Correlates of Dementia and Mild Cognitive Impairment in Patients With Atrial Fibrillation: The Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS)

Managing elderly patients with atrial fibrillation and multimorbidity: call for a systematic approach

INTRODUCTION

Atrial fibrillation (AF) is often accompanied by comorbidities. Not only cardiovascular, but also non-cardiovascular comorbidities have been associated with AF. Multimorbidity is therefore a common finding in patients with AF, especially in elderly patients. Multimorbidity is associated with adverse outcomes, adds complexity to AF management and poses a significant burden on healthcare costs. It is expected that the prevalence of elderly patients with multimorbidity will increase significantly. It is therefore crucial to outline implications for clinical practice and guide comprehensive multimorbidity management.

AREAS COVERED

This perspective article outlines multimorbidity in AF and the importance of comprehensive comorbidity management. It addresses current clinical practice guided by international guidelines and the need for integrated care including a patient-centered focus, comprehensive AF management, coordinated multidisciplinary care, and supporting technology. Moreover, it proposes a novel model of care delivery following a systematic approach to multimorbidity management.

EXPERT OPINION

Providing comprehensive care by means of a multidisciplinary team and patient engagement is crucial to provide optimal personalized care for elderly patients with AF and multimorbidity. A systematic integrated care approach seems promising, but further studies are needed to investigate the feasibility of a systematic approach and prioritization of comorbidity management in patients with multimorbidity.

The Association Between Sickle Cell Anemia and Cognitive Dysfunction: A Systematic Review

A kind of hemoglobinopathy known as sickle cell anemia (SCA) is characterized by aberrant hemoglobin molecules. The most frequent neurological side effects linked to SCA include neurocognitive dysfunction, asymptomatic cerebral infarction, and ischemic stroke. This study aims to investigate the relationship between SCA and cognitive dysfunction. We systematically searched electronic databases like PubMed, MEDLINE, Science Direct, and Scopus. Two independent reviewers screened and extracted data from eligible studies. Eighteen studies, including 2,457 participants in total and nearly half of them 1,151 (46.8%) were males, were included in our data. The prevalence of cognitive dysfunction in the adult population ranged from 11.5% to 70%. Cognitive dysfunction among adults was significantly associated with poorer educational status, reduced family income, decreased kidney function, older age, stroke history, and vasculopathy. The prevalence of cognitive dysfunction in children ranged from 10.2% to 68.2%. The decline in cognitive function among adults was significantly associated with children over the age of four, abnormal transcranial Doppler and previous stroke, school absence, age beyond 13, and increased BMI. Cognitive function deficiencies are a defining feature of SCA that affects people of all ages. These findings suggest that if cognitive decline is not slowed down, or better still, stopped, medical interventions targeting a variety of sequelae in this population will be ineffective. Future analyses of this population's cognition should evaluate the environmental and other biological variables.

Atrial Fibrillation and Dementia: Pathophysiological Mechanisms and Clinical Implications

Numerous longitudinal studies suggest a strong association between cardiovascular risk factors and cognitive impairment. Individuals with atrial fibrillation are at higher risk of dementia and cognitive dysfunction, as atrial fibrillation increases the risk of cerebral hypoperfusion, inflammation, and stroke. The lack of comprehensive understanding of the observed association and the complex relationship between these two diseases makes it very hard to provide robust guidelines on therapeutic indications. With this review, we attempt to shed some light on how atrial fibrillation is related to dementia, what we know regarding preventive interventions, and how we could move forward in managing those very frequently overlapping conditions.

Connections between Cognitive Impairment and Atrial Fibrillation in Patients with Diabetes Mellitus Type 2

(1) Background: Cognitive decline (CD), considered a precursory state of dementia, is frequently encountered in patients with diabetes mellitus type 2 (DM-2) and might even have a higher prevalence in those with associated atrial fibrillation (AF). In this study, we aimed to research if the association of DM-2 and AF favors a precocious onset of CD. (2) Methods: This study was conducted on 160 patients, featuring 50 with DM-2, 54 with DM-2 and AF, and 56 subjects without DM-2 and AF, all evaluated clinically and with five neuropsychiatric scales. (3) Results: The Mini-Mental-State-Examination (MMSE), Montreal Cognitive Assessment (MoCA), Activities of Daily Living Score (ADL), Instrumental Activities of Daily Living Score (IADL), and Geriatric Depression Scale (GDS-15) were significantly altered in patients with DM-2 and AF in comparison to patients without these diseases. The logistic regression model indicated that, in patients with DM-2 and AF, an increase of one year in age is associated with a 7.3% augmentation of the risk of a precocious onset of CD (MMSE < 27). (4) Conclusions: CD is more frequent in patients with DM-2, especially when associated with AF, versus those without DM-2 and AF. Our findings suggest that an older age and associated dyslipidemia represent risk factors for CD in patients with DM-2.

Burden of Illness in People with Alzheimer's Disease: A Systematic Review of Epidemiology, Comorbidities and Mortality

BACKGROUND

Alzheimer's disease (AD) is the most common neurodegenerative disease worldwide, and an updated quantification of its impact on morbidity, disability, and mortality is warranted. We conducted a systematic literature review, focusing on the past decade, to characterize AD and assess its impact on affected individuals.

METHODS

Searches of Embase, MEDLINE, and the Cochrane Library were conducted on August 7, 2020 and updated on November 10, 2021. Observational studies from any country reporting incidence, prevalence, comorbidities, and/or outcomes related to disability and mortality/life expectancy, in people with mild cognitive impairment (MCI) due to AD, or mild, moderate, or severe AD dementia, were considered relevant.

RESULTS

Data were extracted from 88 studies (46 incidence/prevalence; 44 comorbidities; 25 mortality-/disability-related outcomes), mostly from Europe, the USA, and Asia. AD dementia diagnosis was confirmed using biomarkers in only 6 studies. Estimated 5-year mortality in AD was 35%, and comorbidity prevalence estimates varied widely (hypertension: 30.2-73.9%; diabetes: 6.0-24.3%; stroke: 2.7-13.7%). Overall, people with AD dementia were more likely to have cardiovascular disease or diabetes than controls, and 5-year mortality in people with AD dementia was double that in the age- and year-matched general population (115.0 vs 60.6 per 1,000 person-years).

CONCLUSIONS

AD is associated with excess morbidity and mortality. Future longitudinal studies of population aging, incorporating biomarker assessment to confirm AD diagnoses, are needed to better characterize the course of MCI due to AD and AD dementia.

