Cyclosporine may affect improvement of cognitive brain function after successful cardiac transplantation

The impact of postoperative cognitive impairment on mid-term survival after heart transplantation

BACKGROUND

Heart transplantation is the definitive therapy for patients with end-stage heart failure. Antecedent studies reported that a substantial proportion of heart transplant recipients developed postoperative cognitive impairment in the long term. However, no studies have explored the association between postoperative cognitive impairment and survival after heart transplantation.

METHODS

The data of 43 adult patients who underwent heart transplantation were consecutively enrolled and assessed using the MMSE and MoCA neuropsychological tests. Kaplan-Meier curves and Cox proportional hazards models were used for survival analyses. Primary component analysis was performed to integrate MoCA subtests into the "Attention factor," "Naming factor," and "Orientation factor."

RESULTS

About 30% of the patients were diagnosed with short-term postoperative cognitive impairment. The impairment group was older and had lower baseline cognitive performances, larger LV diameter, worse MMSE decline and higher ratio of significant MoCA decline. Postoperative cognitive impairment was significantly associated with worse survival (P = .028). Multivariate Cox analyses showed that higher postoperative MoCA score was significantly associated with lower mid-term post-transplant mortality (HR = .744 [.584, .949], P = .017), in which "Attention factor" contributed to this association most (HR = .345 [.123, .970], P = .044) rather than "Naming factor" or "Orientation factor." Notably, preoperative cognitive impairment was closely related with postoperative cognitive impairment and also indicated the worse post-transplant survival (P = .015).

CONCLUSION

Postoperative as well as preoperative cognitive impairments were associated with a worse mid-term survival after heart transplantation, indicating that neuropsychological assessments before and after heart transplantation should be routinely performed for heart transplant recipients for better risk stratification.

Tacrolimus Decreases Cognitive Function by Impairing Hippocampal Synaptic Balance: a Possible Role of Klotho

The influence of long-term tacrolimus treatment on cognitive function remains to be elucidated. Using a murine model of chronic tacrolimus neurotoxicity, we evaluated the effects of tacrolimus on cognitive function, synaptic balance, its regulating protein (Klotho), and oxidative stress in the hippocampus. Compared to vehicle-treated mice, tacrolimus-treated mice showed significantly decreased hippocampal-dependent spatial learning and memory function. Furthermore, tacrolimus caused synaptic imbalance, as demonstrated by decreased excitatory synapses and increased inhibitory synapses, and downregulated Klotho in a dose-dependent manner; the downregulation of Klotho was localized to excitatory hippocampal synapses. Moreover, tacrolimus increased oxidative stress and was associated with activation of the PI3K/AKT pathway in the hippocampus. These results indicate that tacrolimus impairs cognitive function via synaptic imbalance, and that these processes are associated with Klotho downregulation at synapses through tacrolimus-induced oxidative stress in the hippocampus.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes

BACKGROUND

Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood.

OBJECTIVES

To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact.

METHODS

Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6^th and 12^th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death.

RESULTS

43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA.

CONCLUSIONS

Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Heart and brain interactions in heart failure: Cognition, depression, anxiety, and related outcomes

BACKGROUND

Cognitive impairment, anxiety and depression are common in heart failure (HF) patients and its evolution is not fully understood.

OBJECTIVES

To assess the cognitive status of HF patients over time, its relation to anxiety and depression, and its prognostic impact.

METHODS

Prospective, longitudinal, single center study including patients enrolled in a structured program for follow-up after hospital admission for HF decompensation. Cognitive function, anxiety/depression state, HF-related quality of life (QoL) were assessed before discharge and during follow-up (between 6^th and 12^th month) using Montreal Cognitive Assessment (MoCA), Hospital Anxiety and Depression Scale (HADS) and Kansas City Cardiomyopathy Questionnaire, respectively. HF related outcomes were all cause readmissions, HF readmissions and the composite endpoint of all-cause readmissions or death.

RESULTS

43 patients included (67±11.3 years, 69% male); followed-up for 8.2±2.1 months. 25.6% had an abnormal MoCA score that remained stable during follow-up (22.6±4.2 vs. 22.2±5.5; p=NS). MoCA score <22 at discharge conferred a sixfold greater risk of HF readmission [HR=6.42 (1.26-32.61); p=0.025], also predicting all-cause readmissions [HR=4.00 (1.15-13.95); p=0.03] and death or all-cause readmissions [HR=4.63 (1.37-15.67); p=0.014]. Patients with higher MoCA score showed a greater ability to deal with their disease (p=0.038). At discharge, 14% and 18.6% had an abnormal HADS score for depression and anxiety, respectively, which remained stable during follow-up and was not related to MoCA.

CONCLUSIONS

Cognitive function, anxiety and depressive status remain stable in HF patients despite optimized HF therapy. Cognitive status shall be routinely screened to adopt attitudes that improve management as it has an impact on HF-related QoL and prognosis.

Impact of Cardiovascular Hemodynamics on Cognitive Aging

[Figure: see text].

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.

Cardiorespiratory Fitness Mediates Cognitive Performance in Chronic Heart Failure Patients and Heart Transplant Recipients

We compared cognitive profiles in chronic heart failure patients (HF), heart transplant recipients (HT) and healthy controls (HC) and examined the relationship between cardiorespiratory fitness (V˙O_2peak), peak cardiac output (CO_peak) and cognitive performance. Stable HT patients (n = 11), HF patients (n = 11) and HC (n = 13) (61.5 ± 8.5 years) were recruited. Four cognitive composite scores targeting different cognitive functions were computed from neuropsychological tests: working memory, processing speed, executive functions and verbal memory. Processing speed and executive function scores were higher, which indicates lower performances in HF and HT compared to HC (p < 0.05). V˙O_2peak and first ventilatory threshold (VT₁) were lower in HF and HT vs. HC (p < 0.01). CO_peak was lower in HF vs. HT and HC (p < 0.01). Processing speed, executive function and verbal memory performances were correlated with V˙O_2peak, VT₁ and peak cardiac hemodynamics (p < 0.05). Mediation analyses showed that V˙O_2peak and VT₁ mediated the relationship between group and processing speed and executive function performances in HF and HT. CO_peak fully mediated executive function and processing speed performances in HF only. V˙O_2peak and CO_peak were related to cognitive performance in the entire sample. In addition, V˙O_2peak and VT₁ fully mediated the relationship between group and executive function and processing speed performances.

