Stroke-independent contribution of atrial fibrillation to dementia: a meta-analysis

Advances in Atrial Fibrillation Management: A Guide for General Internists

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, impacting approximately 6.1 million adults in the United States, with projections to increase two-fold by 2030. AF significantly increases the risk of stroke and other adverse cardiovascular events, leading to increased morbidity and mortality. The 2023 ACC/AHA/ACCP/HRS guidelines present a paradigm shift in AF management, moving from a duration-based classification to a more comprehensive, patient-centered approach. This includes a novel AF classification system that emphasizes early detection and intervention, including risk factors and lifestyle modification tailored to each patient's risk profile. Moreover, the recommendations advocate for a multidisciplinary care model, ensuring coordinated management involving primary care providers and specialists. Primary care providers play a crucial role in initiating risk factor management and lifestyle interventions, even before the development of AF. This review aims to thoroughly examine the guidelines for the diagnosis and management of AF and equip general internists with the necessary insights to navigate the evolving landscape of AF care effectively.

[Prevention of cognitive decline in old age : Selected primary preventive approaches]

There are currently 1.8 million people in Germany affected by dementia. Despite advances in research and new treatments, there is no cure for most cases of dementia. The evidence regarding the prevention of cognitive decline in old age is unclear. In addition to the optimized adjustment of drug treatment (e.g., arterial hypertension and diabetes mellitus), preventive measures that can be influenced by individuals themselves play an important role. These include areas such as physical and cognitive activity, remedying hearing loss, sleep, social contacts, abstaining from alcohol as well as tobacco consumption and nutrition. Multimodal concepts and digital approaches appear to be promising and an increase in evidence is expected in the coming years.

Role of the vessel morphology on the lenticulostriate arteries hemodynamics during atrial fibrillation: A CFD-based multivariate regression analysis

BACKGROUND AND OBJECTIVE

Atrial fibrillation (AF) is the most common cardiac arrhythmia, inducing accelerated and irregular beating. Beside well-known disabling symptoms - such as palpitations, reduced exercise tolerance, and chest discomfort - there is growing evidence that an alteration of deep cerebral hemodynamics due to AF increases the risk of vascular dementia and cognitive impairment, even in the absence of clinical strokes. The alteration of deep cerebral circulation in AF represents one of the least investigated among the possible mechanisms. Lenticulostriate arteries (LSAs) are small perforating arteries mainly departing from the middle cerebral artery (MCA) and susceptible to small vessel disease, which is one of the mechanisms of subcortical vascular dementia development. The purpose of this study is to investigate the impact of different LSAs morphologies on the cerebral hemodynamics during AF.

METHODS

By combining a computational fluid dynamics (CFD) analysis of LSAs with 7T high-resolution magnetic resonance imaging (MRI), we performed different CFD-based multivariate regression analyses to detect which geometrical and morphological vessel features mostly affect AF hemodynamics in terms of wall shear stress. We exploited 17 cerebral 7T-MRI derived LSA vascular geometries extracted from 10 subjects and internal carotid artery data from validated 0D cardiovascular-cerebral modeling as inflow conditions.

RESULTS

Our results revealed that few geometrical variables - namely the size of the MCA and the bifurcation angles between MCA and LSA - are able to satisfactorily predict the AF impact. In particular, the present study indicates that LSA morphologies exhibiting markedly obtuse LSA-MCA inlet angles and small MCA size downstream of the LSA-MCA bifurcation may be more prone to vascular damage induced by AF.

CONCLUSIONS

The present MRI-based computational study has been able for the first time to: (i) investigate the net impact of LSAs vascular morphologies on cerebral hemodynamics during AF events; (ii) detect which combination of morphological features worsens the hemodynamic response in the presence of AF. Awaiting necessary clinical confirmation, our analysis suggests that the local hemodynamics of LSAs is affected by their geometrical features and some LSA morphologies undergo greater hemodynamic alterations in the presence of AF.

Atrial High-Rate Episodes and Subclinical Atrial Fibrillation: State of the Art and Clinical Questions with Complex Solutions

Atrial high-rate episodes (AHREs) and subclinical atrial fibrillation (AF) are frequently registered in asymptomatic patients with cardiac implantable electronic devices (CIEDs) and insertable cardiac monitors (ICMs). While an increased risk of thromboembolic events (e.g., stroke) and benefits from anticoagulation have been widely assessed in the setting of clinical AF, concerns persist about optimal clinical management of subclinical AF/AHREs. As a matter of fact, an optimal threshold of subclinical episodes' duration to predict stroke risk is still lacking and recently published randomized clinical trials assessing the impact of anticoagulation on thromboembolic events in this specific setting have shown contrasting results. The aim of this review is to summarize current evidence regarding classification and clinical impact of subclinical AF/AHREs and to discuss the latest evidence regarding the potential benefit of anticoagulation in this setting, highlighting which clinical questions are still unanswered.

Cognitive impairment and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study

BACKGROUND

Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes.

METHODS

The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools.

RESULTS

972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies.

CONCLUSIONS

Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.

Revitalizing brain perfusion: Unveiling advancements through rhythm control strategies in atrial fibrillation-A systematic review

Background

Recent evidence suggests an elevated risk of cognitive impairment and dementia in individuals with atrial fibrillation (AF), irrespective of stroke occurrence. AF, known to reduce brain perfusion, particularly through silent cerebral ischemia, underscores the intricate relationship between cardiac and cerebral health. The heart plays a crucial role in supporting normal brain function, and rhythm control, a standard AF treatment, has demonstrated enhancements in brain perfusion. This systematic review aimed to examine published data concerning the influence of rhythm control on brain perfusion in patients with atrial fibrillation.

Methods

A systematic search for relevant studies was carried out in Scopus, PubMed, Cochrane Reviews, ProQuest, and EBSCOhost, spanning from their inception until April 30, 2023. Studies that specifically examined brain perfusion following any form of rhythm control in atrial fibrillation were included in the review.

Results

The review encompassed 10 studies involving 436 participants. Among these, six utilized electrical cardioversion for rhythm control. The majority (8 out of 10) demonstrated that restoring sinus rhythm markedly enhances brain perfusion. In one of the two remaining studies, notable improvement was observed specifically in a region closely linked to cognition. Additionally, both studies reporting data on the Mini-Mental State Examination (MMSE) showed a consistent and significant increase in scores following rhythm control.

Conclusion

Successful rhythm control in AF emerges as a significant contributor to enhanced brain perfusion, suggesting a potential therapeutic avenue for reducing cognitive impairment incidence. However, further validation through larger prospective studies and randomized trials is warranted.

Atrial Fibrillation and Cognitive Disorders

The prevalence of atrial fibrillation among older adults is increasing. Research has indicated that atrial fibrillation is linked to cognitive impairment disorders such as Alzheimer and vascular dementia, as well as Parkinson disease. Various mechanisms are believed to be shared between atrial fibrillation and cognitive impairment disorders. The specific pathologies and mechanisms of different cognitive disorders are still being studied. Potential mechanisms include cerebral hypoperfusion, ischemic or hemorrhagic infarction, and cerebrovascular reactivity to carbon dioxide. Additionally, circulatory biomarkers and certain infectious organisms appear to be involved. This review offers an examination of the overlapping epidemiology between atrial fibrillation and cognitive disorders, explores different cognitive disorders and their connections with this arrhythmia, and discusses trials and guidelines for preventing and treating atrial fibrillation in patients with cognitive disorders. It synthesizes existing knowledge on the management of atrial fibrillation and identifies areas that require further investigation to bridge the gap in understanding the complex relationship between dementia and atrial fibrillation.

Atrial fibrillation increases the risk of all-cause dementia, Alzheimer's disease, and vascular dementia: A cohort study of 373, 415 participants in the UK Biobank

BACKGROUND

Accumulated evidence has highlighted the association between atrial fibrillation and the risk of developing dementia.