Evaluation of the Relationship between Cognitive Impairment and Atria Score Systems in Patients with Atrial Fibrillation

Background

Atrial fibrillation (AF) is the main arrhythmia associated with thromboembolic complications and cognitive impairment. In this study, we aimed to evaluate the relationship between cognitive impairment and different scoring systems developed for AF to improve the medical follow-up of cognitive impairment.

Methods

Between January 2019 and December 2020, 124 patients between the age of 30 and 80 years, diagnosed with AF for at least 5 years and complaining about memory impairment during cardiological follow-up, were included in the study. The patients were divided into two groups based on their cognitive status as assessed by the Mini-Mental State Examination group 1 consisted of 52 patients with cognitive impairment and group 2 comprised 72 patients without cognitive impairment.

Results

The ATRIA bleeding score had a positive moderate correlation (r = 0.454, P < 0.001), the ATRIA stroke score had a strong correlation (r = 0.738, P < 0.001), and the SAMe-TT2R2 score had a strong correlation (r = 0.688, P < 0.001) with cognitive impairment. However, CHADS2 and CHA2DS2VASc scores were not statistically correlated with cognitive impairment. According to the receiver operating characteristic (ROC) curve, the area under the curve (AUC) of the ATRIA bleeding score was 0.761 with a 95% confidence interval (CI) of 0.678-0.844 and P < 0.001; also, for the ATRIA stroke score, AUC was 0.930 with a 95% CI of 0.886-0.974 and P < 0.001. In addition, for the SAMe-TT2R2 score, AUC was 0.895 with a 95% CI of 0.838-0.952 and P < 0.001. In the pairwise comparison of AUC on ROC curves, the ATRIA stroke score and the SAMe-TT2R2 score were statistically similar (P = 0.324). ATRIA bleeding, ATRIA stroke, and SAMe-TT2R2 scores were greater than CHADS2 stroke score (P: 0.0004, P < 0.0001, and P < 0.0001, respectively), but CHA2DS2-VASc and CHADS2 stroke scores were statistically similar (P: 0.402).

Conclusion

Both ATRIA stroke and SAMe-TT2R2 scoring systems can provide a better correlation than CHADS2 and CHA2DS2-VASc scores in patients with AF to evaluate their cognitive status. These two scores can be more useful to monitor the patients with AF for medical follow-up of cognitive status.

Is the association between cognitive disease progression and atrial fibrillation modified by sex?

INTRODUCTION

It is unclear if sex differences exist in cognitive disease progression in mild cognitive impairment (MCI) and dementia associated with atrial fibrillation (AF).

METHODS

Using a variety of statistical methods, we examined sex differences between AF and neuropsychological tests and cognitive disease progression, using the National Alzheimer's Coordinating Center data (N = 43,630).

RESULTS

AF is associated with higher odds of dementia (odds ratio [OR] 3.00, 95% confidence interval [CI] [1.22, 7.37] in women and MCI in women (OR 3.43, 95% CI [1.55, 7.55]) versus men. Women with AF and normal baseline cognition had a higher risk of disease progression (hazard ratio [HR] 1.26, 95% CI [1.06, 1.50]) from normal to MCI and from MCI to vascular dementia (HR3.27, 95% CI [1.89, 5.65]) than men with AF or men and women without AF.

DISCUSSION

AF was associated with more rapid progression to MCI and dementia in women, but more research is needed to confirm these findings.

Comparative Effectiveness and Safety of Oral Anticoagulants by Dementia Status in Older Patients With Atrial Fibrillation

Importance

The development of an optimal stroke prevention strategy, including the use of oral anticoagulant (OAC) therapy, is particularly important for patients with atrial fibrillation (AF) who are living with dementia, a condition that increases the risk of adverse outcomes. However, data on the role of dementia in the safety and effectiveness of OACs are limited.

Objective

To assess the comparative safety and effectiveness of specific OACs by dementia status among older patients with AF.

Design, Setting, and Participants

This retrospective comparative effectiveness study used 1:1 propensity score matching among 1 160 462 patients 65 years or older with AF. Data were obtained from the Optum Clinformatics Data Mart (January 1, 2013, to June 30, 2021), IBM MarketScan Research Database (January 1, 2013, to December 31, 2020), and Medicare claims databases maintained by the Centers for Medicare & Medicaid Services (inpatient, outpatient, and pharmacy; January 1, 2013, to December 31, 2017). Data analysis was performed from September 1, 2021, to May 24, 2022.

Exposures

Apixaban, dabigatran, rivaroxaban, or warfarin.

Main Outcomes and Measures

Composite end point of ischemic stroke or major bleeding events over the 6-month period after OAC initiation, pooled across databases using random-effects meta-analyses.

Results

Among 1 160 462 patients with AF, the mean (SD) age was 77.4 (7.2) years; 50.2% were male, 80.5% were White, and 7.9% had dementia. Three comparative new-user cohorts were established: warfarin vs apixaban (501 990 patients; mean [SD] age, 78.1 [7.4] years; 50.2% female), dabigatran vs apixaban (126 718 patients; mean [SD] age, 76.5 [7.1] years; 52.0% male), and rivaroxaban vs apixaban (531 754 patients; mean [SD] age, 76.9 [7.2] years; 50.2% male). Among patients with dementia, compared with apixaban users, a higher rate of the composite end point was observed in warfarin users (95.7 events per 1000 person-years [PYs] vs 64.2 events per 1000 PYs; adjusted hazard ratio [aHR], 1.5; 95% CI, 1.3-1.7), dabigatran users (84.5 events per 1000 PYs vs 54.9 events per 1000 PYs; aHR, 1.5; 95% CI, 1.2-2.0), and rivaroxaban users (87.4 events per 1000 PYs vs 68.5 events per 1000 PYs; aHR, 1.3; 95% CI, 1.1-1.5). In all 3 comparisons, the magnitude of the benefits associated with apixaban was similar regardless of dementia diagnosis on the HR scale but differed substantially on the rate difference (RD) scale. The adjusted RD of the composite outcome per 1000 PYs for warfarin vs apixaban users was 29.8 (95% CI, 18.4-41.1) events in patients with dementia vs 16.0 (95% CI, 13.6-18.4) events in patients without dementia. The corresponding adjusted RD estimates of the composite outcome were 29.6 (95% CI, 11.6-47.6) events per 1000 PYs in patients with dementia vs 5.8 (95% CI, 1.1-10.4) events per 1000 PYs in patients without dementia for dabigatran vs apixaban users and 20.5 (95% CI, 9.9-31.1) events per 1000 PYs in patients with dementia vs 15.9 (95% CI, 11.4-20.3) events per 1000 PYs in patients without dementia for rivaroxaban vs apixaban users. The pattern was more distinct for major bleeding than for ischemic stroke.

