with heart failure aged 45-85 years. A total of 142 (48.8%) patients reported memory deficit. Three dietary patterns were identified by K-means clustering: nut-fruit-dairy, meat-processed, and traditional (high intake of cereals) diets. Compared to the traditional diet, the nut-fruit-dairy diet and meat-processed diet were associated with lower levels of deficits in short-term memory, delayed memory, and overall memory. What's more, perceived stress was positively associated with deficits in short-term memory and overall memory, but the association was only found in patients adhering to the traditional diet using stratified analyses. Our findings suggest that adhering to a healthy diet may be conducive to improving deficits in short-term memory, delayed memory, and overall memory, while also buffering the adverse association between perceived stress and deficits in short-term memory and overall memory.

Cognitive impairment is associated with BDNF-TrkB signaling mediating synaptic damage and reduction of amino acid neurotransmitters in heart failure

Heart failure (HF) is often accompanied by cognitive impairment (CI). Brain-derived neurotrophic factor (BDNF) deficiency is closely associated with CI. However, the role and mechanism of BDNF in HF with CI is still not fully understood. Here, the case-control study was designed including 25 HF without CI patients (HF-NCI) and 50 HF with CI patients (HF-CI) to investigate the predictive value of BDNF in HF-CI while animal and cell experiments were used for mechanism research. Results found that BDNF levels in serum neuronal-derived exosomes were downregulated in HF-CI patients. There was no significant difference in serum BDNF levels among the two groups. HF rats showed obvious impairment in learning and memory; also, they had reduced thickness and length of postsynaptic density (PSD) and increased synaptic cleft width. Expression of BDNF, TrkB, PSD95, and VGLUT1 was significantly decreased in HF rats brain. In addition, compared with sham rats, amino acids were significantly reduced with no changes in the acetylcholine and monoamine neurotransmitters. Further examination showed that the number of synaptic bifurcations and the expression of BDNF, TrkB, PSD95, and VGLUT1 were all decreased in the neurons that interfered with BDNF-siRNA compared with those in the negative control neurons. Together, our results demonstrated that neuronal-derived exosomal BDNF act as effective biomarkers for prediction of HF-CI. The decrease of BDNF in the brain triggers synaptic structural damage and a decline in amino acid neurotransmitters via the BDNF-TrkB-PSD95/VGLUT1 pathway. This discovery unveils a novel pathological mechanism underlying cognitive impairment following heart failure.

Recent Trends in Heart Failure and Concomitant Depression, A Retrospective Study

Depression has been shown to predispose to poorer prognosis and outcomes in patients with heart failure, including rehospitalization, poor functional status, and mortality. Our study aimed to decipher the recent trends in hospitalization and in-hospital mortality attributable to heart failure patients with depression in the United States. We analyzed data from the Nationwide Inpatient Sample (NIS) from 2016 to 2020. We obtained data from patients aged ≥18 years diagnosed with heart failure and depression. Death was defined within the NIS as in-hospital mortality. Diagnoses and comorbidities were identified using codes from the International Classification of Disease 10th edition. We used the chi-square test to compare baseline characteristics. Our primary outcome of interest was in-hospital mortality. The secondary outcome was in-hospital events. We studied a total of 726,193 hospitalizations of patients with heart failure and concomitant depression. The annual number of hospitalizations increased from (126,317 to 147,798) over the study period. The most common age groups were 65-74 years (16.06%) followed by 55-64 years (14.62%). The number of hospitalizations was highest among whites (77.02%), followed by blacks (13.03%) (p < 0.0001). Whites had the highest average in-hospital mortality (61.17%), followed by blacks (23.63%). Overall, racial trends of in-hospital mortality among patients remained similar from 2016 to 2020 (P = 0.8910). Over the study period, average hospitalization-related costs increased significantly ($34,954.00 to $44,151.50) (P < 0.0001); however, the median length of hospital stay remained similar (4-5 days). Rates of in-hospital events such as stroke, arrhythmia, and respiratory failure increased significantly (P < 0.0001). Hospitalization increased, while in-hospital mortality remained variable over the study period. The proportion of patients with in-hospital events such as stroke, arrhythmia, respiratory failure increased significantly over the study period.

Internal carotid artery blood flow and pulsatility index in cognitively impaired people with chronic heart failure

AIMS

Mild cognitive impairment and dementia are common and serious co-morbidities in people with chronic heart failure (HF) as they increase hospitalization rates, mortality and health care costs. Upon other factors, dysregulated cerebral perfusion might contribute to brain pathology. We aimed to evaluate the association of non-invasively measured blood flow (BF) and pulsatility index (PI) of the internal carotid artery (ICA) with (i) chronic HF parameters, (ii) brain morphologic measures and (iii) cognitive impairment.

METHODS AND RESULTS

This post-hoc analysis of the observational, prospective Cognition.Matters-HF study included 107 chronic HF patients without atrial fibrillation or carotid artery stenosis (aged 63 ± 10 years; 19% women). Using extracranial sonography, we measured ICA-BF and ICA-PI 1.5 cm distal of the carotid bifurcation. Brain magnetic resonance imaging was performed on a 3-Tesla scanner to quantify cerebral atrophy, hippocampal atrophy and white matter hyperintensities. Extensive neuropsychological testing tested the cognitive domains intensity of attention, visual/verbal memory and executive function (including its subdomains selectivity of attention, visual/verbal fluency and working memory) using a comprehensive test battery. (i) Neither ICA-BF (median 630 (quartiles 570, 700) mL/min) nor ICA-PI (1.05 (0.96. 1.23)) related to left ventricular ejection fraction, left atrial volume index or NT-proBNP. (ii) Higher ICA-PI (r = 0.25; P = 0.011), but not ICA-BF (r = 0.08; P = 0.409), associated with increased volume of white matter hyperintensities beyond ageing, while neither ICA-PI nor ICA-BF related to cerebral or hippocampal atrophy indices. (iii) ICA-BF, but not ICA-PI, positively correlated with age-adjusted T-scores of executive function (r = 0.38; P < 0.001) and its subdomains working memory (r = 0.32; P < 0.001) and visual/verbal fluency (r = 0.32; P < 0.001). In a multivariate linear model of executive function, only ICA-BF (T = 3.79; P < 0.001), but not HF or magnetic resonance imaging parameters, remained a significant correlate of executive function.

CONCLUSIONS

ICA-BF and ICA-PI, measured in broadly available extracranial sonography, independently related to measures of functional and structural brain changes in people with chronic HF, respectively. Due to limitations of this cross-sectional approach without a healthy control group, larger controlled longitudinal studies are needed to further elucidate the role of ICA-BF dysregulation and its implication for clinical care in this vulnerable cohort.

App-based assessment of memory functions in patients after transfemoral aortic valve replacement

BACKGROUND

Transfemoral aortic valve replacement (TAVR) is the standard treatment for elderly patients with aortic valve stenosis. Although safe and well-established, there is a risk of intraprocedural hemodynamic instability and silent cerebral embolism, which can lead to a decline in neurocognitive function and dementia. In clinical practice, comprehensive cognitive testing is difficult to perform. AI-assisted digital applications may help to optimize diagnosis and monitoring.

METHODS

Neurocognitive function was assessed by validated psychometric tests using "∆elta -App", which uses artificial intelligence and computational linguistic methods for extraction and analysis. Memory function was assessed using the 'Consortium to Establish a Registry for Alzheimer's Disease' (CERAD) word list and digit span task (DST) before TAVR and before hospital discharge. The study is registered in the German Register of Clinical Trials (https://drks.de/search/de/trial/DRKS00020813).

RESULTS

From October 2020 until March 2022, 141 patients were enrolled at University Hospital Heart Centre Brandenburg. Mean age was 81 ± 6 years, 42.6% were women. Time between the pre- and post-interventional test was on average 6 ± 3 days. Memory function before TAVR was found to be below average in relation to age and educational level. The pre-post TAVR comparison showed significant improvements in the wordlist repeat, P < 0.001 and wordlist recall test of CERAD, P < 0.001. There were no changes in the digital span test.