METHODS

This current cohort study utilized data from the UK Biobank to explore the association between atrial fibrillation (AF) and all-cause dementia (ACD), encompassing its main subtypes (Alzheimer's disease (AD), and vascular dementia (VD)). Cox proportional hazards models were applied to examine the association of AF and dementia with its primary subtypes after adjusting for different sets of covariates. Hazard ratios (HRs) with 95 % confidential intervals (CIs) were estimated to quantify the associated risks. Competing risk model was applied in sensitivity analysis.

RESULTS

After exclusion, 373, 415 participants entered the primary analysis. Among these, 27, 934 (7.48 %) were with a history AF at baseline, while 345, 481 (92.52 %) were without. During a mean follow-up of 13.45 years, ACD was diagnosed in 1215 individuals with AF and 3988 individuals without AF. Participants with AF had higher risks of ACD (1.79 [1.67-1.91]), AD (1.48 [1.32-1.65]), and VD (2.46 [2.17-2.80]) in the fully adjusted Cox regression models. Results of subgroup and sensitivity analyses predominantly aligned with the positive associations in primary analysis.

LIMITATIONS

The applicability of our findings to diverse ethnicities might require careful consideration and the behind biological mechanisms need to be further revealed.

CONCLUSIONS

It indicated that people with atrial fibrillation had an increased future risk of all-cause dementia, Alzheimer's disease, vascular dementia. Atrial fibrillation screening and prevention strategies should take into account to prevent and delay the onset of dementia.

Modified Haller Index is inversely associated with asymptomatic status in atrial fibrillation patients undergoing electrical cardioversion: a preliminary observation

BACKGROUND

No previous study evaluated the possible influence of chest wall conformation on symptoms perception in atrial fibrillation (AF) patients candidates for electrical cardioversion (ECV). We aimed at evaluating the anthropometric and clinical characteristics of patients with persistent AF undergoing ECV, categorized according to the presence or absence of symptoms.

METHODS

This study retrospectively analyzed a series of persistent AF patients scheduled for early ECV who underwent pre-procedural clinical evaluation, MHI (the ratio of chest transverse diameter over the distance between sternum and spine) assessment, transthoracic and transesophageal echocardiography implemented with strain analysis of both left atrium and left atrial appendage. Thromboembolic risk and burden of comorbidities were assessed by CHA2DS2-VASc Score and Charlson Comorbidity Index (CCI), respectively. The independent predictors of "asymptomatic AF" were assessed.

RESULTS

A total of 25 asymptomatic and 90 symptomatic AF patients were retrospectively examined. Compared to symptomatic AF patients, those asymptomatic were significantly older (78.4±3.8 vs. 71.0±7.7 years, P<0.001), predominantly males (84 vs. 44.4%, P<0.001), with significantly lower MHI (2.0±0.1 vs. 2.4±0.1, P<0.001), higher CHA2DS2-VASc Score (5.8±1.1 vs. 3.6±1.1, P<0.001) and CCI (6.8±1.4 vs. 2.3±0.9, P<0.001), and greater impairment in biventricular systolic function and atrio-auricolar myocardial strain indices. On multivariate logistic regression analysis, CHA2DS2-VASc Score (OR=2.65, 95% CI: 1.53-4.60) and CCI (OR=2.36, 95% CI: 1.16-4.66) were linearly associated with the endpoint "asymptomatic AF," whereas MHI (OR 0.76, 95% CI 0.59-0.97) was inversely associated with the asymptomatic status. A MHI <2.2 was the best cut-off for detecting asymptomatic AF patients.

CONCLUSIONS

MHI is inversely associated with asymptomatic status in persistent AF patients undergoing ECV. MHI assessment might represent an innovative practical approach to AF patients.

Impaired retinal micro-vascular function in patients with atrial fibrillation

BACKGROUND

Cardiovascular (CV) risk factors and CV diseases, in particular heart failure, are strongly associated with impaired microvascular retinal endothelial function. Whether atrial fibrillation (AF) contributes to vascular dysfunction is not clear. Therefore, the aim of this study was to investigate the impact of AF on retinal microvascular function.

METHODS

In this study, vascular function was measured non-invasively with flicker-light induced vasodilatation of retinal arterioles (FIDart%). Patients with a history of AF and risk factors for heart failure (HF) or heart failure (n = 69; age 67.9 ± 9.2 years, 71% male, 35% HFrEF, 56% paroxysmal, 25% persistent, 19% permanent AF), as well as age, sex and ejection fraction matched patients with absent history of AF (n = 66; age 63.4 ± 10.6 years, 67% male, 47% HFrEF) were included. Patients with AF were further divided into those with paroxysmal AF (in sinus rhythm - AFSR: n = 38, age 71.4 ± 9.2, 73% male), and those with AF at the time of the study visit.

RESULTS

Retinal microvascular function was impaired in patients with AF compared to patients without AF (FIDart% 1.1% [0.3-2.8] vs. 2.7% [1.3-5.1], p < 0.001). Patients currently in AF have poorer retinal microvascular function (FIDart% 0.8% [0.1-1.9) compared to patients with a history of AF but currently in SR at the time of retinal function measurement (1.5% [0.6-4.9] p = 0.017). In patients with AF, impaired retinal vascular function was independently associated with larger left atrial volume (mean 49.8 ± 18.4), even after correction for confounding factors in different models (SCR = -0. 251 to -0.256, p = 0.035-0.01).

CONCLUSIONS

AF in patients with heart failure is associated with impaired vascular function, even if currently in sinus rhythm. The association of retinal microvascular dysfunction with left atrial volume, a surrogate for elevated cardiac filling pressures, may further highlight the important interplay between the vasculature and elevated filling pressures in the development of AF.

Role of Cognitive Frailty in Older Adults With Cardiovascular Disease

As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.

Protocol for a multicentre and prospective follow-up cohort study of early detection of atrial fibrillation, silent stroke and cognitive impairment in high-risk primary care patients: the PREFA-TE study

BACKGROUND

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Future estimations suggest an increase in global burden of AF greater than 60% by 2050. Numerous studies provide growing evidence that AF is not only associated with stroke but also with cognitive impairment and dementia.

AIM

The main goal is to assess the impact of the combined use of cardiac rhythm monitoring devices, echocardiography, biomarkers and neuroimaging on the early diagnosis of AF, silent strokes and cognitive decline, in subjects at high risk of AF.

METHODS AND ANALYSIS

Two-year follow-up of a cohort of individuals aged 65-85 years at high risk for AF, with no prior diagnosis of either stroke or dementia. The study involves baseline echocardiography, biomarkers, and neuroimaging, yearly cardiac monitoring, and semiannual clinical assessments. Different parameters from these tests will be analysed as independent variables. Throughout the study period, primary outcomes: new diagnoses of AF, stroke and cognitive impairment, along with any clinical and therapeutic changes, will be registered. A first descriptive and bivariate statistical analysis, appropriate to the types of variables, will be done. The information obtained from the data analysis will encompass adjusted risk estimates along with 95% confidence intervals. Event risk predictions will rely on multivariate Cox proportional hazards regression models. The predictive value of the model will be evaluated through the utilisation of receiver operating characteristic curves for area under the curve calculation. Additionally, time-to-event analysis will be performed using Kaplan-Meier curves.

ETHICS AND DISSEMINATION

This study protocol has been reviewed and approved by the Independent Ethics Committee of the Foundation University Institute for Primary Health Care Research-IDIAP Jordi Gol (expedient file 22/090-P). The authors plan to disseminate the study results to the general public through various scientific events. Publication in open-access journals and presentations at scientific congresses, seminars and meetings is also foreseen.

TRIAL REGISTRATION NUMBER

NCT05772806.