Conclusions and Relevance

In this comparative effectiveness study, apixaban was associated with lower rates of major bleeding and ischemic stroke compared with other OACs. The increased absolute risks associated with other OACs compared with apixaban were greater among patients with dementia than those without dementia, particularly for major bleeding. These findings support the use of apixaban for anticoagulation therapy in patients living with dementia who have AF.

Sex-based disparities and in-hospital outcomes of patients hospitalized with atrial fibrillation with and without dementia

Study objective

We sought to evaluate the sex-based disparities and comparative in-hospital outcomes of principal AF hospitalizations in patients with and without dementia, which have not been well-studied.

Design

This is a non-interventional retrospective cohort study.

Setting and participants

We identified principal hospitalizations of AF in the National Inpatient Sample in adults (≥18 years old) between January 2016 and December 2019.

Main outcome measure

In-hospital mortality.

Results

Of 378,230 hospitalized patients with AF, 49.2 % (n = 186,039) were females and 6.1 % (n = 22,904) had dementia. The mean age (SD) was 71 (13) years. Patients with dementia had higher odds of in-hospital mortality {adjusted odds ratio (aOR): 1.48, 95 % confidence interval (CI): 1.34, 1.64, p < 0.001} and nontraumatic intracerebral hemorrhage (aOR: 1.60, 95 % CI: 1.04, 2.47, p = 0.032), but they had lower odds of catheter ablation (0.39, 95 % CI: 0.35, 0.43, p < 0.001) and electrical cardioversion (aOR: 0.33, 95 % CI: 0.31, 0.35, p < 0.001). In patients with AF and dementia, compared to males, females had similar in-hospital mortality (aOR: 1.00, 95 % CI: 0.93, 1.07, p = 0.960), fewer gastrointestinal bleeds (aOR: 0.92, 95 % CI: 0.85, 0.99, p = 0.033), lower odds of getting catheter ablation (aOR: 0.79, 95 % CI: 0.76, 0.81, p < 0.001), and less likelihood of getting electrical cardioversion (aOR: 0.78, 95 % CI: 0.76, 0.79, p < 0.001).

Conclusions

Patients with AF and dementia have higher mortality and a lower likelihood of getting catheter ablation and electrical cardioversion.

Correlation between Body Mass Index and Cognitive Function in Patients with Atrial Fibrillation

Background

Evidence regarding the relationship between body mass index (BMI) and cognitive function was limited. Therefore, the objective of this research is to investigate whether BMI is independently related to cognitive function in Chinese patients with atrial fibrillation after adjusting for other covariates.

Methods

The present study is a cross-sectional study. A total of 281 patients with atrial fibrillation who were hospitalized at the Affiliated Hospital of Jining Medical University in Shandong Province from January 2021 to November 2021 were included in the study. The target independent variable and the dependent variable were BMI and cognitive function in patients with atrial fibrillation, respectively. The patients' general information, BMI, past history, medication history, and other disease-related data were collected. The Montreal cognitive assessment scale (MoCA) was used to evaluate cognitive function.

Results

A total of 244 patients with atrial fibrillation were collected in this study, with an average age of (67.28 ± 10.33) years, of whom 55.3% were male. The average BMI was (25.33 ± 4.27) kg/m², and the average cognitive function score was (19.25 ± 6.88) points. The results of the smooth curve fitting and threshold effect tests showed that there was a curve correlation between BMI and cognitive function score, and its inflection point was 24.56 kg/m². To the left of the inflection point, the relationship was significant; the effect size and the confidence interval were 0.43 and 0.01-0.85, respectively. To the right of the inflection point, there was no significant correlation between BMI and cognitive function (P=0.152).

Conclusion

When BMI is lower than 24.56 kg/m², the cognitive function score increases by 0.43 points for each unit increase in BMI in patients with atrial fibrillation. An increase in BMI at this time is a protective factor for cognitive function. Within the normal range of BMI, the higher the BMI in atrial fibrillation patients, the higher the cognitive function score. We encourage atrial fibrillation patients with normal BMI to maintain their current weight.

Brain and cardiovascular-related changes are associated with aging, hypertension, and atrial fibrillation

PURPOSE

The neural pathways in which the brain regulates the cardiovascular system is via sympathetic and parasympathetic control of the heart and sympathetic control of the systemic vasculature. Various cortical and sub-cortical sites are involved, but how these critical brain regions for cardiovascular control are altered in healthy aging and other risk conditions that may contribute to cardiovascular disease is uncertain.

METHODS

Here we review the functional and structural brain changes in healthy aging, hypertension, and atrial fibrillation - noting their potential influence on the autonomic nervous system and hence on cardiovascular control.

RESULTS

Evidence suggests that aging, hypertension, and atrial fibrillation are each associated with functional and structural changes in specific areas of the central nervous system involved in autonomic control. Increased muscle sympathetic nerve activity (MSNA) and significant alterations in the brain regions involved in the default mode network are commonly reported in aging, hypertension, and atrial fibrillation.

CONCLUSIONS

Further studies using functional and structural magnetic resonance imaging (MRI) coupled with autonomic nerve activity in healthy aging, hypertension, and atrial fibrillation promise to reveal the underlying brain circuitry modulating the abnormal sympathetic nerve activity in these conditions. This understanding will guide future therapies to rectify dysregulation of autonomic and cardiovascular control by the brain.

Associations of Atrial Fibrillation with Mild Cognitive Impairment and Dementia: An Investigation Using SPRINT Research Materials

BACKGROUND

Atrial fibrillation (AF) is linked to increased risk of dementia and cognitive decline, but whether AF and its ascertainment methods affect cognition in patients with hypertension has received less attention.

METHODS

We studied 8469 participants with elevated systolic blood pressure who were free of stroke and diabetes at baseline enrolled in the Systolic Blood Pressure Intervention Trial. AF was ascertained using three approaches: self-report of AF, AF from a safety event, and study electrocardiogram-determined (ECG) AF. Mild cognitive impairment (MCI) and probable dementia (PD) were ascertained from in-person assessments or telephone interviews from the participant or an informant. We used Cox proportional hazard models to estimate hazard ratios for the association of AF (all three sources) with outcomes of MCI, PD, and a composite MCI/PD outcome.