Cardiac and Pulmonary Disorders and the Nervous System

PURPOSE OF REVIEW

This article reviews the neurologic complications encountered with cardiac and pulmonary disorders, specifically focusing on endocarditis, cardiac arrest, heart failure, hypercapnia, hypoxia, and cystic fibrosis. As neurologic dysfunction is one of the most frequent complications of these diseases and may even be the presenting symptom, it is important to be familiar with these complications to foster early recognition and intervention.

RECENT FINDINGS

Advances have been made in the identification of which patients can safely undergo valvular surgery for treatment of infective endocarditis in the setting of stroke, which, ideally, will minimize the risk of recurrent stroke in these patients. Additionally, technologic advances are improving our ability to use a multimodal approach for prognostication after cardiac arrest.

SUMMARY

The neurologic complications from the described disorders range from cerebrovascular complications to encephalitis, cognitive impairment, sleep-disordered breathing, headache, and increased intracranial pressure leading to coma or even death. Given the severity of these symptoms, it is paramount that neurologists be closely involved in the care of patients with neurologic complications from cardiac and pulmonary disorders.

Improvements in functional and cognitive status following short-term pulmonary rehabilitation in COPD lung transplant recipients: a pilot study

BACKGROUND

Pulmonary rehabilitation (PR) following lung transplantation (LTx) is considered part of the optimal treatment in chronic obstructive pulmonary disease (COPD) for favourable post-operative outcomes. We investigated the effects of a PR intervention in the post-transplant phase with regard to lung function, exercise responses and cognitive function in COPD LTx recipients.

METHODS

24 COPD LTx recipients (mean±sd forced expiratory volume in 1 s 75±22% predicted) were assigned to a comprehensive 3-week inpatient PR programme. Changes from PR admission to discharge in lung function variables, 6-min walk test-derived outcomes and cognitive function were assessed and examined for several factors. The magnitude of changes was interpreted by effect size (ES).

RESULTS

In response to the PR intervention, LTx recipients had improved lung function with regard to diffusing capacity of the lung for carbon monoxide (+4.3%; p=0.012) and static hyperinflation (residual volume/total lung capacity -2.3%; p=0.017), increased exercise capacity (6-min walk test +86 m; p<0.001), and had small to large improvements (ES range 0.23-1.00; all p≤0.34) in 50% of the administered cognitive tests. Learning skills and memory ability presented the greatest benefits (ES composite scores 0.62 and 0.31, respectively), which remained similar after stratification by single or bilateral LTx and sex.

CONCLUSIONS

PR is an effective treatment for LTx recipients in the post-transplant phase, improving lung function, exercise responses, and domains of cognitive function of learning, memory and psychomotor speed. PR may facilitate the course of post-operative treatment and should be recommended in LTx.

Impact of Immunosuppression on Executive Functioning After Pediatric Liver Transplantation: An Observational Cohort Study

OBJECTIVES

Children after liver transplantation show increased rates of impaired cognitive functioning. We aimed to assess the potential effects of immunosuppressive therapy on executive functioning measured by the Children's Color Trail Test and the cognitive functioning module of the PedsQL (cogPedsQL) in liver transplanted children to explore potential targets for intervention to improve executive functioning.

METHODS

We performed a cross-sectional study in 155 children (78 girls) aged 10.4 (2-18) years at 5.0 (0.1-17) years after liver transplantation, with follow-up at 6 months in n = 114. Executive functioning was assessed by Children's Color Trail Test (ages 8-16) and by patients and parent-proxy cogPedsQL (ages 5-18/2-18, respectively). Results were correlated with clinical parameters. Stability of results over time was compared between n = 23 patients who for clinical reasons switched from twice daily calcineurin inhibitor (CNI) to once-daily slow-release tacrolimus (Tac) during the study period, and patients with unchanged CNI.

RESULTS

Worse executive functioning was associated with longer stay in the intensive care unit and longer time elapsed since transplantation. No difference was found between users of cyclosporine and Tac. Children on once-daily slow-release Tac performed better than children on twice-daily Tac. In children who switched from twice-daily CNI to once-daily Tac, parent-proxy cogPedsQL improved significantly compared to stable results in the nonswitch group.

CONCLUSIONS

In addition to a strong impact of disease burden around transplantation, executive functioning appears to deteriorate over time. Although there is no clear-cut advantage of any CNI, once-daily Tac appears to be advantageous compared to twice-daily Tac.

Cognitive decline in heart failure

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Cognitive function after heart transplantation: Comparing everolimus-based and calcineurin inhibitor-based regimens

BACKGROUND

Studies have shown conflicting results concerning the occurrence of cognitive impairment after successful heart transplantation (HTx). Another unresolved issue is the possible differential impact of immunosuppressants on cognitive function. In this study, we describe cognitive function in a cohort of HTx recipients and subsequently compare cognitive function between subjects on either everolimus- or calcineurin inhibitor (CNI)-based immunosuppression.

METHODS

Cognitive function, covering attention, processing speed, executive functions, memory, and language functions, was assessed with a neuropsychological test battery. Thirty-seven subjects were included (everolimus group: n=20; CNI group: n=17). The extent of cerebrovascular pathology was assessed with magnetic resonance imaging.

RESULTS

About 40% of subjects had cognitive impairment, defined as performance at least 1.5 standard deviations below normative mean in one or several cognitive domains. Cerebrovascular pathology was present in 33.3%. There were no statistically significant differences between treatment groups across cognitive domains.