CONCLUSIONS

Despite impaired preoperative memory function before TAVR, no global negative effect on memory function after TVAR was detected. The improvements shown in the word list test should be interpreted as usual learning effects in this task.

Executive Attentional Dyscontrol as a Core Cognitive and Behavioral Feature of Individuals with Obesity and Cardiovascular Disease: A Cross-Sectional Investigation

Executive attention as a frontal domain ability that is effective in potentially blocking distracting information, reconciling conflicts among simultaneous attentional demands, and regulating impulsive behavior may be impaired in individuals with obesity and cardiovascular disease (CVD). This study aimed (i) to explore the presence of selected cognitive (global cognitive impairment, sensitivity to interference, and attention) and psychological (quality of life, depression, anxiety, and impulsivity) dimensions and (ii) to examine the interactive relationship between attentional dyscontrol-both as a psychological and as a cognitive measure-and the above-mentioned variables in a sample of patients with CVD attending a cardiac rehabilitation program across different body mass index (BMI) levels. Clinical information of 104 patients with CVD was retrospectively collected. Participants were classified into three groups according to their BMI as follows: normal weight (NW = 30), overweight (OW = 19), and obese (OB = 55). Individuals with CVD and a higher BMI showed problems in controlling executive attention-through both neuropsychological and behavioral measures. Specifically, OB patients demonstrated reduced sensitivity to cognitive interference, lower capabilities in divided attention during visual-tracking tasks, and greater impulsivity compared to NW patients. This behavioral characteristic was also found to be correlated with higher levels of anxiety and depression and a lower quality of life. Implications for cognitive rehabilitation were discussed to offer directions for better management of patients with CVD and obesity.

Cognitive Impairment in Patients With Cardiac Disease: Implications for Clinical Practice

Cognitive impairment is common in patients with cardiovascular disease. One in 3 patients presenting at cardiology clinics have some degree of cognitive impairment, depending on the cardiac condition, comorbidities, and age. In up to half of these cases cognitive impairment may go unrecognized; however, it may affect self-management and treatment adherence. The high prevalence of cognitive impairment in patients with cardiac disease is likely due to shared risk factors, as well as direct consequences of cardiac dysfunction on the brain. Moreover, cardiac interventions may have beneficial as well as adverse effects on cognitive functioning. In this review, we describe prevalence and risk factors for cognitive impairment in patients with several common cardiac conditions: heart failure, coronary artery disease, and aortic valve stenosis. We discuss the potential effects of guideline-based treatments on cognition and identify open questions and unmet needs. Given the high prevalence of unrecognized cognitive impairment in cardiac patients, we recommend a stepwise approach to improve detection and management of cognitive impairment.

The pathophysiology of cognitive impairment in individuals with heart failure: a systematic review

Introduction

Heart Failure and Cognitive Impairment are both on the rise and shown to be interlinked. Despite existing reviews delineating a relationship between heart failure and cognitive impairment, the underlying pathophysiology is not researched in great depth. Current literature proposed varying pathophysiological mechanisms and focused heavily on the prevalence of cognitive impairment and treatment interventions such as cardiac rehabilitation. In view of the limitations of previous reviews, this systematic review summarized the best existing evidence concerning different pathophysiological mechanisms behind cognitive impairment in individuals with heart failure.

Methods

Eight electronic databases including PubMed, Cochrane Library and EMBASE etc., two grey literatures (ProQuest Theses and Dissertations and Mednar) and hand-searching of references were performed using specific criteria regarding population, exposures and outcomes, before duplicate removal and screening using Endnote and Rayyan respectively. JBI critical appraisal tools for non-randomized studies were used for appraisal. Data extraction was performed using two modified forms from JBI Manual for Evidence Synthesis.

Results

Narrative synthesis was performed to summarize the data from 32 studies. There were three main themes-cognitive impairment due to changes in the brain: brain atrophy, alterations in grey matter and white matter, cerebral alterations, pathway or axis changes, neuroinflammation and hippocampal gene changes; cognitive impairment due to changes in the heart or systemic circulation: inflammation, oxidative stress and changes in serum biomarkers or proteins and the riser rhythm; cognitive impairment due to changes in both the brain and the heart, with seven studies obtaining negative results. There are some limitations such as having non-human studies and large numbers of cross-sectional studies etc.

Discussion

Considering the findings, future research should examine the bi-directional relationship between the brain and the heart as most of the existing research is about the effect of the heart on the brain. By understanding the different pathophysiological mechanisms, the management and prognosis of heart failure patients will be ameliorated. Interventions that slow down or even reverse cognitive impairment can be explored so that these two common issues will not add to the already aggravating disease burden.

Systematic Review Registration

This review is registered under PROSPERO. Identifier: CRD42022381359.

Depression in Heart Failure with Reduced Ejection Fraction, an Undervalued Comorbidity: An Up-To-Date Review

Introduction: Depression is a common and severe comorbidity among individuals with heart failure (HF). Up to a third of all HF patients are depressed, and an even higher proportion have symptoms of depression. Aim: In this review, we evaluate the relationship between HF and depression, explain the pathophysiology and epidemiology of both diseases and their relationship, and highlight novel diagnostic and therapeutic options for HF patients with depression. Materials and Methods: This narrative review involved keyword searches of PubMed and Web of Science. Review search terms included ["Depression" OR "Depres*" OR "major depr*"] AND ["Heart Failure" OR "HF" OR "HFrEF" OR "HFmrEF" OR "HFpEF" OR "HFimpEF"] in all fields. Studies included in the review met the following criteria: (A) published in a peer-reviewed journal; (B) described the impact of depression on HF and vice versa; and (C) were opinion papers, guidelines, case studies, descriptive studies, randomized control trials, prospective studies, retrospective studies, narrative reviews, and systematic reviews. Results: Depression is an emergent HF risk factor and strongly relates with worse clinical outcomes. HF and depression share multiple pathways, including platelet dis-reactivity, neuroendocrine malfunction, inappropriate inflammation, tachi-arrhythmias, and frailty in the social and community setting. Existing HF guidelines urge evaluation of depression in all HF patients, and numerous screening tools are available. Depression is ultimately diagnosed based on DSM-5 criteria. There are both non-pharmaceutical and pharmaceutical treatments for depression. Regarding depressed symptoms, non-pharmaceutical treatments, such as cognitive-behavioral therapy and physical exercise, have shown therapeutic results, under medical supervision and with an effort level adapted to the patient's physical resources, together with optimal HF treatment. In randomized clinical studies, selective serotonin reuptake inhibitors, the backbone of antidepressant treatment, did not demonstrate advantage over the placebo in patients with HF. New antidepressant medications are currently being studied and could provide a chance to enhance management, treatment, and control of depression in patients with HF. Conclusions: Despite the substantial link between depression and HF, their combination is underdiagnosed and undertreated. Considering the hopeful yet unclear findings of antidepressant trials, further research is required to identify people who may benefit from antidepressant medication. The goal of future research should be a complete approach to the care of these patients, who are anticipated to become a significant medical burden in the future.

Heart failure and cognitive impairment: A narrative review of neuroimaging mechanism from the perspective of brain MRI

Both heart failure (HF) and cognitive impairment (CI) have a significant negative impact on the health of the elderly individuals. Magnetic resonance imaging (MRI) can non-invasively detect functional and structural variations in the heart and brain, making it easier to explore the connection between the heart and brain. According to neuroimaging studies, HF patients have a higher chance of developing CI because they have a variety of different types of brain injuries. To examine how HF and CI are influenced by one another, English-language literature was searched in the Web of Science, PubMed EMBASE (OVID), PsycInfo, and Scopus databases. The search terms included “high-frequency,” “brain function,” “brain injury,” “cognition,” “cognitive impairment,” and “magnetic resonance imaging.” Normal brain function is typically impaired by HF in the form of decreased cerebral perfusion pressure, inflammation, oxidative stress, and damage to the BBB, resulting in CI and subsequent HF. Early pathophysiological alterations in patients’ brains have been widely detected using a range of novel MRI techniques, opening up new avenues for investigating the connection between HF and CI. This review aims to describe the pathogenesis of HF with CI and the early diagnostic role of MRI in the heart-brain domain.