RESULTS

During a mean follow-up of 4.6 years, 974 (12%) participants had AF (prevalent or incident), 634 were diagnosed with MCI, and 316 with PD. When comparing those with AF (from any source) to those without, no differences were detected in the risk of MCI or PD. Comparison between AF sources found ECG-AF to be associated with an elevated risk of MCI/PD (hazard ratio (HR) 1.59, 95% confidence interval (95%CI) 1.06, 2.38). Neither AF ascertained through safety events nor self-reported AF were associated with MCI or PD.

CONCLUSION

The association of AF with incidence of MCI/PD differed by method of AF ascertainment. Case definition of AF and quantification of AF burden are important factors in studies evaluating the link between AF and cognitive dysfunction.

Diagnosis of vascular cognitive impairment: recommendations of the scientific department of cognitive neurology and aging of the Brazilian Academy of Neurology

ABSTRACT Since the publication of the latest recommendations for the diagnosis and treatment of Vascular Dementia by the Brazilian Academy of Neurology in 2011, significant advances on the terminology and diagnostic criteria have been made. This manuscript is the result of a consensus among experts appointed by the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology (2020-2022). We aimed to update practical recommendations for the identification, classification, and diagnosis of Vascular Cognitive Impairment (VCI). Searches were performed in the MEDLINE, Scopus, Scielo, and LILACS databases. This guideline provides a comprehensive review and then synthesizes the main practical guidelines for the diagnosis of VCI not only for neurologists but also for other professionals involved in the assessment and care of patients with VCI, considering the different levels of health care (primary, secondary and tertiary) in Brazil.

Diagnóstico do comprometimento cognitivo vascular: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

RESUMO Desde a publicação das últimas recomendações para o diagnóstico e tratamento da Demência Vascular pela Academia Brasileira de Neurologia em 2011, avanços significativos ocorreram na terminologia e critérios diagnósticos. O presente manuscrito é resultado do consenso entre especialistas indicados pelo Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia (2020-2022). O objetivo foi atualizar as recomendações práticas para a identificação, classificação e diagnóstico do Comprometimento Cognitivo Vascular (CCV). As buscas foram realizadas nas plataformas MEDLINE, Scopus, Scielo e LILACS. As recomendações buscam fornecer uma ampla revisão sobre o tema, então sintetizar as evidências para o diagnóstico do CCV não apenas para neurologistas, mas também para outros profissionais de saúde envolvidos na avaliação e nos cuidados ao paciente com CCV, considerando as diferentes realidades dos níveis de atenção à saúde (primário, secundário e terciário) no Brasil.

Risk Factors for Dementia in Patients With Atrial Fibrillation

Although dementia and atrial fibrillation (AF) are common in older adults, risk factors for dementia have not been sufficiently characterized in patients with AF. We studied 621,773 patients with AF without dementia at the time of AF diagnosis who were enrolled in the MarketScan Commercial and Medicare Supplemental databases from 2007 to 2015. Dementia incidence and presence of predictors at the time of AF diagnosis (cardiometabolic conditions, mental and neurologic disorders, and other chronic conditions) were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in outpatient and inpatient claims, whereas medication usage was based on outpatient pharmacy claims. A frailty score was calculated using a previously established algorithm. The associations between the predictors of interest and dementia were assessed with multivariable Cox models. Patients had a mean age of 68 years (SD 14 years) and 41% were women. During a mean follow-up of 2.0 years, there were 16,073 cases of dementia. The strongest predictors of dementia were frailty (hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.40 to 1.45, per 1-SD increase in the score), cognitive impairment (HR 1.50, 95% CI 1.36 to 1.65), mood disorders (HR 1.49, 95% CI 1.32 to 1.70), schizophrenia (HR 1.86, 95% CI 1.75 to 1.98), and substance abuse (HR 1.58, 95% CI 1.39 to 1.80). Among cardiometabolic conditions, only stroke (HR 1.17, 95% CI 1.13 to 1.22) and diabetes mellitus (HR 1.14, 95% CI 1.11 to 1.18) were associated with small increases in dementia risk after adjusting for demographics, frailty, co-morbidities, and medications. We have identified several risk factors for dementia in patients with AF.

Validation of T-MoCA in the Screening of Mild Cognitive Impairment in Chinese Patients With Atrial Fibrillation

Background

Atrial fibrillation (AF) is associated with a high risk of mild cognitive impairment (MCI) and dementia. However, feasible and simple instruments that facilitate the regular assessment of cognitive status in patients with AF remain underdeveloped.

Methods

Cognitive function was first evaluated using telephone Montreal cognitive assessment (T-MoCA), and then patients were invited for an in-person interview for cognitive assessment using both Clinical Dementia Rating (CDR) and mini-mental status evaluation (MMSE). Using CDR = 0.5 as a reference standard, the ability of T-MoCA and MMSE to discriminate cognitive dysfunction, stratified by education level, was tested by receiver–operating curve (ROC) analysis. The net reclassification index was calculated for comparison between the performance of T-MoCA and MMSE.

Results

One hundred and one patients completed both telephone and in-person interview. Thirty-five MCI patients were identified as MCI using the criteria of CDR = 0.5. The areas under the ROC curve of T-MoCA were 0.80 (0.71–0.89), 0.83 (0.71–0.95), and 0.85 (0.64–0.92) for all patients, patients with high educational level, and patients with low education level, respectively. The optimal threshold was achieved at 16/17 with a sensitivity of 85.7% and a specificity of 69.7% in overall patients, 15/16 with a sensitivity of 88.2% and a specificity of 64.5% in the low educational level patients, and 16/17 with a sensitivity of 77.8% and a specificity of 87.9% in the high educational level patients. Compared to the criterion MMSE ≤ 27 and MMSE norms for the elderly Chinese community, the stratified T-MoCA threshold improves correct classification by 23.7% (p = 0.033) and 30.3% (p = 0.020), respectively.

Conclusion

T-MoCA is a feasible and effective instrument for MCI screening in patients with AF.