CONCLUSIONS

Given the high prevalence of cognitive impairment in the sample, plus the known negative impact of cognitive impairment on clinical outcome, our results indicate that cognitive assessment should be an integrated part of routine clinical follow-up after HTx. However, everolimus- and CNI-based immunosuppressive regimens did not show differential impacts on cognitive function.

Human Auditory Evoked Potentials in the Assessment of Brain Function During Major Cardiovascular Surgery

Focal neurologic and intellectual deficits or memory problems are relatively frequent after cardiac surgery. These complications have been associated with cerebral hypoperfusion, embolization, and inflammation that occur during or after surgery. Auditory evoked potentials, a neurophysiologic technique that evaluates the function of neural structures from the auditory nerve to the cortex, provide useful information about the functional status of the brain during major cardiovascular procedures. Skepticism regarding the presence of artifacts or difficulty in their interpretation has outweighed considerations of its potential utility and noninvasiveness. This paper reviews the evidence of their potential applications in several aspects of the management of cardiac surgery patients. The sensitivity of auditory evoked potentials to the effects of changes in brain temperature makes them useful for monitoring cerebral hypothermia and rewarming during cardiopulmonary bypass. The close relationship between evoked potential waveforms and specific anatomic structures facilitates the assessment of the functional integrity of the central nervous system in cardiac surgery patients. This feature may also be relevant in the management of critical patients under sedation and coma or in the evaluation of their prognosis during critical care. Their objectivity, reproducibility, and relative insensitivity to learning effects make auditory evoked potentials attractive for the cognitive assessment of cardiac surgery patients. From a clinical perspective, auditory evoked potentials represent an additional window for the study of underlying cerebral processes in healthy and diseased patients. From a research standpoint, this technology offers opportunities for a better understanding of the particular cerebral deficits associated with patients who are undergoing major cardiovascular procedures.

Co-morbidities in heart failure

Heart failure is a clinical syndrome characterized by poor quality of life and high morbidity and mortality. Co-morbidities frequently accompany heart failure and further decrease in both quality of life and clinical outcome. We describe that the prevalence of co-morbidities in patients with heart failure is much higher compared to age-matched controls. We will specifically address the most studied organ-related co-morbidities, that is, renal dysfunction, cerebral dysfunction, anaemia, liver dysfunction, chronic obstructive pulmonary disease, diabetes mellitus and sleep apnoea. The pathophysiologic processes underlying the interaction between heart failure and co-morbid conditions are complex and remain largely unresolved. Although common risk factors are likely to contribute, it is reasonable to believe that factors associated with heart failure might cause other co-morbid conditions. Inflammation, neurohumoral pathway activation and hemodynamic changes are potential factors. We try to provide explanations for the observed association between co-morbidities and heart failure, as well as its impact on survival.

Minimized extracorporeal circulation does not impair cognitive brain function after coronary artery bypass grafting

OBJECTIVES

Objective evaluation of the impact of minimized extracorporeal circulation (MECC) on perioperative cognitive brain function in coronary artery bypass grafting (CABG) by electroencephalogram P300 wave event-related potentials and number connection test (NCT) as metrics of cognitive function.

METHODS

Cognitive brain function was assessed in 31 patients in 2013 with a mean age of 65 years [standard deviation (SD) 10] undergoing CABG by the use of MECC with P300 auditory evoked potentials (peak latencies in milliseconds) directly prior to intervention, 7 days after and 3 months later. Number connection test, serving as method of control, was performed simultaneously in all patients.

RESULTS

Seven days following CABG, cognitive P300 evoked potentials were comparable with preoperative baseline values [vertex (Cz) 376 (SD 11) ms vs 378 (18) ms, P = 0.39; frontal (Fz) 377 (11) vs 379 (21) ms, P = 0.53]. Cognitive brain function at 3 months was compared with baseline values [(Cz) 376 (11) ms vs 371 (14 ms) P = 0.09; (Fz) 377 (11) ms vs 371 (15) ms, P = 0.04]. Between the first postoperative measurement and 3 months later, significant improvement was observed [(Cz) 378 (18) ms vs 371 (14) ms, P = 0.03; (Fz) 379 (21) vs 371 (15) ms, P = 0.02]. Similar clearly corresponding patterns could be obtained via the number connection test. Results could be confirmed in repeated measures analysis of variance for Cz (P = 0.05) and (Fz) results (P = 0.04).

CONCLUSIONS

MECC does not adversely affect cognitive brain function after CABG. Additionally, these patients experience a substantial significant cognitive improvement after 3 months, evidentiary proving that the concept of MECC ensures safety and outcome in terms of brain function.

Aerobic exercise as an adjunct therapy for improving cognitive function in heart failure

Persons with heart failure (HF) are typically older and are at a much higher risk for developing cognitive impairment (CI) than persons without HF. Increasingly, CI is recognized as a significant, independent predictor of worse clinical outcomes, more frequent hospital readmissions, and higher mortality rates in persons with HF. CI can have devastating effects on ability to carry out HF effective self-care behaviors. If CI occurs, however, there are currently no evidence based guidelines on how to manage or improve cognitive function in this population. Improvement in cognition has been reported following some therapies in HF and is thought to be the consequence of enhanced cerebral perfusion and oxygenation, suggesting that CI may be amenable to intervention. Because there is substantial neuronal loss with dementia and no effective restorative therapies, interventions that slow, reverse, or prevent cognitive decline are essential. Aerobic exercise is documented to increase cerebral perfusion and oxygenation by promoting neuroplasticity and neurogenesis and, in turn, cognitive functioning. Few studies have examined exercise as a potential adjunct therapy for attenuating or alleviating cognitive decline in HF. In this review, the potential benefit of aerobic exercise on cognitive functioning in HF is presented along with future research directions.

Cognitive change in heart failure: a systematic review

BACKGROUND

Cognitive impairment, highly prevalent in patients with heart failure (HF), increases risk for hospitalization and mortality. However, the course of cognitive change in HF is not well characterized. The purpose of this systematic review was to examine the available evidence longitudinal changes in cognitive function in patients with HF.