Effects of rhythm-control and rate-control strategies on cognitive function and dementia in atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Growing evidence suggests that atrial fibrillation (AF) is an independent risk factor for cognitive impairment and dementia, even in the absence of thromboembolic events and stroke. Whether rhythm-control therapy can protect cognitive function remains unclear. We aimed to evaluate the efficacy of rhythm-control strategies in patients with AF regarding cognitive function and dementia risk.

METHODS

We systematically searched the PubMed, Embase and Cochrane Library databases for randomised clinical trials, cohort and case-control studies evaluating the associations between rhythm-control strategies and cognitive function outcomes up to May 2023. We assessed the risk of bias using the ROBINS-I and the Cochrane risk-of-bias tool. Both fixed- and random-effects models were used to create summary estimates of risk.

RESULTS

We included a total of 14 studies involving 193,830 AF patients. In the pooled analysis, compared with rate-control, rhythm-control therapy was significantly associated with a lower risk of future dementia (hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.62-0.89; I2 = 62%). Among the rhythm-control strategies, AF ablation is a promising treatment that was related to significantly lower risks of overall dementia (HR 0.62; 95% CI 0.56-0.68; I2 = 42%), Alzheimer's disease (HR 0.78; 95% CI 0.66-0.92; I2 = 0%) and vascular dementia (HR 0.58; 95% CI 0.42-0.80; I2 = 31%). Pooled results also showed that compared with patients without ablation, those who underwent AF ablation had significantly greater improvement in cognitive score (standardized mean difference (SMD) 0.85; 95% CI 0.30-1.40; P = 0.005; I2 = 76%).

CONCLUSIONS

Rhythm-control strategies, especially ablation, are effective in protecting cognitive function, reducing dementia risk and thus improving quality of life in AF patients.

MRI pattern characterization of cerebral cardioembolic lesions following atrial fibrillation ablation

Background

Recognizing etiology is essential for treatment and secondary prevention of cerebral ischemic events. A magnetic resonance imaging (MRI) pattern suggestive of an embolic etiology has been described but, to date, there are no uniformly accepted criteria.

Aim

The purpose of the study is to describe MRI features of ischemic cerebral lesions occurring after transcatheter ablation of atrial fibrillation (AF).

Methods

A systematic review and meta-analysis of studies performing brain imaging investigations before and after AF transcatheter ablation was performed. The incidence of cerebral ischemic lesions after AF transcatheter ablation was the primary endpoint. The co-primary endpoints were the prevalence of the different neuroimaging features regarding the embolic cerebral ischemic lesions.

Results

A total of 25 studies, encompassing 3,304 patients, were included in the final analysis. The incidence of ischemic cerebral lesions following AF transcatheter ablation was 17.2% [95% confidence interval (CI) 12.2%-23.8%], of which a minimal fraction was symptomatic [0.60% (95% CI 0.09%-3.9%)]. Only 1.6% of the lesions (95% CI 0.9%-3.0%) had a diameter >10 mm, and in 20.5% of the cases the lesions were multiple (95% CI 17.1%-24.4%). Brain lesions were equally distributed across the two hemispheres and the different lobes; cortical location was more frequent [64.0% (95% CI 42.9%-80.8%)] while the middle cerebral artery territory was the most involved 37.0% (95% CI 27.3-48.0).

Conclusions

The prevailing MRI pattern comprises a predominance of small (<10 mm) cortical lesions, more prevalent in the territory of the middle cerebral artery.

Neurologic impact of atrial fibrillation

PURPOSE OF REVIEW

Cognitive dysfunction is a complex condition that is becoming increasingly more prevalent. There has been growing acknowledgement that individuals with atrial fibrillation are at an increased risk of cognitive dysfunction beyond the association of age with both disorders. The purpose of this review is to explore the potential underlying mechanisms connecting atrial fibrillation and cognitive dysfunction and to examine the existing evidence for potential treatment options.

RECENT FINDINGS

Many mechanisms have been proposed for the association between cognitive dysfunction and atrial fibrillation. These include cerebral infarction (both micro and macro embolic events), cerebral microbleeds including those secondary to therapeutic anticoagulation, an increased inflammatory state, cerebral hypoperfusion, and a genetic predisposition to both diseases. Treatments designed to target each of these mechanisms have led to mixed results and there are no specific interventions that have definitively led to a reduction in the incidence of cognitive dysfunction.

SUMMARY

The relationship between cognitive dysfunction and atrial fibrillation remains poorly understood. Standard of care currently focuses on reducing risk factors, managing stroke risk, and maintaining sinus rhythm in appropriately selected patients. Further work needs to be conducted in this area to limit the progression of cognitive dysfunction in patients with atrial fibrillation.

Dementia Risk of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation: Systematic Review and Meta-Analysis

BACKGROUND

Direct-acting oral anticoagulants (DOACs) have demonstrated superior efficacy in preventing stroke and death compared with warfarin in patients with atrial fibrillation (AF), but their influence on dementia risk remains unclear.

OBJECTIVES

The purpose of this study was to evaluate the relative risks of dementia in DOAC vs warfarin in patients with AF.

METHODS

An electronic literature search was conducted to retrieve studies reporting comparisons of dementia incidence between patients treated with DOACs and warfarin for AF. HRs and 95% CI were pooled in a random-effects meta-analysis. Meta-regression was performed to identify prognostic baseline variables. Network meta-analysis was performed to determine dementia risk between individual DOACs and warfarin.

RESULTS

Ten studies (n = 342,624) were retrieved. DOAC was associated with a significantly lower risk of developing dementia compared with warfarin (HR: 0.88; 95% CI: 0.80-0.98; P = 0.017; I2 = 75%); significance was also seen in Asian patients (HR: 0.81; 95% CI: 0.68-0.86) but not non-Asian patients. Subgroup analyses of propensity score-matched studies and patients aged 65-75 years showed similar significance, but not for patients aged ≥75 years. Meta-regression found that a lower mean age corresponded to significantly greater favoring of DOAC over warfarin. Network meta-analysis found significant reductions in dementia risk over warfarin for rivaroxaban (HR: 0.854; 95% CI: 0.763-0.955), apixaban (HR: 0.881; 95% CI: 0.778-0.997), and dabigatran (HR: 0.871; 95% CI: 0.770-0.987); the highest-ranked treatment based on P scores was edoxaban.

CONCLUSIONS

The use of DOAC in AF significantly reduces dementia risk compared with warfarin, particularly in Asian patients. The possible reversal of this effect with increasing age merits further randomized trials with long-term follow-up. (Dementia Risk of Direct Oral Anticoagulants Versus Warfarin for Atrial Fibrillation: A Systematic Review and Meta-Analysis; CRD42022365634).

The gray areas of oral anticoagulation for prevention of thromboembolic events in atrial fibrillation patients

Thromboembolic events (TEE) associated with atrial fibrillation (AF) are highly recurrent and usually severe, causing permanent disability or, even, death. Previous data consistently showed significantly lower TEE in anticoagulated patients. While warfarin, a vitamin K antagonist, is still used worldwide, direct-acting oral anticoagulants (DOACs) have shown noninferiority to warfarin in the prevention of TEE, and represent, to date, the preferred treatment. DOACs present favorable pharmacokinetic, safety and efficacy profiles, especially among vulnerable patients including the elderly, those with renal dysfunction or previous TEE. Yet, regarding specific settings of AF patients it is unclear whether oral anticoagulation therapy is beneficial, or otherwise it is the maintenance of sinus rhythm, mostly achieved through a catheter ablation-based rhythm control strategy, that prevents the causal complications linked to AF. While it is known that low-risk patients [CHA2DS2-VASc 0 (males), or score of 1 (females)] present low ischemic stroke or mortality rates (<1%/year), it remains unclear whether they need any prophylaxis. Furthermore, the appropriate anticoagulation regimen for those individuals requiring cardioversion, either pharmacologic or electric, as well as peri-procedural anticoagulation in patients undergoing trans-catheter ablation that nowadays encompasses different energies, are still a matter of debate. In addition, AF concomitant with other clinical conditions is discussed and, lastly, the choice of prescribing anticoagulation to asymptomatic patients diagnosed with subclinical AF at either wearable or implanted devices. The aim of this review will be to provide an update on current strategies in the above-mentioned settings, and to suggest possible therapeutic options, finally focusing on AF-related cognitive decline.