Left Atrial Remodeling and Stroke in Patients With Sinus Rhythm and Normal Ejection Fraction: ARIC-NCS

Background Age-related left atrial (LA) structural and functional abnormalities may be related to subclinical cerebral infarcts (SCIs) and stroke. We evaluated the association of 3-dimensional echocardiographic LA contractility parameters with SCIs and stroke across the spectrum of tertiles of age increment in elderly patients with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation. Methods and Results We enrolled 407 participants (mean age, 76±8 years; 40% men) from ARIC-NCS (Atherosclerosis Risk in Communities Neurocognitive Study) undergoing a brain magnetic resonance imaging and 3-dimensional echocardiographic examinations in 2011 to 2013. The sample was analyzed among age tertiles and subgroups: no cerebral magnetic resonance imaging-detectable infarcts (n=315), magnetic resonance imaging-diagnosed SCIs (n=58), and clinically diagnosed stroke (n=34). The frequency of SCIs significantly increased over age tertiles (P trend 0.023). LA global longitudinal strain-a 3-dimensional echocardiographic index of LA reservoir function-and E/e' divided by LA global longitudinal strain-an index of LA stiffness-worsened across age tertiles (P trend 0.014 and 0.001, respectively), and only in the categories of SCIs (P trend <0.001 and 0.045, respectively) and stroke (P trend 0.001 and 0.011, respectively). LA global longitudinal strain was negatively associated with increased odds of SCIs (P=0.036, P=0.008, and P=0.001, respectively) and strokes (P=0.043, P=0.015, and P=0.001, respectively) over age tertiles, with a significant interaction between age tertiles (interaction P=0.043 and P=0.010, respectively). E/e' divided by LA global longitudinal strain was positively associated with the presence of SCIs (P=0.037, P=0.007, and P=0.001, respectively) and strokes (P=0.045, P=0.007, and P=0.003, respectively) over age tertiles, with a significant interaction only for SCIs (interaction P=0.040) and not for clinical stroke. Conclusions In a large cohort study of elderly patients, among participants with sinus rhythm, normal ejection fraction, and no history of atrial fibrillation, measures of worse age-related LA reservoir function and stiffness are associated with higher odds of SCIs and stroke.

[Modern issues of improving the prognosis in patients with atrial fibrillation after ischemic stroke]

The anticoagulant therapy with a priority of direct oral anticoagulants is an approach to the prevention of recurrent stroke in patients with atrial fibrillation (AF) that has presently proved its efficacy and is stated in international clinical guidelines. An extensive evidence-based database demonstrates advantages of rivaroxaban over other drugs of this class in secondary prevention of stroke in AF. Furthermore, these advantages are combined with the optimal safety profile. The rivaroxaban treatment may provide the most favorable prognosis due to the prevention of recurrent stroke in AF, reducing the rate of kidney disease progression, and slowing vascular atherosclerosis. An important beneficial feature of rivaroxaban is once-a-day intake, which is important in the context of a high incidence of cognitive disorders in this patient category, and may improve their compliance and, thus, help achieving the expected profile of treatment efficacy. Thus, rivaroxaban can be regarded as a drug of choice for secondary prevention of stroke in AF.

Association of Echocardiographic Measures of Left Atrial Function and Size With Incident Dementia

IMPORTANCE

Atrial myopathy-characterized by alterations in left atrial (LA) function and size-is associated with ischemic stroke, independent of atrial fibrillation (AF). Electrocardiographic markers of atrial myopathy are associated with dementia, but it is unclear whether 2-dimensional echocardiographic (2DE)-defined LA function and size are associated with dementia.

OBJECTIVE

To examine the association of LA function and size with incident dementia.

DESIGN, SETTING, AND PARTICIPANTS

The Atherosclerosis Risk in Communities (ARIC) study is a community-based prospective cohort. An exploratory, retrospective analysis was conducted. ARIC centers are located in Forsyth County, North Carolina; Jackson, Mississippi; Washington County, Maryland; and suburban Minneapolis, Minnesota. For this analysis, visit 5 (2011-2013) served as the baseline. Participants without prevalent AF and stroke and who had 2DEs in 2011-2013 were included and surveilled through December 31, 2019.

EXPOSURES

LA function (reservoir strain, conduit strain, contractile strain, emptying fraction, passive emptying fraction, and active emptying fraction), and LA size (maximal and minimal volume index) as evaluated by 2DE.

MAIN OUTCOMES AND MEASURES

Dementia cases were identified using in-person and phone cognitive assessments, hospitalization codes, and death certificates. Cox proportional hazards models were used.

RESULTS

Among 4096 participants (mean [SD] age, 75 [5] years; 60% women; 22% Black individuals), 531 dementia cases were ascertained over a median follow-up of 6 years. Dementia incidence for the lowest LA quintile was 4.80 for reservoir strain, 3.94 for conduit strain, 3.29 for contractile strain, 4.20 for emptying fraction, 3.67 for passive emptying fraction, and 3.27 for active emptying fraction per 100 person-years. After full-model adjustments, there were statistically significant associations between measures of LA function and dementia; the hazard ratios (HRs) from the lowest vs highest quintile for reservoir strain were 1.98 (95% CI, 1.42-2.75); for conduit strain, 1.50 (95% CI, 1.09-2.06); for contractile strain, 1.57 (95% CI, 1.16-2.14); for emptying fraction, 1.87 (95% CI, 1.31-2.65); and for active emptying fraction, 1.43 (95% CI, 1.04-1.96). LA passive emptying fraction was not significantly associated with dementia (HR, 1.26 [95% CI, 0.93-1.71]). Dementia incidence for the highest LA maximal volume index quintile was 3.18 per 100 person-years (HR for highest vs lowest quintile, 0.77 [95% CI, 0.58-1.02]) and for the highest minimal volume index quintile was 3.50 per 100 person-years (HR for the highest vs lowest quintile, 0.95 [95% CI, 0.71-1.28]). Both measures were not significantly associated with dementia. These findings were robust to sensitivity analyses that excluded participants with incident AF or stroke.

CONCLUSIONS AND RELEVANCE

In this exploratory analysis of a US community-based cohort, several echocardiographic measures of lower LA function were significantly associated with an increased risk of subsequent dementia. Measures of LA size were not significantly associated with dementia risk. These findings suggest that impaired LA function may be a risk factor associated with dementia.

Predictive role of atrial fibrillation in cognitive decline: a systematic review and meta-analysis of 2.8 million individuals

Aims

To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment.

Methods and results

PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25–1.53, I² = 90.3%; follow-up 3.8–25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66–3.74, I² = 0.0%; follow-up 0.25–3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11–1.73, I² = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58–2.64, I² = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke.

Conclusion

Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.