Association Between Cardiovascular Disease and Cognitive Dysfunction in Breast Cancer Survivors

BACKGROUND

Breast cancer survivors (BCSs) may have a greater risk for cardiovascular disease (congestive heart failure and hypertension), which in turn, can affect cognitive dysfunction, a frequent, bothersome, and potentially debilitating symptom.

OBJECTIVE

The purpose of this study was to examine the relationship of cardiovascular disease on cognitive function in BCSs.

METHODS

Baseline data from a double-blind randomized controlled trial for cognitive training of BCSs were examined. Early-stage BCS (stages I-IIIA) who were 21 years or older, completed adjuvant therapy (≥6 months), and reported cognitive concerns completed questionnaires and a brief neuropsychological assessment, including tests of memory, attention and working memory, speed of processing, and verbal fluency. Descriptive statistics, Pearson correlation coefficient, and separate linear regression models for each cognitive domain were conducted.

RESULTS

Forty-seven BCSs, who were on average 57.3 (SD, 8.1) years old, were 58% White, and had some college education (75%), completed the study. Furthermore, 44.7% of the BCS had cardiovascular disease (congestive heart failure or hypertension). In linear regression models, cardiovascular disease was significantly related to immediate and delayed memory and attention and working memory ( P < .01-.05).

CONCLUSION

Breast cancer survivors who have cardiovascular disease may also be at a greater risk for cognitive dysfunction post treatment. Results from this study inform both clinical practice and future research, specifically by examining the intersection between cancer, cardiovascular disease (cardiotoxicity), and cognition.

IMPLICATIONS FOR PRACTICE

Nurses should be aware that BCSs with co-occurring cardiovascular disease are at a higher risk for cognitive dysfunction and work within the multidisciplinary team to optimize BCS health and function.

Chronic Neuroinflammation and Cognitive Decline in Patients with Cardiac Disease: Evidence, Relevance, and Therapeutic Implications

Acute and chronic cardiac disorders predispose to alterations in cognitive performance, ranging from mild cognitive impairment to overt dementia. Although this association is well-established, the factors inducing and accelerating cognitive decline beyond ageing and the intricate causal pathways and multilateral interdependencies involved remain poorly understood. Dysregulated and persistent inflammatory processes have been implicated as potentially causal mediators of the adverse consequences on brain function in patients with cardiac disease. Recent advances in positron emission tomography disclosed an enhanced level of neuroinflammation of cortical and subcortical brain regions as an important correlate of altered cognition in these patients. In preclinical and clinical investigations, the thereby involved domains and cell types of the brain are gradually better characterized. Microglia, resident myeloid cells of the central nervous system, appear to be of particular importance, as they are extremely sensitive to even subtle pathological alterations affecting their complex interplay with neighboring astrocytes, oligodendrocytes, infiltrating myeloid cells, and lymphocytes. Here, we review the current evidence linking cognitive impairment and chronic neuroinflammation in patients with various selected cardiac disorders including the aspect of chronic neuroinflammation as a potentially druggable target.

Cognitive functions and patterns of brain activity in patients after simultaneous coronary and carotid artery revascularization

Background

On-pump coronary artery bypass grafting (CABG) is associated with a high risk of neurological complications in patients with severe carotid stenosis. Moreover, early postoperative cognitive dysfunction (POCD) incidence remains high in patients undergoing simultaneous coronary and carotid surgery. Recent studies have shown that even moderate carotid stenosis (≥50%) is associated with postoperative cognitive decline after CABG. Data on brain health in the postoperative period of simultaneous coronary and carotid surgery are limited.

Objectives

This study aimed to analyze early postoperative changes in the cognitive function and patterns of brain electrical activity in patients after simultaneous coronary and carotid artery revascularization.

Materials and methods

Between January 2017 and December 2020, consecutive patients were assigned to on-pump CABG with or without carotid endarterectomy (CEA) according to clinical indications. An extended neuropsychological and electroencephalographic (EEG) assessment was performed before surgery and at 7-10 days after CABG or CABG + CEA.

Results

A total of 100 patients were included [median age 59 (55; 65), 95% men, MMSE 27 (26; 28)], and among these, 46 underwent CEA. POCD was diagnosed in 29 (63.0%) patients with CABG + CEA and in 32 (59.0%) patients with isolated CABG. All patients presented with a postoperative theta power increase. However, patients with CABG + right-sided CEA demonstrated the most pronounced theta power increase compared to patients with isolated CABG.

Conclusion

The findings of our study show that patients with CABG + CEA and isolated CABG have comparable POCD incidence; however, patients with CABG + right-sided CEA presented with lower brain activity.

Altered brain networks and connections in chronic heart failure patients complicated with cognitive impairment

Objective

Accumulating evidence shows that cognitive impairment (CI) in chronic heart failure (CHF) patients is related to brain network dysfunction. This study investigated brain network structure and rich-club organization in chronic heart failure patients with cognitive impairment based on graph analysis of diffusion tensor imaging data.

Methods

The brain structure networks of 30 CHF patients without CI and 30 CHF patients with CI were constructed. Using graph theory analysis and rich-club analysis, changes in global and local characteristics of the subjects' brain network and rich-club organization were quantitatively calculated, and the correlation with cognitive function was analyzed.

Results

Compared to the CHF patients in the group without CI group, the CHF patients in the group with CI group had lower global efficiency, local efficiency, clustering coefficient, the small-world attribute, and increased shortest path length. The CHF patients with CI group showed lower nodal degree centrality in the fusiform gyrus on the right (FFG.R) and nodal efficiency in the orbital superior frontal gyrus on the left (ORB sup. L), the orbital inferior frontal gyrus on the left (ORB inf. L), and the posterior cingulate gyrus on the right (PCG.R) compared with CHF patients without CI group. The CHF patients with CI group showed a smaller fiber number of edges in specific regions. In CHF patients with CI, global efficiency, local efficiency and the connected edge of the orbital superior frontal gyrus on the right (ORB sup. R) to the orbital middle frontal gyrus on the right (ORB mid. R) were positively correlated with Visuospatial/Executive function. The connected edge of the orbital superior frontal gyrus on the right to the orbital inferior frontal gyrus on the right (ORB inf. R) is positively correlated to attention/calculation. Compared with the CHF patients without CI group, the connection strength of feeder connection and local connection in CHF patients with CI group was significantly reduced, although the strength of rich-club connection in CHF patients complicated with CI group was decreased compared with the control, there was no statistical difference. In addition, the rich-club connection strength was related to the orientation (direction force) of the Montreal cognitive assessment (MoCA) scale, and the feeder and local connection strength was related to Visuospatial/Executive function of MoCA scale in the CHF patients with CI.

Conclusion

Chronic heart failure patients with CI exhibited lower global and local brain network properties, reduced white matter fiber connectivity, as well as a decreased strength in local and feeder connections in key brain regions. The disrupted brain network characteristics and connectivity was associated with cognitive impairment in CHF patients. Our findings suggest that impaired brain network properties and decreased connectivity, a feature of progressive disruption of brain networks, predict the development of cognitive impairment in patients with chronic heart failure.

Profiles of cognitive impairment in chronic heart failure-A cluster analytic approach

Background

Cognitive impairment is a major comorbidity in patients with chronic heart failure (HF) with a wide range of phenotypes. In this study, we aimed to identify and compare different clusters of cognitive deficits.

Methods

The prospective cohort study "Cognition.Matters-HF" recruited 147 chronic HF patients (aged 64.5 ± 10.8 years; 16.2% female) of any etiology. All patients underwent extensive neuropsychological testing. We performed a hierarchical cluster analysis of the cognitive domains, such as intensity of attention, visual/verbal memory, and executive function. Generated clusters were compared exploratively with respect to the results of cardiological, neurological, and neuroradiological examinations without correction for multiple testing.