Clinical implications of different types of dementia in patients with atrial fibrillation: Insights from a global federated health network analysis

BACKGROUND

Atrial fibrillation (AF) associates with higher Alzheimer's disease (AD) and vascular dementia risks but the clinical implications have been scarcely investigated. We examined the association between AD or vascular dementia and adverse outcomes in AF patients.

METHODS

Cohort study between January 2000 and 2017. AF patients were divided into two groups according to vascular dementia or AD, and balanced using propensity score matching (PSM). During 4-years of follow-up, incident intracranial hemorrhages (ICH), the composite of ischemic stroke/transient ischemic attack (TIA), hospitalizations, and all-cause deaths, were recorded.

RESULTS

Two thousand three hundred seventy-seven AF patients with dementia (1225 with vascular dementia, and 1152 with AD) were identified. Following a PSM, 615 patients were included in each cohort (i.e., 1:1) and all variables were well-matched. After PSM, 22 (3.6%) patients with vascular dementia and 55 (8.1%) patients with AD had incident ICH during follow-up (hazard ratio [HR]: 2.22, 95% confidence interval [CI]: 1.33-3.70, log-rank p = 0.002). Overall, 237 (38.5%) patients with vascular dementia and 193 (31.4%) patients with AD, developed an ischemic stroke/TIA. The risk of ischemic stroke/TIA was 1.32-fold higher in vascular dementia (HR: 1.32, 95% CI: 1.09-1.59, log-rank p = 0.003). The risk of rehospitalization (HR: 1.14, 95% CI: 1.01-1.31), and mortality (HR: 1.25, 95% CI: 1.01-1.58) were also higher among AF patients with vascular dementia compared to AD.

CONCLUSIONS

The two forms of dementia in AF patients are associated with different prognosis, with AD being associated with a higher risk of ICH, and vascular dementia with a higher risk of stroke/TIA, hospitalization, and mortality.

Impact of atrial fibrillation on the cognitive decline in Alzheimer's disease

BACKGROUND

Atrial fibrillation (AF) is a strong risk factor for Alzheimer's disease (AD) independent of ischemic stroke. However, the clinicopathological impact of AF on the severity of AD has not been well elucidated. We aimed to investigate the clinical differences between dementia patients with AF and those without AF by means of imaging data.

METHODS

Following approval from the institutional ethics committee, patients with newly diagnosed AD or amnestic mild cognitive impairment (aMCI) were retrospectively screened (n = 170, 79.5 ± 7.4 years old). Cognitive function was assessed using the Mini-Mental State Examination (MMSE). Based on the MRI data, the cerebral volume, cerebral microbleeds (CMBs), periventricular white matter lesions (WMLs), and deep WMLs were evaluated. The regional cerebral blood flow (rCBF) was measured using ¹²³I-IMP SPECT.

RESULTS

Of the patients, 14 (8.2%) and 156 (91.8%) had AF (AF group) and sinus rhythm (SR group), respectively. The AF group had significantly lower MMSE scores than the SR group (average [standard deviation (SD)]: 19.4 [4.4] and 22.0 [4.4], respectively; p = 0.0347). Cerebral volume and CMBs did not differ between the two groups. The periventricular WMLs, but not the deep WMLs, were significantly larger in the AF group than in the SR group (mean [SD] mL: 6.85 [3.78] and 4.37 [3.21], respectively; p = 0.0070). However, there was no significant difference in rCBF in the areas related to AD pathology between the two groups.

CONCLUSION

AD and aMCI patients with AF showed worse cognitive decline along with larger periventricular WMLs compared to those with SR, although the reduction of rCBF was not different between patients with AF and SR. The white matter lesions may be a more important pathology than the impairment of cerebral blood flow in dementia patients with AF. A larger study is needed to confirm our findings in the future.

Comparative risk of dementia among patients with atrial fibrillation treated with catheter ablation versus anti-arrhythmic drugs

Atrial fibrillation (AF) is associated with an increased risk of dementia. Emerging evidence suggests AF suppression is associated with reduced risk of dementia, but the optimal strategy to achieve this is unknown. We sought to compare the risk of dementia in patients with AF who underwent catheter ablation (CA) versus anti-arrhythmic drug (AAD) treatment. METHODS AND RESULTS: Using the 2000 to 2021 Optum Clinformatics database, patients with AF who underwent CA versus AAD treatment (≥1 prescription fill for ≥2 different AADs) were identified and propensity score matched overall and within sex subgroups. A cause-specific hazard model was performed to assess dementia overall and in sex-specific subgroups. After matching, there were 19,088 patients per group. CA was associated with a 41% lower risk of dementia compared with AAD alone (1.9% vs 3.3%; hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.52-0.67, log-rank P < .0001). When examined by sex, dementia risk reduction associated with CA versus AAD use alone was observed among both males (HR 0.55, 95% CI 0.46-0.66) and females (HR 0.60, 95% CI 0.50-0.72). Though not studied as a primary outcome, patients treated with CA were also observed to have 49% lower associated risk of mortality compared with AAD only (HR 0.51 95% CI 0.46-0.55, P < .0001). CONCLUSIONS: Among patients treated for AF, CA was associated with significantly lower risk of dementia and death compared with AADs only. These reductions in risk associated with CA versus AAD were seen in both males and females.

Cardiovascular risk in subjects over 55 years of age and cognitive performance after five years. NEDICES2-RISK study. Study protocol

BACKGROUND

Cognitive impairment and dementia have a high prevalence among the elderly and cause significant socio-economic impact. Any progress in their prevention can benefit millions of people. Current data indicate that cardiovascular risk (CVR) factors increase the risk of developing cognitive impairment and dementia. Using models to calculate CVR specific for the Spanish population can be useful for estimating the risk of cognitive deterioration since research on this topic is limited and predicting this risk is mainly based on outcomes in the Anglo-Saxon population. The aim of this study is to assess the relationship between CVR in the Spanish population, as calculated using the FRESCO (Función de Riesgo Española de acontecimientos Coronarios y Otros) and REGICOR (Registre Gironí del Cor) CVR tables, and the change in cognitive performance at a 5-year follow-up.

METHODS

Design: Observational, analytic, prospective cohort study, with a 5-year follow-up. Ambit: Population. Population: Subjects 55 to 74 years of age, included in the NEDICES2 (2014-2017) cohort, who did not present dementia and had undergone the neuropsychological evaluation (N = 962). Variables: Exposure factors (CVR factors and estimated risk according to the CVR predictors by REGICOR and FRESCO), dependent variables (change in the score of the brief neuropsychological test in the study NEDICES2 five years after the first evaluation), and clinical and socio-demographic variables. Statistical analysis: Analysis of data quality. Descriptive analysis: socio-demographic and clinical variables of subjects. Bivariate analysis: relationship between basal CVR and change in neuropsychological tests. Multivariate analysis: relationship between basal CVR and change in neuropsychological tests adjusted by co-variables. Analysis and comparison of the reliable change in independent samples.

DISCUSSION

The Spanish population can benefit from determining if individuals with high CVR, which is commonly detected in usual clinical practice, will present decreased cognitive performance compared to subjects with lower CVR. This study can affect how to address CVR factors and the design of effective prevention strategies for cognitive deterioration.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03925844.