Renal Function Protection as an Important Component of a Comprehensive Approach to the Management of Patients with Atrial Fibrillation

The increase in the life expectancy of the population  is accompanied by an increase in the prevalence of diseases for which old and senile age are risk factors. Atrial fibrillation (AF) and chronic kidney disease (CKD) are two diseases that can coexist in a patient. The risk of ac thromboembolic and hemorrhagic events in this case increases due to the mutual aggravating influence of these diseases. In addition,  these patients have a high incidence of coronary  events, and cardiovascular complications are the main cause of death in patients with AF and CKD. Consequently, such patients require an integrated  approach  to treatment,  and their management is a complex  clinical task. The direct oral anticoagulant rivaroxaban has been most studied in a population  of comorbid  AF and CKD  patients and has proven a high efficacy and safety profile in these patients in randomized controlled trials. In addition,  rivaroxaban has shown  a significant  reduction in the risk of myocardial  infarction  in various patients,  as well as the possibility of preserving renal function to a greater extent compared  with warfarin therapy, and a possible positive effect on reducing  the risk of cognitive impairment.  A single dosing  regimen  can improve adherence  to treatment,  which is one of the key conditions  for achieving  the above effects. Thus, these factors make it possible to achieve comprehensive protection of comorbid  patients with AF and CKD.

Global cognitive performance at 4-year follow-up in individuals with atrial fibrillation-findings from The Irish Longitudinal Study on Ageing

INTRODUCTION

Atrial fibrillation (AF) has been proposed as a risk factor for cognitive impairment, even in the absence of a history of stroke. This study investigates whether AF is associated with increased risk of cognitive decline in a community-dwelling population of adults over the age of 50.

METHODS

Data from the 1st and 3rd waves of The Irish Longitudinal Study on Ageing (TILDA) were used (4-year follow-up period). TILDA is a large prospective cohort study of community-dwelling adults over the age of 50 in Ireland. AF was assessed via electrocardiogram. Global cognitive function was assessed at baseline and follow-up using Montreal Cognitive Assessment (MOCA). Analysis of global cognition was repeated stratifying by age. Mixed-effects Poisson regression was used to assess for change in rate of errors on MOCA and MOCA subdomains.

RESULTS

A total of 3,417 participants were included in the study. Results found that participants with AF had a greater increase in rate of errors on MOCA over 4-year follow-up (incident rate ratio (IRR) 1.18; 95% confidence interval (CI) 1.02, 1.37; P-value 0.023). However, this was no longer significant on controlling for age, sex and level of education (IRR 1.08; 95% CI 0.93, 1.25; P-value 0.332). There was no difference when stratifying by age group, or when separating MOCA into subdomains.

CONCLUSION

Individuals with AF were more likely to show an increase in rate of errors between waves 1 and 3 (4-year follow-up period) in the TILDA population; however, results were not significant when controlling for age, sex and level of education.

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.

A Traditional Review of Sickle Cell Disease and the Associated Onset of Dementia: Hematological and Neurocognitive Crossroads

Sickle cell trait and disease are potential risk factors for dementia and cognitive dysfunction in African Americans, as are genetic variants. This illness affects around 300 million people globally. Due to its ability to defend against severe malaria, it represents an evolutionary survival advantage. It has been shown that sickle cell disease and trait are independent risk factors for the prevalence and incidence of albuminuria and chronic renal disease. Sickle cell anemia impairs cognitive performance in people with minimal or mild manifestations of the genetic blood disorder, owing mostly to its cerebrovascular implications. Similarly, various cerebral minor vascular disorders, such as silent cerebral infarcts, have been linked to the sickle cell trait, which is associated with impaired cognitive ability. It has been found that patients with sickle cell disease have a significantly decreased subcortical and cortical brain volume. Adults and children with sickle cell disease have been documented to have attention-related issues, particularly reduced sustained attention.

The Impact of Hypertension and Atrial Fibrillation on Cognitive Decline and Subclinical Atherosclerosis

BACKGROUND

Assessment of cognitive impairment and the presence of subclinical atherosclerosis are very important especially in patients with cardiovascular risk factors.

METHODS

We included 155 hypertensive patients (84 with AF versus 71 without AF) to identify the premature cognitive impairment, the earliest signs of subclinical atherosclerosis and onset of myocardial dysfunction and to evaluate the type of anticoagulation used, the importance of CHA₂DS₂-VASc score (3), age (65 years) in hypertensive patients with AF.

RESULTS

Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment Scale (MoCA), Left Ventricular Ejection Fraction (LVEF) were significantly decreased, and Activities of Daily Living Score (ADL), Geriatric Depression Scale(GDS-15), and intima-media thickness (IMT) were significantly increased in hypertensive patients with AF vs. without AF (p < 0.05). MMSE was significantly decreased, ADL and IMT were significant increased in patients with AF and CHA₂DS₂-VASc>3 and non-vitamin K antagonists oral anticoagulants therapy (NOACs)(p < 0.05). Patients with age >65 with AF had higher rates of cognitive impairment (MMSE significant decrease) and a larger IMT (significant increase) versus patients with AF and age <65 (p < 0.05).

CONCLUSIONS

Cognitive impairment is encountered in hypertensive patients having AF. Our conclusions suggest a direct link between cognitive impairment, depression, hypertension, AF, age, CHA₂DS₂-VASc score, type of anticoagulants used, LVEF, cognitive parameters, and IMT. We acknowledge the importance of identifying and preventing cognitive changes.

Cerebral Structure and Function in Stroke-free Patients with Atrial Fibrillation

OBJECTIVES

Atrial fibrillation (AF) is associated with high risk of dementia and brain atrophy in stroke-free patients, but the mechanisms underlying this association remain unclear. We aimed to examine the brain volume and connectivity of paramount cognitive brain networks in stroke-free patients with AF without dementia.

MATERIALS AND METHODS

Twenty-six stroke-free patients with AF and 26 age and sex-matched subjects without AF were submitted to a 3-tesla brain structural and functional MRI. An extensive clinical evaluation excluded stroke, dementia, low cardiac output, carotid stenosis and metabolic diseases without optimal therapy. We used CHA₂DS₂-VASc score to classify the cardiovascular risk factor burden and a broad neuropsychological battery to assess the cognitive performance. Voxel based morphometry analysis of. structural MRI defined whole-brain gray and white matter volumes. Finally, we used eco-plannar MRI images to compare the differences of functional connectivity of 7 large-scale resting-state networks between AF patients and controls.

RESULTS

Taking into account the history of hypertension and heart failure, AF was associated to volume decrease of the right basal frontal lobe and right inferior cerebellum. Decreased connectivity of the ventral Default Mode Network (vDMN) was observed in the AF group. No disruption of connectivity was observed in the executive, visuospatial and salience networks.

CONCLUSION

Individuals with AF without stroke or dementia have subtle reduction of gray and white matter, restricted to frontal areas and cerebellum. These patients show decreased vDMN connectivity, without other large-scale brain network disruption.