Results

Dendrogram and the scree plot suggested three distinct cognitive profiles: In the first cluster, 42 patients (28.6%) performed without any deficits in all domains. Exclusively, the intensity of attention deficits was seen in the second cluster, including 55 patients (37.4%). A third cluster with 50 patients (34.0%) was characterized by deficits in all cognitive domains. Age (p = 0.163) and typical clinical markers of chronic HF, such as ejection fraction (p = 0.222), 6-min walking test distance (p = 0.138), NT-proBNP (p = 0.364), and New York Heart Association class (p = 0.868) did not differ between clusters. However, we observed that women (p = 0.012) and patients with previous cardiac valve surgery (p = 0.005) prevailed in the "global deficits" cluster and the "no deficits" group had a lower prevalence of underlying arterial hypertension (p = 0.029). Total brain volume (p = 0.017) was smaller in the global deficit cluster, and serum levels of glial fibrillary acidic protein were increased (p = 0.048).

Conclusion

Apart from cognitively healthy and globally impaired HF patients, we identified a group with deficits only in the intensity of attention. Women and patients with previous cardiac valve surgery are at risk for global cognitive impairment when suffering HF and could benefit from special multimodal treatment addressing the psychosocial condition.

Serum phosphorylated tau protein 181 and neurofilament light chain in cognitively impaired heart failure patients

BACKGROUND

Chronic heart failure (HF) is known to increase the risk of developing Alzheimer's dementia significantly. Thus, detecting and preventing mild cognitive impairment, which is common in patients with HF, is of great importance. Serum biomarkers are increasingly used in neurological disorders for diagnostics, monitoring, and prognostication of disease course. It remains unclear if neuronal biomarkers may help detect cognitive impairment in this high-risk population. Also, the influence of chronic HF and concomitant renal dysfunction on these biomarkers is not well understood.

METHODS

Within the monocentric Cognition.Matters-HF study, we quantified the serum levels of phosphorylated tau protein 181 (pTau) and neurofilament light chain (NfL) of 146 extensively phenotyped chronic heart failure patients (aged 32 to 85 years; 15.1% women) using ultrasensitive bead-based single-molecule immunoassays. The clinical work-up included advanced cognitive testing and cerebral magnetic resonance imaging (MRI).

RESULTS

Serum concentrations of NfL ranged from 5.4 to 215.0 pg/ml (median 26.4 pg/ml) and of pTau from 0.51 to 9.22 pg/ml (median 1.57 pg/ml). We detected mild cognitive impairment (i.e., T-score < 40 in at least one cognitive domain) in 60% of heart failure patients. pTau (p = 0.014), but not NfL, was elevated in this group. Both NfL (ρ = - 0.21; p = 0.013) and pTau (ρ = - 0.25; p = 0.002) related to the cognitive domain visual/verbal memory, as well as white matter hyperintensity volume and cerebral and hippocampal atrophy. In multivariable analysis, both biomarkers were independently influenced by age (T = 4.6 for pTau; T = 5.9 for NfL) and glomerular filtration rate (T = - 2.4 for pTau; T = - 3.4 for NfL). Markers of chronic heart failure, left atrial volume index (T = 4.6) and NT-proBNP (T = 2.8), were further cardiological determinants of pTau and NfL, respectively. In addition, pTau was also strongly affected by serum creatine kinase levels (T = 6.5) and ferritin (T = - 3.1).

CONCLUSIONS

pTau and NfL serum levels are strongly influenced by age-dependent renal and cardiac dysfunction. These findings point towards the need for longitudinal examinations and consideration of frequent comorbidities when using neuronal serum biomarkers.

Prevalence and incidence of stroke, white matter hyperintensities, and silent brain infarcts in patients with chronic heart failure: A systematic review, meta-analysis, and meta-regression

Introduction

Heart failure (HF) is associated with ischemic stroke (IS). However, there are limited studies on the prevalence of IS, white matter hyperintensities (WMHs), and silent brain infarcts (SBIs). Furthermore, interaction with ejection fraction (EF) is unclear.

Methods

We searched three databases (viz., PubMed, Embase, and Cochrane) for studies reporting the incidence or prevalence of IS, WMHs, and SBIs in HF. A total of two authors independently selected included studies. We used random-effects models, and heterogeneity was evaluated with I2 statistic. Meta-regression was used for subgroup analysis.

Results

In total, 41 articles involving 870,002 patients were retrieved from 15,267 records. Among patients with HF, the pooled proportion of IS was 4.06% (95% CI: 2.94–5.59), and that of WMHs and SBIs was higher at 15.67% (95% CI: 4.11–44.63) and 23.45% (95% CI: 14.53–35.58), respectively. Subgroup analysis of HFpEF and HFrEF revealed a pooled prevalence of 2.97% (95% CI: 2.01–4.39) and 3.69% (95% CI: 2.34–5.77), respectively. Subgroup analysis of WMH Fazekas scores 1, 2, and 3 revealed a decreasing trend from 60.57 % (95% CI: 35.13–81.33) to 11.57% (95% CI: 10.40–12.85) to 3.07% (95% CI: 0.95–9.47). The relative risk and hazard ratio of patients with HF developing IS were 2.29 (95% CI: 1.43–3.68) and 1.63 (95% CI: 1.22–2.18), respectively. Meta-regression showed IS prevalence was positively correlated with decreasing anticoagulant usage.

Conclusion

We obtained estimates for the prevalence of IS, WMH, and SBI in HF from systematic review of the literature.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=255126, PROSPERO [CRD42021255126].

Cognitive Dysfunction in Heart Failure: Pathophysiology and Implications for Patient Management

PURPOSE OF REVIEW

There is increasing recognition of the prevalence and impact of cognitive dysfunction (CD) in heart failure (HF) patients. This contemporary review appraises the evidence for epidemiological association, direct pathophysiological links and emerging pharmacological and non-pharmacological interventions. Furthermore, we present evidence for care models that aim to mitigate the morbidity and poor quality of life associated with these dual processes and propose future work to improve outcomes.

RECENT FINDINGS

CD disproportionately affects heart failure patients, even accounting for known comorbid risk factors, and this may extend to subclinical left ventricular dysfunction. Neuroimaging studies now provide evidence of anatomical and functional differences which support previously postulated mechanisms of reduced cerebral blood flow, micro-embolism and systemic inflammation. Interventions such as multidisciplinary ambulatory HF care, education and memory training improve HF outcomes perhaps to a greater degree in those with comorbid CD. Additionally, optimisation of standard heart failure care (cardiac rehabilitation, pharmacological and device therapy) may lead to additional cognitive benefits. Epidemiological, neuroimaging and intervention studies provide evidence for the causal association between HF and CD, although evidence for Alzheimer's dementia is less certain. Specific reporting of cognitive outcomes in HF trials and evaluation of targeted interventions is required to further guide care provision.

Cognitive decline in heart failure: Biomolecular mechanisms and benefits of exercise

By definition, heart failure (HF) is a human pathological condition affecting the structure and function of all organs in the body, and the brain is not an exception to that. Failure of the heart to pump enough blood centrally and peripherally is at the foundation of HF patients' inability to attend even the most ordinary daily activities and progressive deterioration of their cognitive capacity. What is more, between heart and brain exists a bidirectional relationship that goes well beyond hemodynamics and concerns bioelectric and endocrine signaling. This increasingly consolidated evidence makes the scenario even more complex. Studies have mainly chased how HF impairs cognition without focusing much on preventive measures, notably cardio-cerebral health proxies. Here, we aim to provide a brief account of known and hypothetical factors that may explain how exercise can help obviate cognitive dysfunction associated with HF in its different forms. As we shall see, there is a stringent need for a deeper grasp of such mechanisms. Indeed, gaining this new knowledge will automatically shed new light on the inner workings of HF itself, thus resulting in more effective prevention and treatment of this escalating syndrome.

Prevalence and Incidence of Cognitive Impairment and Dementia in Heart Failure - A Systematic Review, Meta-Analysis and Meta-Regression

INTRODUCTION

The burden of cognitive impairment in HF patients is significant and leads to longer hospital stay, higher readmission rates, and increased mortality. This review seeks to synthesize the available studies to determine the prevalence and incidence of cognitive impairment and dementia in HF patients.