Insights from computational modeling on the potential hemodynamic effects of sinus rhythm versus atrial fibrillation

Atrial fibrillation (AF) is the most common clinical tachyarrhythmia, posing a significant burden to patients, physicians, and healthcare systems worldwide. With the advent of more effective rhythm control strategies, such as AF catheter ablation, an early rhythm control strategy is progressively demonstrating its superiority not only in symptoms control but also in prognostic terms, over a standard strategy (rate control, with rhythm control reserved only to patients with refractory symptoms). This review summarizes the different impacts exerted by AF on heart mechanics and systemic circulation, as well as on cerebral and coronary vascular beds, providing computational modeling-based hemodynamic insights in favor of pursuing sinus rhythm maintenance in AF patients.

Strategies for Maintaining Brain Health: The Role of Stroke Risk Factors Unique to Elderly Women

Stroke risk and prevalence increase with advanced age and women tend to be older than men at the time of their first stroke. Advanced age in women confers unique stroke risks that are beyond reproductive factors. Previous reviews and guidelines have largely focused on risk factors specific to women, with a predominant focus on reproductive factors and, therefore, younger to middle-aged women. This review aims to specifically describe stroke risk factors in elderly women, the population of women where the majority of strokes occur, with a focus on atrial fibrillation, hormone therapy, psychosocial risk factors, and cognitive impairment. Our review suggests that prevention and management of stroke risks that are unique or more prevalent in elderly women needs a coordinated system of care from general physicians, general neurologists, vascular and cognitive neurologists, psychologists, cardiologists, patients, and their caretakers. Early identification and management of the elderly woman-specific and traditional stroke risk factors is key for decreasing stroke burden in elderly women. Increased education among elderly women regarding stroke risk factors and their identification should be considered, and an update to the guidelines for prevention of stroke in women is strongly encouraged.

Atrial Fibrillation and the Risk of Early‐Onset Dementia: A Systematic Review and Meta‐Analysis

Background

Recent studies have identified an increased risk of dementia in patients with atrial fibrillation (AF). However, both AF and dementia usually manifest late in life. Few studies have investigated this association in adults with early‐onset dementia. The aim of this study was to investigate the relationship between AF and early‐onset dementia.

Methods and Results

We searched the PubMed/MEDLINE, Embase, and Scopus databases through April 15, 2022, for studies reporting on the association between AF and dementia in adults aged <70 years, without language restrictions. Two reviewers independently performed the study selection, assessed the risk of bias, and extracted the study data. We performed a meta‐analysis of early‐onset dementia risk according to occurrence of AF using a random‐effects model. We retrieved and screened 1006 potentially eligible studies. We examined the full text of 33 studies and selected the 6 studies that met our inclusion criteria. The pooled analysis of their results showed an increased risk of developing dementia in individuals with AF, with a summary relative risk of 1.50 (95% CI, 1.00–2.26) in patients aged <70 years, and 1.06 (95% CI, 0.55–2.06) in those aged <65 years.

Conclusions

In this systematic review and meta‐analysis, AF was a risk factor for dementia in adults aged <70 years, with an indication of a slight and statistically imprecise excess risk already at ages <65 years. Further research is needed to assess which characteristics of the arrhythmia and which mechanisms play a role in this relationship.

Association of Catheter Ablation and Reduced Incidence of Dementia among Patients with Atrial Fibrillation during Long-Term Follow-Up: A Systematic Review and Meta-Analysis of Observational Studies

Background: Atrial fibrillation (AF) is independently associated with the onset of cognitive decline/dementia. AF catheter ablation (AFCA) is the most effective treatment strategy in terms of sinus rhythm maintenance, but its effects on dementia prevention remain under investigation. The aim of the present study was to perform a systematic review and meta-analysis of the presently available studies exploring the effect of AFCA on dementia occurrence. Methods: PubMed/MEDLINE databases were screened for articles through 14 March 2022 reporting adjusted time-to-event outcome data comparing AFCA and non-AFCA cohorts in terms of de novo dementia occurrence. A random effect meta-analysis was performed to estimate the meta-analytic hazard ratio (HR) of dementia occurrence in AFCA vs. non-AFCA cohorts, as well as the meta-analytic incidence rate of dementia in the non-AFCA cohort. Based on the aforementioned estimates, the number needed to treat (NNT), projected at median follow-up, was derived. Results: Four observational studies were included in the analysis, encompassing 40,146 patients (11,312 in the AFCA cohort; 28,834 in the non-AFCA cohort). AFCA conferred a significant protection to the development of dementia with an overall HR of 0.52 (95% CI 0.35–0.76). The incidence rate of dementia in the non-AFCA group was 1.12 events per 100 person-year (95% CI 0.47–2.67). The derived NNT projected to the median follow-up (4.5 years) was 41. Conclusion: AFCA is associated with a nearly 50% reduction in dementia occurrence during a median 4.5-year follow-up. Future randomized clinical trials are needed to reinforce these findings.

Rhythm Control Better Prevents Dementia than Rate Control Strategies in Patients with Atrial Fibrillation-A Nationwide Cohort Study

Background: Atrial fibrillation (AF) increases the risk of dementia. Whether the pharmacological rhythm control of AF can reduce the risk of dementia compared to the rate control strategy remains unclear. We hypothesize that the rhythm control strategy is better than the rate control strategy in preventing dementia. Methods: AF patients aged ≥65 years were identified from the Taiwan National Health Insurance Database. Patients receiving anti-arrhythmic drugs at a cumulative defined daily dose (cDDD) of >30 within the first year of enrollment constituted the rhythm control group. Patients who used rate control medications for a cDDD of >30 constituted the rate control group. A multivariate Cox hazards regression model was used to determine the hazard ratio (HR) for dementia. Results: A total of 3382 AF patients (698 in the rhythm control group; 2684 in the rate control group) were analyzed. During a 4.86 ± 3.38 year follow-up period, 414 dementia events occurred. The rhythm control group had a lower rate of dementia than the rate control group (adjust HR: 0.75, p = 0.031). The rhythm control strategy reduced the risk of dementia particularly in those receiving aspirin (p = 0.03). Conclusions: In patients with AF, pharmacological rhythm control was associated with a lower risk of dementia than rate control over a long-term follow-up period, particularly in patients receiving aspirin treatment.

Atrial Fibrillation and Dementia: Epidemiological Insights on an Undervalued Association

Background and objectives: Atrial fibrillation (AF) and dementia are growing causes of morbidity and mortality, representing relevant medical and socioeconomic burdens. In this study, based on data from the Global Burden of Disease Injuries and Risk Factors Study (GBD) 2019, we focused on AF and dementia distribution and investigated the potential correlation between the two epidemiological trends. Materials and Methods: Crude and age-standardized incidence, prevalence, mortality rate, and disability-adjusted life years (DALYs) lost, derived from GBD 2019, were reported for AF and dementia. Global features were also stratified by high and low sociodemographic-index (SDI) countries. Granger test analysis was performed to investigate the correlation between AF and dementia incidence time trends. Results: From 1990 to 2019 crude worldwide incidence and prevalence showed a dramatic increase for both conditions (from 43.24 to 61.01 and from 528.72 to 771.51 per 100,000 individuals for AF, respectively; from 54.60 to 93.52 and from 369.88 to 667.2 per 100,000 individuals for dementia, respectively). In the same timeframe, crude mortality rate doubled for AF and dementia (from 2.19 to 4.08, and from 10.49 to 20.98 per 100,000 individuals, respectively). Age-standardized estimate showed a substantial stability over the years, highlighting the key role of the progressively aging population. Crude estimates of all of the investigated metrics are greater in high SDI countries for both conditions. This association was still valid for age-standardized metrics, albeit by a reduced magnitude, suggesting the presence of higher risk factor burden in these countries. Finally, according to Granger test, we found a significant association between the historical trends of AF and dementia incidence (p = 0.004). Conclusions: AF and dementia burden progressively increased in the last three decades. Given the potential association between these two conditions, further clinical data assessing this relationship is needed.