Correlation between Serum Platelet Count and Cognitive Function in Patients with Atrial Fibrillation: A Cross-Sectional Study

BACKGROUND

The risk of cognitive impairment in patients with atrial fibrillation is significantly increased. Its occurrence may be related to blood hypercoagulable state and immune inflammatory reaction. Platelets can mediate immune inflammatory response, but there is no evidence about the relationship between platelet count and cognitive function in patients with atrial fibrillation.

PURPOSE

To explore whether there is a certain correlation between platelet count and cognitive function in patients with atrial fibrillation.

METHODS

A cross-sectional study was conducted in a single center in China, including 254 patients with atrial fibrillation. Cognitive function assessment and clinical and laboratory examinations were performed on all participants. After adjusting the related confounding factors, the relationship between platelet count and cognitive function was analyzed.

RESULTS

A total of 254 subjects with an average age of 59.71 ± 11.14 years were included. The average platelet count was 208.15 ± 68.30, and the average score of cognitive function was 19.29 ± 6.78. Result of fully adjusted binary logistic regression showed platelet count was negatively associated with the cognitive function score after adjusting confounders (hazard ratio (HR) = 0.000, 95%CI -0.01, 0.01). A nonlinear relationship was detected between platelet count and the cognitive function score, whose point was 230. The effect sizes and the confidence intervals of the left and right sides of the inflection point were 0.03 (0.01-0.05, P for nonlinearity = 0.011) and -0.03 (-0.05-0.00, P for nonlinearity = 0.023), respectively.

CONCLUSION

Platelets have a nonlinear relationship with cognitive function in patients with atrial fibrillation. This finding suggests that, in patients with atrial fibrillation, platelets should be maintained at about 230.

Sex Differences in Cardiovascular Disease and Cognitive Dysfunction in Rural West Elderly Texans

BACKGROUND

The prevalence of cognitive dysfunction increases in elderly due to cardiovascular disease related risk factors in rural communities like West Texas.

OBJECTIVE

The purpose of this study was to find risk factors of cardiovascular disease (CVD) related to cognitive dysfunction and their impact on elderly adults in rural West Texans.

METHODS

Statistical methods such as Pearson's chi-squared and a multinomial logistic regression were utilized to analyze data. We used SPSS software to detect and understand the nature of the risk factors.

RESULTS

A summary of statistics was obtained by using Pearson's chi-squared test for categorical variables. CVD, diabetes mellitus, and depression were significantly associated with cognitive dysfunction for both males and females (p = 0.0001), whereas anxiety was found to be significantly associated with cognitive dysfunction for females (p = 0.0001). Age group and race/ethnicity were significantly associated with cognitive dysfunction for both males and females (p = 0.0001). By performing a multinomial logistic regression method and controlling for confounders, the significant risk factors (p <  0.05)- age (65- 84 years), diabetes, and memory loss for age-associated cognitive impairment; diabetes for cognitive impairment no dementia; age (65- 84, ≥85 years), CVD, diabetes, depression, memory loss, non-Hispanic Whites, and Black/African-Americans for mild cognitive impairment; and age, memory loss, non-Hispanic Whites, Black/African-Americans, and male gender were found for dementia.

CONCLUSION

CVD related risk factors in developing cognitive dysfunction exist and integrating such risk variables may guide relevant policy interventions to reduce Alzheimer's incidence or dementia in rural communities in West Texans.

Cognitive Impairment in Patients with Stroke

Despite substantial advances in stroke care, vascular cognitive impairment remains a prominent source of disability. Unlike sensorimotor impairments, cognition often continues to decline after stroke. An aging population will increase the prevalence of vascular cognitive impairment, with stroke playing an important role. Ten percent of patients presenting with stroke have pre-stroke dementia; an additional 10% will develop incident dementia with a first stroke, and 30% with a recurrent stroke. While stroke increases the risk of cognitive impairment, the presence of cognitive impairment also impacts acute stroke treatment and increases risk of poor outcome by nearly twofold. There is substantial overlap in the clinical and pathological aspects of vascular and degenerative dementias in many patients. How they relate to one another is controversial. The treatment of vascular cognitive impairment remains supportive, focusing on treating vascular risk factors. Cognitive rehabilitation after stroke is an area of active research, and existing pharmacologic treatments have limited benefit. Heightened awareness of cognitive impairment in the setting of stroke is imperative for prognostication and management, impetus for research and, ultimately, the discovery of efficacious treatments.

Association of Ventricular Arrhythmias With Dementia: The Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

We performed a cross-sectional analysis to determine whether nonsustained ventricular tachycardia (NSVT) and premature ventricular contractions (PVCs) were associated with dementia in a population-based study.

METHODS

We included 2,517 (mean age 79 years, 26% Black) participants who wore a 2-week ambulatory continuous ECG recording device in 2016 to 2017. NSVT was defined as a wide-complex tachycardia ≥4 beats with a rate >100 bpm. We calculated NSVT and PVC burden as the number of episodes per day. Dementia was adjudicated by experts. We used logistic regression to assess the associations of NSVT and PVCs with dementia.

RESULTS

The mean recording time of the Zio XT Patch was 12.6 ± 2.6 days. There were 768 (31%) participants with NSVT; prevalence was similar in White and Black participants. There were 134 (6.5%) dementia cases (5% in White, 10% in Black participants). After multivariable adjustment, there was no overall association between NSVT and dementia; however, there was a significant race interaction (p < 0.001). In Black participants, NSVT was associated with a 3.67 times higher adjusted odds of dementia (95% confidence interval [CI] 1.92-7.02) compared to those without NSVT, whereas in White participants NSVT was not associated with dementia (odds ratio [95% CI] 0.64 [0.37-1.10]). In Black participants only, a higher burden of PVCs was associated with dementia.

CONCLUSIONS

Presence of NSVT and a higher burden of NSVT and PVCs are associated with dementia in elderly Black people. Further research to confirm this novel finding and to elucidate the underlying mechanisms is warranted.

Atrial Fibrillation and Cognitive Impairment: An Associated Burden or Burden by Association?

Growing evidence suggests that atrial fibrillation (AF), in addition to its thromboembolic risk, is a risk factor for cognitive impairment (CI) via several pathways and mechanisms, further contributing to morbidity/mortality. Prior stroke is a contributor to CI, but AF is also associated with CI independently from prior stroke. Silent brain infarctions, microemboli and microbleeds, brain atrophy, cerebral hypoperfusion from widely fluctuating ventricular rates, altered hemostatic function, vascular oxidative stress, and inflammation may all exacerbate CI, particularly in patients with persistent/permanent rather than paroxysmal AF and with increased duration/burden of the arrhythmia. Brain magnetic resonance imaging is an important screening tool in eliciting and monitoring vascular and nonvascular lesions contributing to CI. Evidence is also emerging about the role of genetics in CI development. Anticoagulation and rhythm/rate control strategies may protect against CI preventing or slowing its progression or conversion to dementia, particularly at the early stages when CI may still be a treatable condition. Importantly, AF and CI share many common risk factors. Thus, screening for these 2 conditions and searching for and managing modifiable risk factors and potentially reversible causes for both AF and CI remains an important step toward prevention or amelioration of the impact incurred by these 2 conditions.