METHODS AND RESULTS

A literature search of several electronic databases was performed. Studies published from January 1, 1980, to September 30, 2012, that used validated measures to diagnose HF and assess cognitive function ≥2× in adults with HF were eligible for inclusion. Change in cognitive function was examined in the context of HF treatments applied (eg, medication initiation, left ventricular assist device implantation), length of follow-up, and comparison group. Fifteen studies met eligibility criteria. Significant decline in cognitive function was noted among patients with HF followed up for >1 year. Improvements in cognition were observed among patients with HF undergoing interventions to improve cardiac function (eg, heart transplantation) and among patients examined over short time periods (<1 year). Studies comparing patients' cognition over time with their own baseline tended to report improvements, whereas studies using a comparison group without HF tended to report declines or stability in cognition over time among patients with HF.

CONCLUSIONS

Patients with HF are at increased risk for cognitive decline, but this risk seems to be modifiable with cardiac treatment. Further research is needed to identify the mechanisms that cause cognitive changes in HF.

[Neurological aspects of chronic heart failure]

Chronic heart failure (CHF) is one of the leading causes of hospitalization, morbidity and mortality. Moreover, there is a high rate of neurological as well as neuropsychological comorbidities, namely ischemic stroke, structural brain alterations, cognitive impairment, sleep apnea and possible side-effects of HF medication such as delirium or (intracerebral) hemorrhage. The higher stroke risk in patients with HF increases further with age, concomitant arterial hypertension or atrial fibrillation (AF). In women the stroke risk increases with reduced ejection fraction (EF). In general stroke in HF patients is associated with a poor outcome and higher mortality, which is increased more than 2-fold. Furthermore, approximately 25-80% of all patients with CHF experience cognitive impairments such as decreased attention and concentration, memory loss, diminished psychomotor reaction time and decreased executive functions. Cognitive impairment in patients with HF has been linked to losses in gray matter, (silent) ischemic strokes, decreased cerebral perfusion and higher mortality. Moreover, sleep apnea occurs in more than half of all patients with CHF and reduced EF. However, prospective studies are needed to test whether early detection and optimal treatment of HF reduces the burden of neurological and neuropsychological sequelae.

A health-related quality of life questionnaire in symptomatic patients with heart failure: validity and reliability of a Japanese version of the MRF28

BACKGROUND

Major characteristics of symptomatic patients with heart failure are exercise intolerance, poor prognosis, and poor quality of life (QOL). However, most QOL questionnaires are applicable for patients with mild to moderate heart failure, and are not sufficiently sensitive to discriminate between patients with NYHA classes III and IV. Therefore, it is necessary to prepare a questionnaire focused on patients with severe heart failure.

OBJECTIVES

We developed a Japanese version of the Maugeri Foundation Respiratory Failure (MRF28) questionnaire and assessed validity and reliability of MRF28 in heart failure patients.

METHODS

The MRF28 questionnaire was evaluated in 124 patients with heart failure (NYHA classes: I, 24; II, 31; III, 52; IV, 17). Reliability was evaluated by internal consistency and test-retest reliability. Validity was determined by correlation with World Health Organization Quality of Life (WHOQOL) questionnaire and physiological parameters.

RESULTS

The MRF28 showed high internal consistency and reproducibility. The total score and subscores were all increased with the progress of heart failure. The total score could differentiate patients among NYHA II, III, and IV, but could not between NYHA I and II. However, all subscores and total score changed consistently with changes in symptoms of heart failure.

CONCLUSION

MRF28 is a valid and reliable disease-specific questionnaire for assessing QOL in symptomatic patients with heart failure. Thus, this questionnaire may be useful for a QOL evaluation of patients with moderate to severe heart failure.

Chronic ischemia and neurocognition

Cognitive impairment from a major stroke as a consequence of carotid disease is an acknowledged clinical outcome; however, cognitive impairment without major stroke is open to discussion. The three recognized mechanisms for cognitive dysfunction from internal carotid artery are microembolization, white-matter disease, and hypoperfusion. The last has been most difficult to characterize physiologically. In this article, the authors review evidence supporting the existence of chronic ischemia in the brain and its direct impact on cognitive functions. By incorporating the pathophysiology of chronic ischemia into the algorithm of the management of carotid artery disease, we may be able to extend the goals of carotid artery revascularization beyond merely preventing stroke to include preventing or reversing cognitive decline.

Cognitive impairment in heart failure: a systematic review of the literature

BACKGROUND

Heart failure (HF) and cognitive impairment are common medical conditions that are becoming increasingly prevalent in the aging Western population. They are associated with frequent hospitalisation and increased mortality, particularly when they occur simultaneously. Evidence from a number of studies suggests that HF is independently associated with impairment in various cognitive domains.

AIMS

This systematic literature review evaluates the relation between cognitive deterioration and heart failure.

METHODS

We searched electronic databases from 1966 to May 2006 for studies that investigated cognitive function in HF patients. Twenty-two controlled studies that met the inclusion criteria were selected for analysis. Study characteristics and data on global cognitive performance, memory scores, psychomotor speed and depression scores were extracted and analysed using the Cochrane Review Manager software.

RESULTS

Pooled analysis shows diminished neuropsychological performance in HF patients, as compared to control subjects. In a pooled sample of 2937 heart-failure patients and 14,848 control subjects, the odds ratio for cognitive impairment was 1.62 (95% confidence interval:1.48-1.79, p<0.0001) among subjects with HF.

CONCLUSION

This review confirms the relationship between HF and cognitive impairment, but it also stresses the need for additional systematic neuropsychological data and adequate neuro-imaging from representative populations of HF patients.

Long-Term Neurocognitive Function After Mechanical Aortic Valve Replacement

BACKGROUND

Mechanical aortic valves are a possible source of microemboli potentially causing cerebral injury. Therefore, the long-term impact of mechanical aortic valve replacement on neurocognitive function is uncertain.