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.

Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines

BACKGROUND

The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS).

METHODS AND RESULTS

In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms.

CONCLUSIONS

On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.

[Atrial fibrillation and cognitive impairment: features of the relationship, developmental and prevention mechanisms]

The article discusses the development of cognitive deficit in patients with atrial fibrillation (AF) and provides data on mechanisms of the development of cognitive disorders in AF. Under discussion are a possibility of reducing the risk of cognitive disorders with the anticoagulant therapy for prevention of stroke in AF and different properties of different anticoagulants, which may be important for patients. Thus, patients with cognitive disorders are more prone to missing the dose, which may entail serious, possibly fatal consequences. Therefore, the convenience of dosing may be essential. The drug rivaroxaban that has once-a-day dosing schedule and a calendar package, may help the patient better adhere to the doctor's recommendations. Therefore, rivaroxaban may help improving the compliance, which is the major condition for comprehensive, necessary protection of an elderly patient with AF, including the protection, with high safety, from stroke, from the risk of coronary complications, and from the impairment of kidney function.

Cardiovascular disease and the risk of dementia: a survival analysis using administrative data from Manitoba

OBJECTIVES

Recent research has shown that cardiovascular disease (CVD) raises the risk of dementia and other forms of cognitive decline. Generally, these studies are unable to model the time of diagnosis of CVD in their analyses and treat CVD as a time-fixed variable. Our objective was to assess the risk of being diagnosed with dementia for individuals diagnosed with CVD when CVD is time-dependent.

METHODS

We performed a retrospective cohort study using administrative health datasets from the Manitoba Population Research Data Repository in Canada. We constructed a longitudinal dataset to track individuals enrolled in the Manitoba Health Insurance Registry between April 1, 1997 and March 31, 2015. The study population consisted of 496,192 individuals 30 years of age or older who were not diagnosed with CVD or dementia prior to April 1, 1997. Diagnoses of CVD and dementia were based on diagnosis codes from medical claims and hospitalizations and the use of prescription medications. Hazard ratios were then computed using adjusted Cox-proportional hazards analyses.

RESULTS

Among the CVD subgroups considered, atrial fibrillation, ischemic heart disease, and stroke increased the risk of developing dementia, with stroke doubling one's risk of being diagnosed with the disease (hazard ratio: 1.95; 95% confidence interval: 1.9, 2.01). Age, lower socioeconomic status, and worsening comorbidities also increased the risk of being diagnosed with dementia.

CONCLUSION

A diagnosis of CVD is associated with an increased risk of a future diagnosis of dementia. Promoting good cardiovascular health may serve as an effective measure for preventing dementia.

Differential Risk of Dementia Between Patients With Atrial Flutter and Atrial Fibrillation: A National Cohort Study

Objectives: Atrial fibrillation (AF) is linked to an increased risk of stroke and dementia. Atrial flutter (AFL) is also linked to an increased risk of stroke but at a different level of risk as compared to AF. Little is known about the difference in the risk of dementia between AF and AFL. This study aims to investigate whether the risk of dementia is different between AF and AFL.

Methods: Patients with newly diagnosed AF and AFL during 2001–2013 were retrieved from Taiwan's National Health Insurance Research Database. Patients with incomplete demographic data, aged <20 years, history of valvular surgery, rheumatic heart disease, hyperthyroidism, and history of dementia were excluded. The incidence of new-onset dementia was set as the primary outcome and analyzed in patients with AF and AFL after propensity score matching (PSM).

Results: A total of 232,425 and 7,569 patients with AF and AFL, respectively, were eligible for analysis. After 4:1 PSM, we included 30,276 and 7,569 patients with AF and AFL, respectively, for analysis. Additionally, patients with AF (n = 29,187) and AFL (n = 451) who received oral anticoagulants were enrolled for comparison. The risk of dementia was higher in patients with AF compared with patients with AFL (subdistribution hazard ratio (SHR) = 1.52, 95% CI 1.39–1.66; p < 0.0001) before PSM and remained higher in patients with AF (SHR = 1.14, 95% CI 1.04–1.25; p = 0.0064) after PSM. The risk of dementia was higher in patients with AF without previous history of stroke after PSM but the risk did not differ between patients with AF and AFL with previous history of stroke. Among patients who received oral anticoagulants, the cumulative incidences of dementia were significantly higher in patients with AF than in patients with AFL before and after PSM (all P < 0.05).

Conclusions: This study found that, among patients without history of stroke, the risk of dementia was higher in patients with AF than in patients with AFL, and CHA₂DS₂-VASc score might be useful for risk stratification of dementia between patients with AF and AFL.

Serum Levels of the Biomarkers Associated with Astrocytosis, Neurodegeneration, and Demyelination: Neurological Benefits of Citicoline Treatment of Patients with Ischemic Stroke and Atrial Fibrillation

Ischemic stroke is a main complication of atrial fibrillation (cardiac arrhythmia). The aim of our study was to estimate the effects of citicoline (CDP-choline) therapy on the levels of circulating neurospecific protein markers in serum of the patients with ischemic stroke and atrial fibrillation. Fiftyfour patients (mean age 76 years) treated with citicoline in a dose of 2.0 g daily intravenously for 12 to 14 days in addition to basic treatment formed the examined group. Thirty-two patients (mean age 68.5 years) obtained only standard therapy and formed the control group. Serum levels of neuronal and glial protein markers, including glial fibrillary acidic protein (GFAP), a neurofilament light subunit (NF-L), myelin basic protein (MBP), and ionized calcium-binding adaptor molecule 1 (Iba1), were measured in patients of both groups before and after treatment; an immunoblotting technique followed by densitometry analysis were used. Supplementary citicoline treatment provided significant reductions of the levels of GFAP (33%, P = 0.034), NF-L (27%, P = 0.019), and MBP (32%, P = 0.018), as compared to the initial values, while there were no marked changes in the studied parameters in the control group. The results obtained allow us to hypothesize that therapeutic benefit of citicoline in patients with ischemic stroke and atrial fibrillation can be mediated through increasing neuronal viability, protecting against axonal injury, decreasing the level of reactive astrogliosis, preventing deficiencies in the blood-brain integrity, and reducing the intensity of demyelination. However, citicoline administration exerted no effect on the blood content of microglial marker Iba-1, thus possibly preserving an important functional significance of microglia, which is needed to resolve local inflammation and clear cellular debris, and also provide protective factors to reduce cell injury in the ischemic brain. The obtained results indicate that serum levels of neurospecific biomarkers are significant and clinically relevant indices of the efficiency of treatment of the above-mentioned pathologies and can be used for further investigations of the stroke pathophysiology and molecular mechanisms of nootropic-mediated neuroprotection.

Atrial Fibrillation Is Associated with Cognitive Impairment, All-Cause Dementia, Vascular Dementia, and Alzheimer's Disease: a Systematic Review and Meta-Analysis

BACKGROUND

Atrial fibrillation (AF) is a risk factor for cognitive impairment and dementia in patients with stroke history. However, the association between AF and cognitive impairment in broader populations is less clear.

OBJECTIVE

To systematically review and quantitatively synthesize the existing evidence regarding the association of AF with cognitive impairment of any severity and etiology and dementia.

METHODS

Medline, Scopus, and Cochrane Central were searched in order to identify studies investigating the association between AF and cognitive impairment (or dementia) cross-sectionally and longitudinally. Studies encompassing and analyzing exclusively patients with stroke history were excluded. A random-effects model meta-analysis was conducted. Potential sources of between-study heterogeneity were investigated via subgroup and meta-regression analyses. Sensitivity analyses including only studies reporting data on stroke-free patients, vascular dementia, and Alzheimer's disease were performed.