METHODS

PubMed, Embase, PsychoINFO and Cochrane databases were systematically searched from their inception through to 3 May 2021. Study and population characteristics, total patients with HF, prevalence of cognitive impairment and dementia in HF patients and cognitive assessment tool were abstracted by two reviewers.

RESULTS

In heart failure patients, overall prevalence for cognitive impairment and dementia was 41.42% (CI) and 19.79% (dementia) respectively. We performed a meta-regression analysis which demonstrated that the risk of cognitive impairment and dementia increased with age.

DISCUSSION

Further research should investigate whether HF accelerates the rate of cognitive decline and the progression of dementia.

The Emerging Role of Combined Brain/Heart Magnetic Resonance Imaging for the Evaluation of Brain/Heart Interaction in Heart Failure

Heart failure (HF) patients frequently develop brain deficits that lead to cognitive dysfunction (CD), which may ultimately also affect survival. There is an important interaction between brain and heart that becomes crucial for survival in patients with HF. Our aim was to review the brain/heart interactions in HF and discuss the emerging role of combined brain/heart magnetic resonance imaging (MRI) evaluation. A scoping review of published literature was conducted in the PubMed EMBASE (OVID), Web of Science, Scopus and PsycInfo databases. Keywords for searches included heart failure, brain lesion, brain, cognitive, cognitive dysfunction, magnetic resonance imaging cardiovascular magnetic resonance imaging electroencephalogram, positron emission tomography and echocardiography. CD testing, the most commonly used diagnostic approach, can identify neither subclinical cases nor the pathophysiologic background of CD. A combined brain/heart MRI has the capability of diagnosing brain/heart lesions at an early stage and potentially facilitates treatment. Additionally, valuable information about edema, fibrosis and cardiac remodeling, provided with the use of cardiovascular magnetic resonance, can improve HF risk stratification and treatment modification. However, availability, familiarity with this modality and cost should be taken under consideration before final conclusions can be drawn. Abnormal CD testing in HF patients is a strong motivating factor for applying a combined brain/heart MRI to identify early brain/heart lesions and modify risk stratification accordingly.

Serum glial fibrillary acidic protein indicates memory impairment in patients with chronic heart failure

Aims

Cognitive dysfunction occurs frequently in patients with heart failure (HF), but early detection remains challenging. Serum glial fibrillary acidic protein (GFAP) is an emerging biomarker of cognitive decline in disorders of primary neurodegeneration such as Alzheimer's disease. We evaluated the utility of serum GFAP as a biomarker for cognitive dysfunction and structural brain damage in patients with stable chronic HF.

Methods and results

Using bead‐based single molecule immunoassays, we quantified serum levels of GFAP in patients with HF participating in the prospective Cognition.Matters‐HF study. Participants were extensively phenotyped, including cognitive testing of five separate domains and magnetic resonance imaging (MRI) of the brain. Univariable and multivariable models, also accounting for multiple testing, were run. One hundred and forty‐six chronic HF patients with a mean age of 63.8 ± 10.8 years were included (15.1% women). Serum GFAP levels (median 246 pg/mL, quartiles 165, 384 pg/mL; range 66 to 1512 pg/mL) did not differ between sexes. In the multivariable adjusted model, independent predictors of GFAP levels were age (T = 5.5; P < 0.001), smoking (T = 3.2; P = 0.002), estimated glomerular filtration rate (T = −4.7; P < 0.001), alanine aminotransferase (T = −2.1; P = 0.036), and the left atrial end‐systolic volume index (T = 3.4; P = 0.004). NT‐proBNP but not serum GFAP explained global cerebral atrophy beyond ageing. However, serum GFAP levels were associated with the cognitive domain visual/verbal memory (T = −3.0; P = 0.003) along with focal hippocampal atrophy (T = 2.3; P = 0.025).

Conclusions

Serum GFAP levels are affected by age, smoking, and surrogates of the severity of HF. The association of GFAP with memory dysfunction suggests that astroglial pathologies, which evade detection by conventional MRI, may contribute to memory loss beyond ageing in patients with chronic HF.

Aberrant static and dynamic functional network connectivity in heart failure with preserved ejection fraction

Aims

Heart failure may lead to brain functional alterations related to cognitive impairment. This study aimed to detect alterations of static functional network connectivity (FNC) and dynamic FNC in heart failure with preserved ejection fraction (HFpEF) and to estimate the association between the altered FNC and clinical features related to HFpEF.

Methods and results

The clinical and resting‐state functional magnetic resonance imaging (fMRI) data of HFpEF patients (n = 35) and healthy controls (HCs) (n = 35) were acquired at baseline. Resting‐state networks (RSNs) were established based on independent component analysis (ICA) and FNC analyses were performed. The associations between the FNC abnormalities and clinical features related to HFpEF were analysed. Compared with HCs, HFpEF patients showed decreased functional connectivity within the default mode network, left frontoparietal network, and right frontoparietal network and increased functional connectivity within the right frontoparietal network and visual network. Negative correlations were observed between decreased dynamic FNC and the left ventricular end‐diastolic diameter (LVDd) (r = −0.435, P = 0.015) as well as the left ventricular end‐systolic diameter (LVDs) (r = −0.443, P = 0.013).

Conclusions

The FNC disruption and altered temporal properties of functional dynamics in HFpEF patients may reflect the neural mechanisms of brain injury after HFpEF, which may deepen our understanding of the disease.

Assessment of cerebral glucose metabolism in patients with heart failure by 18F-FDG PET/CT imaging

BACKGROUND

To evaluate the cerebral metabolism in patients with heart failure (HF).

METHODS

One hundred and two HF patients were prospectively enrolled, who underwent gated 99mTc-sestamibi single photon emission computed tomography (SPECT)/CT, cardiac and cerebral 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT. Fifteen healthy volunteers served as controls. Patients were stratified by extent of hibernating myocardium (HM) and left ventricular ejection fraction (LVEF) into 4 groups where Group1: HM < 10% (n = 33); Group2: HM ≥ 10%, LVEF < 25% (n = 34); Group3: HM ≥ 10%, 25% ≤ LVEF ≤ 40% (n = 16) and Group 4: LVEF > 40% (n = 19). The standardized uptake value (SUV) in the whole brain (SUVwhole-brain) and the SUV ratios (SUVR) in 24 cognition-related brain regions were determined. SUVwhole-brain and SUVRs were compared between the 4 patient groups and the healthy controls.

RESULTS

SUVwhole-brain (r = 0.245, P = 0.013) and SUVRs in frontal areas, hippocampus, and para-hippocampus (r: 0.213 to 0.308, all P < 0.05) were correlated with HM. SUVwhole-brain differed between four patient groups and the healthy volunteers (P = 0.016) and SUVwhole-brain in Group 1 was lower than that in healthy volunteers (P < 0.05). SUVRs of Group 3 in frontal areas were the highest among four patient subgroups (P < 0.05).

CONCLUSIONS

Cerebral metabolism in the whole brain was reduced but maintained in cognition-related frontal areas in HF patients with HM and moderately impaired global left ventricular function.

Brain Imaging Changes and Related Risk Factors of Cognitive Impairment in Patients With Heart Failure

Background/Aims

To explore the imaging changes and related risk factors of heart failure (HF) patients with cognitive impairment (CI).

Methods

A literature search was systematically carried out in PubMed, Web of Science, Embase, and Cochrane Library. In this systematic review, important relevant information was extracted according to the inclusion and exclusion criteria. The methodological quality was assessed by three scales according to the different study types.

Results

Finally, 66 studies were included, involving 33,579 patients. In the imaging changes, the severity of medial temporal lobe atrophy (MTA) and the decrease of gray Matter (GM) volume were closely related to the cognitive decline. The reduction of cerebral blood flow (CBF) may be correlated with CI. However, the change of white matter (WM) volume was possibly independent of CI in HF patients. Specific risk factors were analyzed, and the data indicated that the increased levels of B-type natriuretic peptide (BNP)/N-terminal pro-B-type natriuretic peptide (NT-proBNP), and the comorbidities of HF, including atrial fibrillation (AF), diabetes mellitus (DM) and anemia were definitely correlated with CI in patients with HF, respectively. Certain studies had also obtained independent correlation results. Body mass index (BMI), depression and sleep disorder exhibited a tendency to be associated with CI. Low ejection fraction (EF) value (<30%) was inclined to be associated with the decline in cognitive function. However, no significant differences were noted between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) in cognitive scores.