METHODS

In this prospective, contemporary study, we followed 32 consecutive patients (aged 51 +/- 8 years; range, 38 to 70; EuroSCORE [European System for Cardiac Operative Risk Evaluation] 4.4 +/- 1.7) undergoing isolated aortic valve replacement with a mechanical prosthesis. A cohort of age- and sex-matched patients (n = 28, aged 50 +/- 7 years) served as nonsurgical controls. After aortic valve replacement, neurocognitive function was serially reevaluated at 7-day (n = 32), 4-month (n = 31), and 3-year (n = 29) follow-up. Neurocognitive function was measured by means of P300 auditory evoked potentials.

RESULTS

Before the operation, P300 peak latencies were comparable between surgical patients (361 +/- 32 ms) and nonsurgical controls (365 +/- 33 ms, p = 0.783). In patients undergoing aortic valve replacement, P300 peak latencies were prolonged 7 days after surgery (380 +/- 32 ms) as compared with before the operation (361 +/- 32 ms, p < 0.0001) and as compared with nonsurgical controls (364 +/- 34 ms, p = 0.002). At 4-month (369 +/- 30 ms, p = 0.752) and 3-year (370 +/- 31 ms, p = 0.825) follow-up, P300 peak latencies normalized as compared with before operation and as compared with nonsurgical controls (4-month follow-up 363 +/- 31 ms, p = 0.832; 3-year follow-up 366 +/- 32 ms, p = 0.432). We found no difference in patients with different valve types.

CONCLUSIONS

Despite previous assumptions based on the potential occurrence of microemboli in patients with mechanical valves, mechanical aortic valve replacement has no adverse long-term impact on neurocognitive function. This finding is only valid for patients with a comparable age range undergoing isolated aortic valve replacement.

Neurocognitive Function in Patients with Ventricular Assist Devices: A Comparison of Pulsatile and Continuous Blood Flow Devices

The effect of successful ventricular assist device (VAD) implantation on neurocognitive function in terminal heart failure is uncertain. Additionally, the different impact of continuous versus pulsatile blood flow devices is unknown. A total of 29 patients (mean age 53 years), surviving implantation of a ventricular assist device as bridge to transplantation were prospectively followed (continuous flow: Micromed DeBakey, n = 11; pulsatile flow: Thoratec and Novacor, n = 18). Normative data were obtained in 40 age- and sex-matched healthy subjects (mean age 54 years). Neurocognitive function was objectively measured by means of cognitive P300 auditory evoked potentials before operation (baseline), at intensive care unit (ICU) discharge, and at the 8-week and 12-week follow-up. Before implantation of the VAD, cognitive P300 evoked potentials were impaired (prolonged) compared with age- and sex-matched healthy subjects (p < 0.001). After successful VAD implantation, P300 evoked potentials markedly improved compared with before operation (ICU discharge, p = 0.007; 8-week follow-up, p = 0.022; 12-week follow-up, p < 0.0001). Importantly, there was no difference between continuous and pulsatile VADs (before operation, p = 0.676; ICU discharge, p = 0.736; 8-week follow-up, p = 0.911 and 12-week follow-up, p = 0.397; respectively). Nevertheless, P300 peak latencies did not fully normalize at 12-week follow-up compared with healthy subjects (p = 0.012). Successful VAD implantation improves neurocognitive impairment in patients with terminal heart failure. Importantly, this effect is independent of the type of VAD (pulsatile vs. continuous blood flow).

Cognitive function in adult cardiothoracic transplant candidates and recipients

Innovative surgical and medical techniques have prolonged the life span of cardiothoracic (CT) transplant recipients and made transplantation an option for many older patients. Cognitive function is a key determinant of the CT transplant recipient's ability to manage the complex treatment regimen and experience optimum benefit of the procedure. As the CT population ages, risk of cognitive dysfunction due to normal aging is compounded by the physical and mental changes associated with end-stage organ disease, comorbid conditions, and transplant-related complications. Cognitive abilities consist of (a) receptive functions (ability to select, acquire, classify, and integrate information); (b) memory and learning (ability to store and retrieve information); (c) thinking (ability to mentally organize and reorganize information; and (d) expressive functions (ability to communicate or act upon information). Although each of these functions represents a distinct type of behavior, they are interdependent. The purpose of this article is to (a) discuss the literature regarding cognitive function before and after adult heart, lung, and heart-lung transplantation; (b) identify methodological problems associated with the studies done to date; and (c) make recommendations for future research in this area.

Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey

PURPOSE

Cognitive impairment is an exceedingly prevalent condition among patients with heart failure, independently associated with disability and mortality. However, the determinants of cognitive dysfunction associated with heart failure are still unclear. We assessed the correlates of cognitive impairment among patients with heart failure enrolled in a multicenter pharmacoepidemiology survey.

METHODS

The association with cognition of demographic characteristics, objective tests and measures, medications, and comorbid conditions was assessed in 1511 patients with heart failure who had been admitted to 81 hospitals throughout Italy. Cognitive impairment was defined by a Hodkinson Abbreviated Mental Test score < 7.

RESULTS

According to multivariate logistic regression modeling, age (per each decade: OR = 2.01; 95% confidence interval [CI] 1.72-2.35), the comorbidity score (OR 1.11; 95% CI 1.03-1.20), education (OR 0.88; 95% CI 0.84-0.2), low serum albumin (OR 1.78; 95% CI 1.35-2.34), sodium (OR 1.56; 95% CI 1.06-2.29), and potassium levels (OR 1.58; 95% CI 1.09-2.29), hyperglycemia (OR 1.33; 95% CI 1.02-1.73), anemia (OR 1.38; 95% CI 1.09-1.75), and systolic blood pressure levels > or = 130 mm Hg (OR 0.60; 95% CI 0.37-0.97) were independently associated with cognitive impairment, after adjusting for potential confounders. Among participants with abnormal laboratory findings on admission, restoration of normal glucose, potassium, and hemoglobin levels during hospital stay was associated with improved cognitive performance at discharge.