RESULTS

In total, 43 studies were included. In the pooled analysis, AF was significantly associated with dementia (adjusted OR, 1.6; 95% CI, 1.3 to 2.1; I², 31%) and the combined endpoint of cognitive impairment or dementia (pooled adjusted OR, 1.5; 95% CI, 1.4 to 1.8; I², 34%). The results were significant, even when studies including only stroke-free patients were pooled together (unadjusted OR, 2.2; 95% CI, 1.4 to 3.5; I², 96%), but the heterogeneity rates were high. AF was significantly associated with increased risk of both vascular (adjusted OR, 1.7; 95% CI, 1.2 to 2.3; I², 43%) and Alzheimer's dementia (adjusted HR, 1.4; 95% CI, 1.2 to 1.6; I², 42%).

CONCLUSION

AF increases the risk of cognitive impairment, all-cause dementia, vascular dementia, and Alzheimer's disease. Future studies should employ interventions that may delay or even prevent cognitive decline in AF patients.

Risk of dementia in patients with atrial fibrillation: Short versus long follow-up. A systematic review and meta-analysis

BACKGROUND

No previous meta-analyses have compared the risk of dementia, due to an underlying atrial fibrillation (AF), in the short-term versus the long-term period.

AIM

To perform an update meta-analysis of studies examining the association between AF and dementia and the relative impact of follow-up period.

METHODS

Data were obtained searching MEDLINE and Scopus for all investigations published between 1 January 2000 and March 1, 2021 reporting the risk of dementia in AF patients. The following MeSH terms were used for the search: "Atrial Fibrillation" AND "Dementia" OR "Alzheimer's disease". From each study, the adjusted hazard ratio (aHR) with the related 95% confidence interval (CI) was pooled using a random effect model.

RESULTS

The analysis was carried out on 18 studies involving 3.559.349 subjects, of which 902.741 (25.3%) developed dementia during follow-up. A random effect model revealed an aHR of 1.40 (95% CI: 1.27-1.54, p < 0.0001; I2  = 93.5%) for dementia in subjects with AF. Stratifying the studies according to follow-up duration, those having a follow-up ≥10 years showed an aHR for dementia of 1.37 (95% CI: 1.21-1.55, p < 0.0001, I2  = 96.6%), while those with a follow-up duration <10 years has a slightly higher aHR for dementia (HR: 1.59, 95%CI: 1.51-1.67, p < 0.0001, I2  = 49%). Nine studies showed that the aHR for Alzheimer's disease (AD) in AF patients was 1.30 (95%CI: 1.12-1.51, p < 0.0001, I2  = 87.6%).

CONCLUSIONS

Evidence suggests that patients with AF have an increased risk of developing dementia and AD. The risk of dementia was slightly higher when the follow-up was shorter than 10 years.

Association Between Bipolar Disorder or Schizophrenia and Oral Anticoagulation Use in Danish Adults With Incident or Prevalent Atrial Fibrillation

IMPORTANCE

Individuals with bipolar disorder or schizophrenia have a higher risk of adverse outcomes from cardiovascular diseases. Oral anticoagulation therapy (OAT) for patients with atrial fibrillation (AF) is needed for stroke prevention, but whether patients with bipolar disorder or schizophrenia face disparities in receiving this therapy is unknown.

OBJECTIVE

To assess whether bipolar disorder or schizophrenia is associated with a lower rate of OAT initiation in patients with incident AF and lower prevalence of OAT in those with prevalent AF.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide cohort study of Danish patients with AF was conducted from January 1, 2005, to December 31, 2016, and data were analyzed from January 1 to June 15, 2020. Data from national registries included information on all redeemed prescriptions and all hospital contacts of all patients with incident or prevalent AF (age, 18-100 years) and increased risk status, defined by a CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) risk score greater than or equal to 2.

EXPOSURES

Hospital diagnosis of bipolar disorder or schizophrenia.

MAIN OUTCOMES AND MEASURES

Adjusted proportion differences for OAT initiation and OAT prevalence, comparing individuals with and without bipolar disorder or schizophrenia.

RESULTS

Patients included with incident AF (n = 147 810) had a mean (SD) age of 76.9 (10.1) years, 78 577 (53.2%) were women, 1208 (0.8%) had bipolar disorder, and 572 (0.4%) had schizophrenia. Accounting for age, sex, and calendar time, bipolar disorder and schizophrenia were associated with significantly lower frequency of OAT initiation within 90 days after incident AF (bipolar disorder: -12.7%; 95% CI, -15.3% to -10.0%; schizophrenia: -24.5%; 95% CI, -28.3% to -20.7%) and lower OAT prevalence in patients with prevalent AF (bipolar disorder: -11.6%; 95% CI, -13.9% to -9.3% schizophrenia: -21.6%; 95% CI, -24.8% to -18.4%). Adjusting for socioeconomic factors and other comorbid conditions attenuated these associations, particularly for patients with bipolar disorder. However, schizophrenia continued to be associated with a with a lower rate of OAT initiation (-15.5%, 95% CI, -19.3% to -11.7%) and a -12.8% (95% CI, -15.9% to -9.7%) lower OAT prevalence. These associations were also present after the introduction of non-vitamin K antagonists (adjusted proportion difference in 2013-2016: -12.4%; 95% CI, -18.7% to -6.1% for initiation and -10.1%; 95% CI, -13.8% to -6.4% for prevalence).

CONCLUSIONS AND RELEVANCE

In this study, patients with bipolar disorder or schizophrenia were less likely to receive OAT in the setting of AF. For patients with bipolar disorder, this deficit was largely associated with socioeconomic factors and comorbidities, especially toward the end of the study period. For patients with schizophrenia, disparities in this stroke prevention therapy persistently exceeded what could be explained by other patient characteristics.

Increased beat-to-beat variability of cerebral microcirculatory perfusion during atrial fibrillation: a near-infrared spectroscopy study

AIMS

Atrial fibrillation (AFib) is associated with cognitive decline/dementia, independently from clinical strokes or transient ischaemic attacks (TIA). Recent in silico data suggested that AFib may induce transient critical haemodynamic events in the cerebral microcirculation. The aim of this study is to use non-invasive spatially resolved cerebral near-infrared spectroscopy (SRS-NIRS) to investigate in vivo beat-to-beat microcirculatory perfusion during AFib and after sinus rhythm (SR) restoration.

METHODS AND RESULTS

Cerebral SRS-NIRS with high-frequency sampling (20 Hz) and non-invasive systemic haemodynamic monitoring were recorded before and after elective electrical cardioversion (ECV) for AFib or atrial flutter (AFL). To assess beat-to-beat effects of the rhythm status, the frequency distribution of inter-beat differences in tissue haemoglobin index (THI), a proxy of microcirculatory cerebral perfusion, was compared before and after SR restoration. Fifty-three AFib/AFL patients (mean age 69 ± 8 years, 79% males) were ultimately enrolled. Cardioversion was successful in restoring SR in 51 (96%) patients. In front of a non-significant decrease in arterial blood pressure extreme events between pre- and post-ECV measurements, a significant decrease of both hypoperfusive and hyperperfusive/hypertensive microcirculatory events was observed after SR restoration (P < 0.001 and P = 0.041, respectively).

CONCLUSION

The present is the first in vivo demonstration that SR restoration by ECV significantly reduces the burden of extreme single-beat haemodynamic events in cerebral microcirculation. Future studies are needed to assess whether SR maintenance might slow long-term AFib-correlated cognitive decline/dementia.