Conclusion

BNP/NT-proBNP and the comorbidities of HF including AF, DM and anemia were inextricably correlated with CI in patients with HF, respectively. These parameters were independent factors. The severity of MTA, GM volume, BMI index, depression, sleep disorder, and low EF value (<30%) have a disposition to associated with CI. The reduction in the CBF volume may be related to CI, whereas the WM volume may not be associated with CI in HF patients. The present systematic review provides an important basis for the prevention and treatment of CI following HF.

Cognitive Impairment in Heart Failure: Landscape, Challenges, and Future Directions

Heart failure (HF) is a major global healthcare problem accounting for substantial deterioration of prognosis. As a complex clinical syndrome, HF often coexists with multi-comorbidities of which cognitive impairment (CI) is particularly important. CI is increasing in prevalence among patients with HF and is present in around 40%, even up to 60%, of elderly patients with HF. As a potent and independent prognostic factor, CI significantly increases the hospitalization and mortality and decreases quality of life in patients with HF. There has been a growing awareness of the complex bidirectional interaction between HF and CI as it shares a number of common pathophysiological pathways including reduced cerebral blood flow, inflammation, and neurohumoral activations. Research that focus on the precise mechanism for CI in HF is still ever insufficient. As the tremendous adverse consequences of CI in HF, effective early diagnosis of CI in HF and interventions for these patients may halt disease progression and improve prognosis. The current clinical guidelines in HF have begun to emphasize the importance of CI. However, nearly half of CI in HF is underdiagnosed, and few recommendations are available to guide clinicians about how to approach CI in patients with HF. This review aims to synthesize knowledge about the link between HF and cognitive dysfunction, issues pertaining to screening, diagnosis and management of CI in patients with HF, and emerging therapies for prevention. Based on data from current studies, critical gaps in knowledge of CI in HF are identified, and future research directions to guide the field forward are proposed.

Cognitive Impairment in Heart Failure—A Review

Simple Summary

Compared to the general population, patients with heart failure have reduced cognition and increased dementia risk. Brain changes have been observed in these individuals, including reduced brain volumes and abnormal areas suggestive of ischaemia (lack of blood and hence oxygen supply to tissues). Patients with heart failure who have cognitive impairment have poorer self-care and are at increased risk of rehospitalisation and death. Causes of cognitive impairment in heart failure have been suggested, including reduced blood supply to the brain, inflammatory processes, protein abnormalities and thromboembolic disease (formation of blood clots which may travel to the brain and impede blood flow). In this article, we discuss these potential causes linking heart failure and cognitive impairment, and discuss the recognition and management of cognitive impairment in patients with heart failure.

Abstract

Cognitive impairment (CI) is common in heart failure (HF). Patients with HF demonstrate reduced global cognition as well as deficits in multiple cognitive domains compared to controls. Degree of CI may be related to HF severity. HF has also been associated with an increased risk of dementia. Anatomical brain changes have been observed in patients with HF, including grey matter atrophy and increased white matter lesions. Patients with HF and CI have poorer functional independence and self-care, more frequent rehospitalisations as well as increased mortality. Pathophysiological pathways linking HF and CI have been proposed, including cerebral hypoperfusion and impaired cerebrovascular autoregulation, systemic inflammation, proteotoxicity and thromboembolic disease. However, these mechanisms are poorly understood. We conducted a search on MEDLINE, Embase and Scopus for original research exploring the connection between HF and CI. We then reviewed the relevant literature and discuss the associations between HF and CI, the patterns of brain injury in HF and their potential mechanisms, as well as the recognition and management of CI in patients with HF.

Randomized Controlled Trial of a Cognitive Intervention to Improve Memory in Heart Failure

BACKGROUND

The objective of this 3-arm randomized controlled trial was to evaluate efficacy of computerized cognitive training (CCT) to improve primary outcomes of delayed recall memory and serum brain-derived neurotrophic factor (BDNF) levels and secondary outcomes of working memory, instrumental activities of daily living (IADL), and health-related quality of life (HRQL) among patients with heart failure (HF).

METHODS AND RESULTS

Patients (N = 256) were randomly assigned to 8 weeks of CCT using BrainHQ, computerized crossword puzzles active control intervention, and usual care. All patients received weekly nurse enhancement interventions. Data were collected at enrollment and baseline visits and at 10 weeks and 4 and 8 months. In mixed effects models, there were no statistically significant group or group by time differences in outcomes. There were statistically significant differences over time in all outcomes in all groups. Patients improved over time on measures of delayed recall memory, working memory, IADL, and HRQL and had decreased serum BDNF.

CONCLUSIONS

CCT did not improve outcomes compared with the active control intervention and usual care. Nurse enhancement interventions may have led to improved outcomes over time. Future studies are needed to test nurse enhancement interventions in combination with other cognitive interventions to improve memory in HF.

LAYSUMMARY

In 256 patients with heart failure, 8 weeks of computerized cognitive training, computerized crossword puzzles, or usual care were studied for effects on (1st) recall memory and serum brain-derived neurotrophic factor (BDNF) and (2nd) working memory, instrumental activities of daily living (IADL), and health-related quality of life (HRQL). Measurements were at baseline, 10 weeks, 4- and 8-months. Nurse enhancement interventions (e.g., support, assessment) were provided. Recall memory, working memory, IADL, and HRQL improved over time. There were no statistically significant differences among treatment groups over time. BDNF unexpectedly decreased. Nurse enhancement interventions may explain improved outcomes. Future studies are needed.

Reciprocal organ interactions during heart failure: a position paper from the ESC Working Group on Myocardial Function

Heart failure-either with reduced or preserved ejection fraction (HFrEF/HFpEF)-is a clinical syndrome of multifactorial and gender-dependent aetiology, indicating the insufficiency of the heart to pump blood adequately to maintain blood flow to meet the body's needs. Typical symptoms commonly include shortness of breath, excessive fatigue with impaired exercise capacity, and peripheral oedema, thereby alluding to the fact that heart failure is a syndrome that affects multiple organ systems. Patients suffering from progressed heart failure have a very limited life expectancy, lower than that of numerous cancer types. In this position paper, we provide an overview regarding interactions between the heart and other organ systems, the clinical evidence, underlying mechanisms, potential available or yet-to-establish animal models to study such interactions and finally discuss potential new drug interventions to be developed in the future. Our working group suggests that more experimental research is required to understand the individual molecular mechanisms underlying heart failure and reinforces the urgency for tailored therapeutic interventions that target not only the heart but also other related affected organ systems to effectively treat heart failure as a clinical syndrome that affects and involves multiple organs.

Brain and heart-specific death in cancer patients: Population-based study

BACKGROUND

The occurrence of cardiovascular events is a major cause of death in patients with cancer. Small studies have documented a connection between specific brain alterations and autonomic cardiac dysfunctions, possibly resulting in a worse prognosis. We aimed to refine the knowledge of fatal cardiac events in patients with brain metastasis (BM).

METHODS

We performed a Surveillance, Epidemiology, and End Results SEER registry-based investigation (timeline: 2010-2016) and extracted all the advanced patients who had experienced fatal cardiac outcomes. Populations were compared according to the presence or not BM. Kaplan-Meier (KM) methodology was used for survival analysis and a multivariate model was developed by adjusting for multiple possible confounders.