CONCLUSIONS

Cognitive impairment among patients with heart failure is associated with several comorbid conditions, some of which are potentially treatable. This highlights the key role of comprehensive approach to the assessment and treatment of patients with heart failure.

Use of angiotensin-converting enzyme inhibitors and variations in cognitive performance among patients with heart failure

AIMS

Cognitive dysfunction is a prevalent condition among patients with heart failure, and is independently associated with disability and mortality. Angiotensin-converting enzyme (ACE)-inhibitors might increase cerebral blood flow in subjects with heart failure. Our aim was to assess whether starting treatment with ACE-inhibitors might improve cognition in patients with heart failure.

METHODS AND RESULTS

Analyses involved 12 081 subjects, 1220 of whom had a verified diagnosis of heart failure, enrolled in a multi-centre pharmaco-epidemiology survey. None of these participants received ACE-inhibitors before hospitalization. Among participants with heart failure, cognitive performance improved in 30% of 446 participants who started ACE-inhibitors, but only in 22% of remaining patients (P=0.001). Among participants without heart failure, cognition improved in 19% of those receiving ACE-inhibitors, and in 18% of untreated patients (P=0.765). Use of ACE-inhibitors among patients with heart failure was associated with improving cognition (odds ratio=1.57; 95% CI 1.18-2.08) also in the multivariable regression modelling, independently of baseline or discharge blood pressure levels. The probability of improving cognitive performance was higher for dosages above the median values, as compared with lower doses (odds ratios=1.90 and 1.42; P for trend=0.001), and increased with duration of treatment (odds ratios for the lower, middle, and upper tertiles=1.25, 1.34, and 1.59; P for trend=0.007).

CONCLUSION

Treatment with ACE-inhibitors might selectively improve cognitive performance in patients with heart failure. However, up-titration of these agents might be required to yield the greatest benefit.

Neurocognitive deficit following coronary artery bypass grafting: a prospective study of surgical patients and nonsurgical controls

BACKGROUND

To objectively measure long-term neurocognitive deficit in patients undergoing coronary artery bypass grafting and compare the findings with nonsurgical controls.

METHODS

We prospectively measured neurocognitive function in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (n = 104; mean age 64.1 years old; EuroSCORE 2.7 [means]). A cohort of age- and sex-matched patients (n = 80; mean age 63.4 years old) served as nonsurgical controls. After CABG, neurocognitive function was serially reevaluated at 7-day (n = 104), 4-month (n = 100), and 3-year follow-up (n = 88). Neurocognitive function was objectively measured by means of cognitive P300 evoked potentials. Additionally, standard psychometric tests were performed (Trailmaking Test A, Mini Mental State Examination).

RESULTS

As compared to preoperative measures (364 +/- 36 ms), cognitive P300 evoked potentials were prolonged (=impaired) at 7-day (381 +/- 36 ms; p = 0.001), 4-month (378 +/- 31 ms; p = 0.08), and 3-year follow-up (379 +/- 35 ms; p = 0.002), respectively. Trailmaking Test A was abnormal, as compared to preoperative, at 3-year follow-up (p < 0.001). Before the operation, surgical patients were fully comparable in P300 measures to nonsurgical controls (363 +/- 32 ms; p = 0.362). Most importantly, throughout the entire postoperative follow-up cognitive measures in surgical patients were prolonged (=impaired) as compared with controls (7-day p = 0.001; 4-month p = 0.002 and 3-year p = 0.003, respectively). In stepwise multivariate regression analysis, neurocognitive deficit at 4-month follow-up (p < 0.001), age (p = 0.012), and persistent atrial fibrillation (p = 0.024) were predictive for long-term neurocognitive deficit at 3-year follow-up.

CONCLUSIONS

As shown by means of objective measures, and in comparison to nonsurgical controls, coronary artery bypass grafting with cardiopulmonary bypass grafting causes long-term neurocognitive deficit.

A longitudinal perspective on neurodevelopmental outcome after infant cardiac transplantation

BACKGROUND

With improvement in medical outcomes, the current research has shifted toward understanding and enhancing the quality of life after pediatric heart transplantation. Previous research has indicated that infant heart transplant recipients are generally at risk for neurodevelopmental delays; however, no longitudinal studies exploring the patterns of development within this medical population have been performed.

METHODS

Using the Bayley Scales of Infant Development-II, 39 children (2 to 38 months of age) who underwent heart transplantation in infancy (<1 year) at Loma Linda University Children's Hospital were assessed consecutively over time.

RESULTS

Mean Mental Development Index (MDI) scores for all age groups were within normal limits, except for the age ranges of 18 to 23 and 24 to 35 months, which were mildly delayed. Average Psychomoter Development Index (PDI) scores for all age groups reflected mildly delayed performance, except for the 36- to 38-month age group, which was within normal limits. Repeated measures analyses of variance on a sub-set of participants with at least 4 consecutive assessments revealed within-subject effects on MDI scores (F = 5.7, p < 0.01), but not on PDI scores (F = 1.6, p = 0.22). Significant decreases in MDI scores at 18 and 28 to 36 months were noted.

CONCLUSIONS

Motor development in this population was consistently mildly delayed. Age-dependent variability in cognitive skills was apparent. The delays appeared due to speech/language acquisition (18 months), and abstract reasoning/goal-directed behaviors (28 to 36 months). Possible etiologies for cognitive delays include test artifacts, auditory functioning and effects of immunosuppressive agents. Understanding risk factors in this patient population will allow for early and effective intervention.

The effects of cognitive impairment on mortality among hospitalized patients with heart failure

PURPOSE

Cognitive impairment is a common, potentially reversible condition among older patients with heart failure. Because cerebral metabolic abnormalities have been associated with reduced survival in younger patients with advanced heart failure, we assessed the effect of cognitive impairment on the survival of older patients with heart failure.

METHODS

The association between cognitive dysfunction and in-hospital mortality was assessed in 1113 patients (mean [+/- SD] age, 78 +/- 9 years) who had been admitted for heart failure to 81 hospitals throughout Italy. One-year mortality was assessed in 968 patients with heart failure (age, 76 +/- 10 years) participating in the same study. Cognitive impairment was defined as a Hodkinson Abbreviated Mental Test score <7.