Research Priorities in Atrial Fibrillation Screening: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop

Clinically recognized atrial fibrillation (AF) is associated with higher risk of complications, including ischemic stroke, cognitive decline, heart failure, myocardial infarction, and death. It is increasingly recognized that AF frequently is undetected until complications such as stroke or heart failure occur. Hence, the public and clinicians have an intense interest in detecting AF earlier. However, the most appropriate strategies to detect undiagnosed AF (sometimes referred to as subclinical AF) and the prognostic and therapeutic implications of AF detected by screening are uncertain. Our report summarizes the National Heart, Lung, and Blood Institute's virtual workshop focused on identifying key research priorities related to AF screening. Global experts reviewed major knowledge gaps and identified critical research priorities in the following areas: (1) role of opportunistic screening; (2) AF as a risk factor, risk marker, or both; (3) relationship between AF burden detected with long-term monitoring and outcomes/treatments; (4) designs of potential randomized trials of systematic AF screening with clinically relevant outcomes; and (5) role of AF screening after ischemic stroke. Our report aims to inform and catalyze AF screening research that will advance innovative, resource-efficient, and clinically relevant studies in diverse populations to improve the diagnosis, management, and prognosis of patients with undiagnosed AF.

Opportunistic atrial fibrillation screening and detection in "self-service health check-up stations": a brief overview of current technology potential and possibilities

Up to a fifth of patients who suffer a stroke had undiagnosed atrial fibrillation (AF). About 30% of AF patients are asymptomatic and remain undiagnosed, so there are no obvious (to the patient) forewarnings. Opportunistic screening for AF applied to the above clinical situation can save lives, since the strokes that occur as a result of AF are often large, severely debilitating or fatal. Today, anyone can buy a good, FDA-approved mobile electrocardiogram (ECG) device/smartwatch for AF detection on Amazon for €100-400, but not very many asymptomatic AF patients, particularly older patients, will do so on their own. In this article, we introduce the concept and potential benefits of opportunistic AF screening and detection in a community setting using the latest generation of affordable digital ECG capture and interpretation solutions integrated into easy-to-use "self-service health check-up stations" installed in public spaces, such as supermarkets and pharmacies. A comprehensive trial of the proposed self-service health check-up stations for AF screening is needed to produce more evidence to convince decision makers to fully buy into the idea of a nation-wide screening programme using these kiosks.

Association of Risk of Dementia With Direct Oral Anticoagulants Versus Warfarin Use in Patients With Non-valvular Atrial Fibrillation: A Systematic Review and Meta-analysis

ABSTRACT

Atrial fibrillation (AF) is associated with an increased risk of dementia. Studies have shown the beneficial effects of anticoagulants in preventing dementia in this population. However, evidence around the use of direct oral anticoagulants (DOACs) versus warfarin in AF-related dementia prevention remains sparse. This systematic review and meta-analysis aimed to evaluate the use of DOACs versus warfarin in dementia prevention in this population. MEDLINE, EMBASE, PsycINFO, and the CENTRAL databases were systematically searched from its inception until May 2020. Nine studies (n = 611,069) were included for quantitative meta-analysis. DOACs use was associated with a lower risk of composite dementia outcomes compared with warfarin use [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.34-0.94, P = 0.03]. No significant difference was found in subtypes of dementia (vascular dementia, Alzheimer's disease, and cognitive disorder) between both groups. No significant difference in the risk of composite dementia outcomes between the dabigatran and warfarin groups (OR 0.97, 95% CI 0.88-1.08, P = 0.61). Apixaban (OR 0.58, 95% CI 0.50-0.67, P < 0.00001) and rivaroxaban (OR 0.67, 95% CI 0.61-0.75, P < 0.00001) use were both associated with a significantly lower risk of composite dementia outcomes compared with warfarin use. Findings need to be interpreted with caution because of low certainty of evidence. In conclusion, this systematic review and meta-analysis of 9 comparative studies demonstrated the superiority of DOACs over warfarin in prevention of dementia in AF. Future prospective trials with adequate follow-up period are warranted to ascertain its causal relationship.

Prevention of dementia in an ageing world: Evidence and biological rationale

As the population ages, the number of people with dementia is expected to increase in the coming decades, with consequences at the societal and individual levels. In this narrative review, we provide a summary of the scientific evidence concerning dementia prevention, with a focus on the following three strategies: 1) Targeting the body to protect the brain, including prevention and treatment of cardiovascular morbidity; 2) Compensatory interventions to counteract brain ageing, including education and life-long engagement in cognitively and socially stimulating activities; and 3) Lifespan health promotion, such as a physically active lifestyle, smoking cessation, and a healthy and balanced diet. Next, we consider the biological mechanisms by which these strategies may act by taking into account the main pathways implicated in the development and progression of dementia: neurodegeneration, brain resilience, vascular damage, neuroinflammation, and oxidative stress. Based on the current evidence, and in line with the declining trends of dementia incidence in high-income countries, we conclude that timely multidomain preventive actions are promising strategies to reduce the dementia epidemic worldwide. There is still a considerable gap between the epidemiological evidence and its underlying biological mechanisms. Filling this gap will be crucial to move forward in dementia prevention worldwide.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Pulmonary Vein Activity Organization to Determine Atrial Fibrillation Recurrence: Preliminary Data from a Pilot Study

Ablation of pulmonary veins has emerged as a key procedure for normal rhythm restoration in atrial fibrillation patients. However, up to half of ablated Atrial fibrillation (AF) patients suffer recurrences during the first year. In this article, simultaneous intra-atrial recordings registered at pulmonary veins previous to the ablation procedure were analyzed. Spatial cross-correlation and transfer entropy were computed in order to estimate spatial organization. Results showed that, in patients with arrhythmia recurrence, pulmonary vein electrical activity was less correlated than in patients that maintained sinus rhythm. Moreover, correlation function between dipoles showed higher delays in patients with AF recurrence. Results with transfer entropy were consistent with spatial cross-correlation measurements. These results show that arrhythmia drivers located at the pulmonary veins are associated with a higher organization of the electrical activations after the ablation of these sites.

Psychological aspects of atrial fibrillation: A systematic narrative review : Impact on incidence, cognition, prognosis, and symptom perception

PURPOSE OF THE REVIEW

Atrial fibrillation (AF) is the most frequent arrhythmia in the general population. This review aims to provide a comprehensive overview of the psychological aspects of AF, compiling evidence from epidemiological, clinical, and basic research sources.

RECENT FINDINGS

Findings from large-scale population-based and clinical longitudinal studies reveal an association between negative affectivity (e.g. depression) and the incidence and clinical prognosis of AF. Studies investigating the impact of work stress parameters on AF onset show conflicting results. Researchers have reported the impact of AF on cognitive decline and on health-related quality of life, and have highlighted the role of interoceptive cues in the development of AF symptom burden and gender differences in psychological covariates of AF. Among biological pathways linking psychosocial factors to AF, research on autonomic regulation has yielded the most evidence so far, showing that the onset of AF is associated with simultaneous sympatho-vagal activation rather than an increase in vagal or sympathetic drive alone. Thus, modulation of the autonomic nervous system is likely to be a promising strategy for protecting the myocardium from pro-arrhythmic autonomic influences. In total, the findings show that AF is embedded as a disease condition in a psycho-societal context and is not an isolated medical problem per se. A broader perspective than a focus on the electrophysiology alone is urgently needed.

Epidemiology of Atrial Fibrillation in the 21st Century: Novel Methods and New Insights

Accompanying the aging of populations worldwide, and increased survival with chronic diseases, the incidence and prevalence of atrial fibrillation (AF) are rising, justifying the term global epidemic. This multifactorial arrhythmia is intertwined with common concomitant cardiovascular diseases, which share classical cardiovascular risk factors. Targeted prevention programs are largely missing. Prevention needs to start at an early age with primordial interventions at the population level. The public health dimension of AF motivates research in modifiable AF risk factors and improved precision in AF prediction and management. In this review, we summarize current knowledge in an attempt to untangle these multifaceted associations from an epidemiological perspective. We discuss disease trends, preventive opportunities offered by underlying risk factors and concomitant disorders, current developments in diagnosis and risk prediction, and prognostic implications of AF and its complications. Finally, we review current technological (eg, eHealth) and methodological (artificial intelligence) advances and their relevance for future prevention and disease management.