RESULTS

Most related BM and cardiac death were observed at the site of lung cancer (81.4%). We extracted 3187 patients with lung cancer site, including 417 patients who had experienced fatal heart-specific with a history of BM, which is considered a BM group. The second group of heart-specific death included 2770 patients was stated as a non-BM group. Patients who had experienced heart-specific death in the BM group were predominately male, right side, upper site, and non-small type (62.11%, 54.92%, 51.56%, 69.78%), respectively. The survival outcomes between BM and the non- BM was significantly prominent (p = 0.003; median: 2 months vs. 3 months).The negative prognostic independent significance of heart-fatal events was confirmed after adjusting for multiple variables (HR = 0.76, CI = 0.68-84, p < 0.0001). The metastatic liver site was significantly associated with poorer survival rates (HR = 0.68; CI = 0.52-0.88, p = 0.005). We revealed a possible connection between the brain and heart functions.

CONCLUSIONS

The prognosis of heart-specific death patients in BM is unfavorable compared to non-BM settings in lung cancer. We may be at the gates of a new field of neurocardiooncology.

Cerebral Hypoxia: Its Role in Age-Related Chronic and Acute Cognitive Dysfunction

Postoperative cognitive dysfunction (POCD) has been reported with widely varying frequency but appears to be strongly associated with aging. Outside of the surgical arena, chronic and acute cerebral hypoxia may exist as a result of respiratory, cardiovascular, or anemic conditions. Hypoxia has been extensively implicated in cognitive impairment. Furthermore, disease states associated with hypoxia both accompany and progress with aging. Perioperative cerebral hypoxia is likely underdiagnosed, and its contribution to POCD is underappreciated. Herein, we discuss the various disease processes and forms in which hypoxia may contribute to POCD. Furthermore, we outline hypoxia-related mechanisms, such as hypoxia-inducible factor activation, cerebral ischemia, cerebrovascular reserve, excitotoxicity, and neuroinflammation, which may contribute to cognitive impairment and how these mechanisms interact with aging. Finally, we discuss opportunities to prevent and manage POCD related to hypoxia.

Associations of subclinical heart failure and atrial fibrillation with mild cognitive impairment: a cross-sectional study in a subclinical heart failure screening programme

OBJECTIVES

Effective identification and management of subclinical left ventricular (LV) dysfunction (LVD) and subclinical atrial fibrillation (AF) by screening elderly populations might be compromised by mild cognitive impairment (MCI). We sought to characterise the prevalence and profile of MCI and evaluate associations with LV and left atrial (LA) dysfunction and AF, in a trial of screening for subclinical LVD and AF.

DESIGN

Cross-sectional.

SETTING

Australian, community-based intervention trial.

PARTICIPANTS

Adults aged ≥65 years with ≥1 LVD risk factors without ischaemic heart disease (n=337).

OUTCOME MEASURES

The Montreal cognitive assessment (MoCA) was obtained. Subclinical LVD was defined as echocardiographic global longitudinal strain ≤16%, diastolic dysfunction or LV hypertrophy; abnormal LA reservoir strain (LARS) was defined as <24%. Subclinical AF was detected using a single-lead portable electrocardiographic device in those without pre-existing AF who gave consent (n=293).

RESULTS

Subclinical LVD was found in 155 (46%), abnormal LARS in 9 (3.6%) and subclinical AF in 11 (3.8%). MoCA score consistent with MCI (<26) was found in 101 (30%); executive function (69%) and delayed recall (93%), were the most frequently abnormal domains. Compared with normal cognition, MCI was associated with non-adherence to AF screening (25% vs 40%, p=0.01). In multivariable logistic regression modelling, educational achievement, systolic blood pressure, body mass index and waist-to-hip ratio were independently associated with MCI. However, neither subclinical AF nor any measure of cardiac dysfunction, were associated with MCI.

CONCLUSIONS

The 30% prevalence of MCI among elderly subjects with risk factors for subclinical LVD and AF has important implications for screening strategies and management. However, MCI is not associated with subclinical myocardial dysfunction nor subclinical AF.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12617000116325).

Temporal changes in total and hippocampal brain volume and cognitive function in patients with chronic heart failure-the COGNITION.MATTERS-HF cohort study

Aims

We quantified the concurring dynamics affecting total and hippocampal brain volume and cognitive function in patients with chronic heart failure (HF) over a period of three years.

Methods and results

A total of 148 patients with mild stable HF entered this monocentric prospective cohort study: mean age 64.5 (10.8) years; 16.2% female; 77% in New York Heart Association functional classes I–II; 128 and 105 patients attended follow-up visits after 1 and 3 years, respectively. The assessment included cardiological, neurological, psychological work-up, and brain magnetic resonance imaging. Total and regional brain volumes were quantified using an operator-independent fully automated approach and reported normalized to the mean estimated intracranial volume. At baseline, the mean hippocampal volume was ∼13% lower than expected. However, the 3-year progressive hippocampal volume loss was small: −62 mm³ [95% confidence interval (CI) −81 to −42, P < 0.0001). This corresponded to a relative change of −1.8% (95% CI −2.3 to −1.2), which was similar in magnitude as observed with physiological aging. Moreover, the load of white matter hypointensities increased within the limits of normal aging. Cognitive function during the 3-year observation period remained stable, with ‘intensity of attention’ as the only domain declining (LSmean −1.82 points, 95% CI −3.05 to −0.58, P = 0.004). After 3 years, performance in all domains of cognition remained associated with hippocampal volume (r ≥ 0.29).

Conclusion

In patients with predominantly mild HF, the markedly reduced hippocampal volume observed at baseline was associated with impaired cognitive function, but no accelerated deterioration in cognition and brain atrophy became evident over a mid-term period of three years.

Cognitive impairment in heart failure: clinical implications, tools of assessment, and therapeutic considerations

Cognitive impairment (CI) is an important comorbidity in patients with heart failure (HF). Its prevalence parallels the severity of heart failure, while it is an independent prognostic marker of adverse events. Various factors contribute to cognitive decline in HF, influencing self-care. There are no standardized screening methods for the diagnosis and management of these patients. The aim of the present manuscript is to provide an overview of the impact of cognitive impairment in HF, describe the utility of assessment tools and imaging methods for the evaluation of CI, and propose a comprehensive diagnostic and management approach.

Cerebrovascular Disease and Cognitive Outcome in Patients with Cardiac Disease

The pace of understanding cognitive decline and dementia has rapidly accelerated over the past decade, with constantly evolving insights into the vascular contributions to cognitive impairment and dementia (VCID). Notably, more overlap has been discovered in the pathophysiology between what was previously understood to be Alzheimer's disease and VCID, leading to a heightened emphasis on disease prevention through early and aggressive control of vascular risk factors. One particularly vulnerable population may be those with cardiac disease, as they are at risk for cerebrovascular disease, which itself can lead to dementia, and increasing evidence supports cognitive impairment in disease processes such as heart failure and atrial fibrillation, independent of ischemic stroke, suggesting other potential mechanisms. In this article, we review the evidence supporting the relationship between cardiac disease, cerebrovascular disease, and cognitive decline and discuss the ongoing and future research efforts aimed at defining the important relationship between these entities.

[Care of patients with chronic heart failure: an interdisciplinary challenge]

The diverse manifestations of heart failure led to complex treatment guidelines and care scenarios and therefore always require an integrated, multidisciplinary care approach. Patients with chronic heart failure suffer from a large number of cardiac and noncardiac comorbidities. For example, iron deficiency leads to decreased performance and exertional dyspnea and should be diagnosed. Psychological screening questionnaires should be used for the early detection of psychological comorbidities.ARNI and SGLT-inhibitors expand the pharmacotherapeutic possibilities and gain in importance. The constant development of diagnostic possibilities and therapeutic options must be implemented consistently into the care continuum in order to have a lasting effect. The challenge of interdisciplinary coordination can be significantly reduced through jointly agreed process logs (e. g. within the framework of integrated supply contracts or a Heart Failure Unit Network).