RESULTS

In-hospital death occurred in 65 (18%) of the 357 participants with cognitive impairment and in 26 (3%) of the 756 patients with normal cognition (P <0.0001). Out-of-hospital mortality was 27% (51/191) among patients with cognitive impairment and 15% (115/777) among other participants (P <0.0001). In multivariate Cox regression models, decreasing levels of cognitive functioning were associated with increasing in-hospital mortality; cognitive impairment was associated with an almost fivefold increase in mortality (relative risk = 4.9; 95% confidence interval: 2.9 to 8.3) after adjusting for several potential confounders.

CONCLUSION

Cognitive impairment is an independent prognostic marker in older patients with heart failure. Assessment of cognitive functioning, even by simple screening tests, should be part of the routine assessment of elderly patients with heart failure.

Cognitive deficits in patients with heart failure: a review of the literature

PURPOSE

Chronic heart failure (HF) and cognitive impairments (CI) are common problems in the elderly. Both are associated with increased mortality and disability, decreased quality of life, and increased health care costs. While these conditions may occur by chance in the same individual, there is increasing evidence that HF is independently associated with CI. The purpose of this article is to review and critique the literature addressing the prevalence, type, and severity of CI in HF patients, the clinical factors associated with CI, and the potential pathophysiology underlying the development of CI, and to recommend priority areas for future research.

RESULTS

Memory and attention deficits are the most frequently occurring CI in this patient population, followed by slowed motor response times and difficulties in problem solving. Prevalence rates range from 30% to 80% depending upon the age of the patients and the characteristics of the sample being studied. Most patients have mild impairments, although as many as one fourth may have moderate to severe CI. The relationship between left ventricular ejection fraction and cognition is inconsistent and may be nonlinear. The pathophysiology underlying the development of CI in HF patients may be related to both cerebral infarction and cerebral hypoperfusion either alone or in combination.

CONCLUSIONS

The current literature is limited by studies with sometimes small or nonrepresentative samples, few matched control studies, and lack of longitudinal data that could indicate the conditions that favor the development of CI over time. Future research needs to focus on (1) determining the types, frequency, and severity of impairments in cognitive functioning among a representative sample of HF patients, (2) explicating the pathological mechanisms and the clinical factors that underlie the development of cognitive deficits, and (3) identifying the ways CI influences quality of life. Interventions can then be developed to prevent or delay the occurrence of CI or to minimize their effect on patient self-management and quality of life.

Neurocognitive deficit following aortic valve replacement with biological/mechanical prosthesis

OBJECTIVE

The aim of this study was to objectively measure neurocognitive deficit following aortic valve replacement with a mechanical or biological prosthesis.

MATERIALS AND METHODS

In this prospective, contemporary study we followed 82 consecutive patients undergoing isolated aortic valve replacement with either a mechanical (n=29, mean age=52+/-7 years) or a biological (n=53, mean age=68+/-10 years) valve prosthesis. Neurocognitive function was measured by means of objective P300 auditory evoked potentials (peak latencies, ms) and two standard psychometric tests (Trailmaking Test A, Mini Mental State Examination) before the operation, 7 days and 4 months after the operation, respectively.

RESULTS

Since P300 peak latencies increase with age, preoperative P300 measures are lower in patients receiving mechanical valves (360+/-35 ms, mean 52 years) as compared to patients receiving biological valves (381+/-34 ms, 68 years, P=0.0001). Seven days after surgery, P300 peak latencies were prolonged (-worsened) in both groups as compared to preoperative values (mechanical valves: 384+/-36 ms; P=0.0001 and biological valves: 409+/-39 ms; P=0.0001). Although on a different level (-age-related), this development was comparable within both groups (P=0.800). Four months after surgery, P300 peak latencies normalized in the mechanical valve group (372+/-27 ms, P=0.857 versus preoperative), while in contrast in the biological valve group they remained prolonged (417+/-37 ms, P=0.0001). We found no difference within patients receiving different types of biological or mechanical aortic valves.

CONCLUSION

Postoperative neurocognitive damage is not reversible in (-elderly) patients with biological aortic valve replacement, while in contrast postoperative neurocognitive damage is reversible in (-younger) patients with mechanical valve replacement. For this contrary development, age seems to be most important, whereas damage related to type of valve prosthesis may be overestimated.

Neurocognitive outcome in pediatric liver transplant recipients

Studies have shown that children with liver transplants demonstrate deficits on intellectual, academic, and language measures. However, limited information is known about the long-term cognitive development of these children. In this study, 15 children who were at least 2 yr post-liver transplantation (LT) were compared on cognitive measures to an equated group of 15 children with cystic fibrosis (CF). Children with CF were selected as a clinical control given similarities in disease onset and chronicity, as well as physical growth and development. Results indicated that children with LT tended to have lower verbal intelligence quotient scores and performed significantly lower than CF children on language measures, particularly on receptive language tasks. No significant differences were obtained on measures of academic achievement or visual-spatial performance. In the LT group, days in the intensive care unit, total number of days spent in the hospital during the first year following the transplant, and elevated pretransplant bilirubin levels significantly predicted the speech and language delays.

Cardiopulmonary bypass affects cognitive brain function after coronary artery bypass grafting

BACKGROUND

The causes for cognitive impairment after coronary artery bypass grafting (CABG) have long been a topic for debate.

METHODS

We prospectively followed 308 consecutive, unselected survivors of CABG at our institution. In addition to determination of clinical measurements, cognitive brain function was measured objectively by P300 auditory-evoked potentials before CABG, at 7-day and at 4-month follow-up. Standard psychometric tests (Trail Making Test A, Mini Mental State Examination) were also performed.

RESULTS

At 7-day follow-up cognitive P300 auditory-evoked potentials were significantly impaired compared with preoperative levels (peak latencies: 376 +/- 40 ms versus 366 +/- 37 ms, p = 0.0001). P300 measurements were almost normalized at 4-month follow-up (peak latencies: 369 +/- 33 ms, p = NS versus preoperative). Standard psychometric tests failed to detect this subclinical cognitive impairment. Multiple regression analysis revealed that use of cardiopulmonary bypass was the only independent predictor of impaired cognitive brain function at 7-day (p < 0.0001) and 4-month follow-up (p = 0.0008). The presence of diabetes mellitus (p = 0.0135) or concomitant repair of significant carotid artery stenosis (p = 0.0049) was predictive of late improvement of cognitive brain function at 4-month follow-up.

CONCLUSIONS

Objective cognitive P300 auditory-evoked potential measurements demonstrate that the use of cardiopulmonary bypass is the only predictor of short- and long-term cognitive brain dysfunction after CABG. Interestingly, the presence of diabetes mellitus and concomitant repair of a significant carotid artery stenosis were predictive for long-term cognitive benefit.

Cerebral metabolic abnormalities in congestive heart failure detected by proton magnetic resonance spectroscopy

OBJECTIVES

Using proton magnetic resonance spectroscopy, we investigated cerebral metabolism and its determinants in congestive heart failure (CHF), and the effects of cardiac transplantation on these measurements.

BACKGROUND

Few data are available about cerebral metabolism in CHF.

METHODS

Fifty patients with CHF (ejection fraction < or = 35%) and 20 healthy volunteers were included for this study. Of the patients, 10 patients underwent heart transplantation. All subjects performed symptom-limited bicycle exercise test. Proton magnetic resonance spectroscopy (1H MRS) was obtained from localized regions (8 to 10 ml) of occipital gray matter (OGM) and parietal white matter (PWM). Absolute levels of the metabolites (N-acetylaspartate, creatine, choline, myo-inositol) were calculated.

RESULTS

In PWM only creatine level was significantly lower in CHF than in control subjects, but in OGM all four metabolite levels were decreased in CHF. The creatine level was independently correlated with half-recovery time and duration of heart failure symptoms in PWM (r = -0.56, p < 0.05), and with peak oxygen consumption and serum sodium concentration in OGM (r = 0.58, p < 0.05). Cerebral metabolic abnormalities were improved after successful cardiac transplantation.

CONCLUSIONS

This study shows that cerebral metabolism is abnormally deranged in advanced CHF and it may serve as a potential marker of the disease severity.

The relationship between cardiac function and neuropsychological status among heart transplant candidates

BACKGROUND

Cognitive deficits among heart transplant candidates have been well documented. This study was designed to examine the hypothesis that impaired cognitive test performance among heart transplant candidates may be attributed, in part, to decreased cerebral perfusion secondary to poor cardiac function.

METHODS AND RESULTS

Sixty-two patients participated in the study who underwent heart catheterization within 1 day of completing a battery of cognitive tests. Multiple demographic and patient characteristics were examined for their potential moderating role in the relationship between measures of cardiac function and cognitive performance including age, education, race, gender, psychiatric history, medication usage, cardiac surgical history, and self-reported symptoms of depression and anxiety. Only age and education were significantly related to cognitive performance (P < .01). Thus, partial correlation analyses controlling for age and education were used to examine the relationship between cardiac function and cognitive performance. In general, increasing hemodynamic pressure variables (ie, pulmonary artery pressure and right atrial pressure), and to a lesser extent cardiac output and cardiac index, were related (r = - .32 to - .43; P < .01) to decreased performance on cognitive tasks that assessed simple attention, speed of mental processing, and mental flexibility (Digit Span-Forward, Trail Making Test-Part B, Symbol Digits Modalities Test, and Stroop Neuropsychological Screening Test). Left ventricular ejection fraction, systemic and pulmonary vascular resistance, and mean arterial pressure were largely unrelated to cognitive performance in this sample of patients with end stage cardiac disease.

CONCLUSIONS

Hemodynamic pressure variables seem to be most consistently related (ie, inversely) to cognitive functioning among heart transplant candidates.

Congestive heart failure and cognitive impairment in an older population. Osservatorio Geriatrico Campano Study Group

OBJECTIVE

Congestive heart failure (CHF) is potentially preventable, and the identification of modifiable risk factors for cognitive impairment (CI) for older persons is a very important issue. We examined the cross-sectional relationship between CHF and CI in an older population.

DESIGN

A cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 1339 subjects aged 65 and older were selected from the electoral rolls of Campania, a region of southern Italy.

MEASUREMENTS

Sociodemographic characteristics were recorded, as was the presence of cardiovascular diseases, including CHF classified according to the New York Heart Association (NYHA) guidelines for disease severity; CI evaluated by means of the Mini-Mental State Examination (MMSE), with a score of <24 indicating impairment; geriatric depression scale (GDS) rating; blood pressure (BP); and heart rate (HR).

RESULTS

The final sample numbered 1075; 172 subjects were excluded because of neurological disorders and psychotropic therapy, and 92 were excluded because their BP, HR, or cognitive examination was not recorded. Prevalence of CHF was 8.2%, and 23.0% of subjects scored <24 on the MMSE. The prevalence of CHF in subjects with an MMSE score of <24 and > or =24 was 20.2% and 4.6%, respectively (P < .001). Logistic regression analysis showed that CHF was associated independently with CI by sex, age, educational level, GDS, diabetes, hypertension, alcohol consumption, smoking, atrial fibrillation, systolic and diastolic BP, and HR. The risk of CI was 1.96-fold greater in subjects with CHF (odds ratio: 1.96; 95% confidence interval: 1.07-3.58; P < .028). Systolic BP decrease was correlated negatively with NYHA classes only in subjects with CI (r = -0.981; P < .020), whereas HR increase was correlated positively with NYHA classes only in subjects without CI (r = 0.985; P < .015).

CONCLUSIONS

In our population, CHF is associated with CI in subjects aged 65 years and older. Systolic BP reduction and the lack of HR increase, related to NYHA classes, might characterize cognitively impaired subjects with CHF.