Quantitative evaluation of white matter hyperintensities in patients with heart failure using an innovative magnetic resonance image analysis method: Association with disrupted circadian blood pressure variation

White matter hyperintensities (WMHs) are risk factors for future cognitive impairment and are associated with an abnormal circadian blood pressure (BP) rhythm in patients with hypertension. However, whether this association exists in patients with heart failure (HF) is unclear. We performed a cross‐sectional study of hospitalized patients with HF who underwent ambulatory BP monitoring and brain magnetic resonance imaging (MRI). A non‐dipper BP pattern was defined as a < 10% nocturnal BP decline. WMHs on brain MRI scans were quantitated using a novel image analysis software (FUSION: FUsed Software for Imaging Of Nervous system). We enrolled 28 hospitalized patients with HF (age: 70.0 ± 9.8 years, 64.3% men). In the brain MRI analysis, the non‐dipper group had higher WMH volume (18.9 ± 19.8 vs. 7.7 ± 8.3 mL, P = .047) and percentage of WMH/total brain volume (1.31 ± 1.28% vs. 0.55 ± 0.58%, P = .04) than the dipper group. In conclusion, using the newly developed MRI analysis software, we successfully quantitatively measured the volume of WMHs and found that the WMH volume increased 2.4 times in patients with a non‐dipper pattern of nocturnal BP compared with those with a normal dipper pattern.

Neuropsychological Assessment and Screening in Heart Failure: a Meta-Analysis and Systematic Review

A variety of neuropsychological changes secondary to heart failure have been documented in the literature. However, what remains unclear are which neuropsychological abilities are the most impacted by heart failure and what tests have the sensitivity to measure that impact. Eight databases were searched for articles that examined the neuropsychological functioning of patients with heart failure. Some of the inclusion criteria were articles had to have a heart failure group with a demographically comparable control group and standardized neuropsychological testing. Exclusion criteria included articles with a heart failure group with any other type of major organ failure, or comparisons that were between different classes of heart failure rather than between a heart failure and non-heart failure group. A total of 33 articles met the inclusion criteria (total heart failure sample n = 8900) and provided effect size data for 20 neuropsychological domains. All observed domain-level differences between heart failure and non-heart failure groups were statistically significant, except for simple motor functioning and confrontation naming. The greatest differences in performance were in executive functioning, global cognition, complex psychomotor speed, and verbal memory. The highest effect sizes came from Trail-Making Test-Part B, CAMCOG, Symbol Digit Modality Test, and California Verbal Learning Test. The neuropsychological patterns of heart failure suggested diffuse cognitive involvement, with higher-level processes being most affected. It is important to track neurocognition in this clinical population since neuropsychological impairment is prevalent, and screening measures appear to be reliable. Such screening and further assessment would inform future medical treatment and may improve patient care management.

Heart failure is independently associated with white matter lesions: insights from the population-based LIFE-Adult Study

Aims

White matter lesions (WML) are common structural alterations in the white matter of the brain and their prevalence increases with age. They are associated with cerebral ischaemia and cognitive dysfunction. Patients with heart failure (HF) are at risk for cognitive decline. We hypothesized that the presence and duration of HF are associated with WML.

Methods and results

The LIFE‐Adult Study is a population‐based study of 10 000 residents of Leipzig, Germany. WML were quantitated in 2490 participants who additionally underwent cerebral MRI using the Fazekas score. Mean age was 64 years, and 46% were female; 2156 (86.6%) subjects had Fazekas score of 0–1, and 334 (13.4%) had Fazekas score of 2–3. Thirty participants had a medical history of HF, 1019 had hypertension, and 51 had a history of stroke. Median left ventricular ejection fraction of the participants with HF was 57% (interquartile ranges 54–62). Age, troponin T, NT‐proBNP, body mass index, history of acute myocardial infarction, stroke, HF, and diabetes were positively associated with WML in univariate analysis. On multivariate analysis, age, hypertension, stroke, and HF were independently associated with WML. The odd's ratio for the association of WML (Fazekas 2–3) with HF was 2.8 (95% CI 1.2–6.5; P = 0.019). WML increased with longer duration of HF (P = 0.036 for trend).

Conclusions

In addition to age, hypertension, and stroke, the prevalence and duration of HF are independently associated with WML. This observation sets the stage to investigate the prognostic value of WML in HF and the impact of HF therapies on WML.

Cognition, Physical Function, and Quality of Life in Older Patients With Acute Decompensated Heart Failure

BACKGROUND

Older adults with acute decompensated heart failure have persistently poor clinical outcomes. Cognitive impairment (CI) may be a contributing factor. However, the prevalence of CI and the relationship of cognition with other patient-centered factors such a physical function and quality of life (QOL) that also may contribute to poor outcomes are incompletely understood.

METHODS AND RESULTS

Older (≥60 years) hospitalized patients with acute decompensated heart failure were assessed for cognition (Montreal Cognitive Assessment [MoCA]), physical function (Short Physical Performance Battery [SPPB], 6-minute walk distance [6MWD]), and QOL (Kansas City Cardiomyopathy Questionnaire, Short Form-12). Among patients (N = 198, 72.1 ± 7.6 years), 78% screened positive for CI (MoCA of <26) despite rare medical record documentation (2%). Participants also had severely diminished physical function (SPPB 6.0 ± 2.5 units, 6MWD 186 ± 100 m) and QOL (scores of <50). MoCA positively related to SPPB (ß = 0.47, P < .001), 6MWD ß = 0.01, P = .006) and inversely related to Kansas City Cardiomyopathy Questionnaire Overall Score (ß = -0.05, P < .002) and Short Form-12 Physical Component Score (ß = -0.09, P = .006). MoCA was a small but significant predictor of the results on the SPPB, 6MWD, and Kansas City Cardiomyopathy Questionnaire.

CONCLUSIONS

Among older hospitalized patients with acute decompensated heart failure, CI is highly prevalent, is underrecognized clinically, and is associated with severe physical dysfunction and poor QOL. Formal screening may reduce adverse events by identifying patients who may require more tailored care.

Psychomotor speed as a predictor of functional status in older chronic heart failure (CHF) patients attending cardiac rehabilitation

Background

The association among psychological, neuropsychological dysfunctions and functional/clinical variables in Chronic Heart Failure (CHF) has been extensively addressed in literature. However, only a few studies investigated those associations in the older population.

Purpose

To evaluate the psychological/neuropsychological profile of older CHF patients, to explore the interrelation with clinical/functional variables and to identify potential independent predictors of patients’ functional status.

Methods

This study was conducted with a multi-center observational design. The following assessments were performed: anxiety (Hospital Anxiety and Depression Scale, HADS), depression (Geriatric Depression Scale, GDS), cognitive impairment (Addenbrooke’s Cognitive Examination Revised, ACE-R), executive functions (Frontal Assessment Battery, FAB), constructive abilities (Clock Drawing Test, CDT), psychomotor speed and alternated attention (Trail Making Test, TMT-A/B), functional status (6-minute walking test, 6MWT) and clinical variables (New York Heart Association, NYHA; Brain Natriuretic Peptide, BNP; left ventricular ejection fraction, LVEF; left ventricular end diastolic diameter, LVEDD; left ventricular end diastolic volume, LVEDV; tricuspid annular plane systolic excursion, TAPSE).

Results

100 CHF patients (mean age: 74.9±7.1 years; mean LVEF: 36.1±13.4) were included in the study. Anxious and depressive symptoms were observed in 16% and 24,5% of patients, respectively. Age was related to TMT-A and CDT (r = 0.49, p<0.001 and r = -0.32, p = 0.001, respectively), Log-BNP was related to ACE-R-Fluency subtest, (r = -0.22, p = 0.034), and 6MWT was related to ACE-R-Memory subtest and TMT-A (r = 0.24, p = 0.031 and r = -0.32, p = 0.005, respectively). Both anxiety and depression symptoms were related to ACE-R-Total score (r = -0.25, p = 0.013 and r = -0.32, p = 0.002, respectively) and depressive symptoms were related to CDT (r = -0.23, p = 0.024). At multiple regression analysis, Log-BNP and TMT-A were significant and independent predictors of functional status: worse findings on Log-BNP and TMT-A were associated with shorter distance walked at the 6MWT.

Conclusions

Psychological and neuropsychological screening, along with the assessment of psychomotor speed (TMT-A), may provide useful information for older CHF patients undergoing cardiac rehabilitation.