Atrial Cardiomyopathy: An Unexplored Limb of Virchow's Triad for AF Stroke Prophylaxis

The most dreaded complication of atrial fibrillation is stroke, and 70–80% of patients with AF-related stroke die or become disabled. The mechanisms of thromboembolism in AF are multifactorial, with evidence demonstrating that all three criteria of Virchow's triad are satisfied in AF: abnormal stasis of blood, endothelial damage, and hypercoagulability. Mechanistic insights into the latter two limbs have resulted in effective stroke prophylactic therapies (left atrial appendage occlusion and oral anticoagulants); however, despite these advances, there remains an excess of stroke in the AF population that may be due, in part, to a lack of mechanistic understanding of atrial hypocontractility resulting in abnormal stasis of blood within the atrium. These observations support the emerging concept of atrial cardiomyopathy as a cause of stroke. In this Review, we evaluate molecular, translational, and clinical evidence for atrial cardiomyopathy as a cause for stroke from AF, and present a rationale for further investigation of this largely unaddressed limb of Virchow's triad in AF.

Investigation of Causal Effect of Atrial Fibrillation on Alzheimer Disease: A Mendelian Randomization Study

Background

Atrial fibrillation (AF) has been shown to be associated with an increased risk of dementia as well as Alzheimer disease in observational studies. Whether this association reflects causal association is still unclear. The purpose of this study was to examine the causal association of AF with Alzheimer disease.

Methods and Results

We used a 2‐sample Mendelian randomization approach to evaluate the causal effect of AF on Alzheimer disease. Summary data on the association of single nucleotide polymorphisms with AF were obtained from a recently published genome‐wide association study with up to 1 030 836 individuals and data on single nucleotide polymorphism‐Alzheimer disease association from another genome‐wide association study with up to 455 258 individuals. AF was mainly diagnosed according to International Classification of Diseases, Ninth Revision (ICD‐9 or ICD‐10) and Alzheimer disease was mainly diagnosed according to clinical criteria (eg, National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association [NINCDS‐ADRDA] criteria). Effect estimates were calculated using the inverse‐variance weighted method. The Mendelian randomization analysis showed nonsignificant association of genetically predicted AF with risk of Alzheimer disease (odds ratio=1.002, 95% CI: 0.996–1.009, P=0.47) using 93 single nucleotide polymorphisms as the instruments. Mendelian randomization‐Egger indicated no evidence of genetic pleiotropy (intercept=0.0002, 95% CI: −0.001 to 0.001, P=0.70).

Conclusions

This Mendelian randomization analysis found no evidence to support causal association between AF and Alzheimer disease.

Prevalence and Progression of Cognitive Impairment in Atrial Fibrillation Patients after Treatment with Catheter Ablation or Drug Therapy

Purpose

In atrial fibrillation (AF) patients, the effect of catheter ablation or drug therapy on cognition is currently not well investigated. Therefore, we prospectively evaluated AF patients who were either treated 'with drug therapy or underwent catheter ablation for the prevalence and progression of cognitive impairment (CI).

Methods

Randomized participants of the CABANA trial (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation) and the CASTLE-AF (catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation) study were assessed twice within 6 months by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in our institution.

Results

Forty-five patients from both trials were investigated, and twenty-eight patients received catheter ablation, whereas seventeen patients received drug therapy for rhythm or rate control. The mean age of the twenty-one CABANA trial patients (AF group) was 68.8 ± 7.0 years and of the twenty-four CASTLE-AF study patients (AF/HF group) was 66.8 ± 8.1 years, respectively. Mean time from ablation/randomization to the first interview was 16.8 ± 11 months in the AF group and 28.3 ± 18.4 months in the AF/HF group, respectively. All patients investigated were classified as cognitively impaired with mean cutoff scores <24 by MoCA. Overall, we could not detect significant differences in medically treated versus catheter ablation patients within both groups in mean MMSE or MoCA scores between the first and the second interview (p > 0.09). Moreover, patients who received catheter ablation did not show statistically significant differences in the prevalence or progression of cognitive impairment compared to patients who were treated medically, neither within the two groups nor between AF and AF/HF patients (p > 0.05).

Conclusions

Prevalence of cognitive impairment in AF patients with comorbidities is substantial. However, in this preliminary prospective study, no apparent impact of AF pretreatment on the prevalence and course of cognitive impairment could be observed.

[Cognitive Dysfunction at the Background of Atrial Fibrillation: Clinical-Pathological Aspects, Diagnostics and Prevention, Issues of the Use of the Application of Anticoagulant Therapy]

Atrial fibrillation (AF) and cognitive dysfunction - common states with similar risk factors. Recently significant scientific epidemiological data has been received in favor of independence of effect of AF on possibility of development of cognitive dysfunction. In this review we present problems of prevalence, pathogenesis, and diagnostics of various variants of cognitive disorders at the background of AF, as well as methods of their prevention and tactics of anticoagulant therapy in the presence of cognitive disturbances.

Associations Between Left Ventricular Structure, Function, and Cerebral Amyloid: The ARIC-PET Study

Background and Purpose- Cardiovascular disease is a known risk factor for cognitive decline, although the mechanisms remain unclear. We hypothesize that Aβ (β-amyloid), a core pathology of Alzheimer's disease, will be associated with subclinical cardiac structure and function echocardiogram indices. Methods- Three hundred six nondemented participants from the ARIC study (Atherosclerosis Risk in Communities Study) underwent florbetapir positron emission tomography and 2D echocardiography (echo). Cross-sectional associations between echo markers of left ventricular structure and function and global cortical Aβ (≥1.2 standardized uptake value ratio were evaluated using multivariable logistic regression with interaction terms when appropriate. Results- Participants ranged in age from 67 to 88 years, were 57% female and 42% black. Per 1 cm increase in end-diastolic left ventricular diameter, the odds of elevated florbetapir standardized uptake value ratio doubled (odds ratio, 2.04 [95% CI, 1.10-3.77]), with similar findings when excluding mild cognitive impairment (odds ratio, 2.61 [95% CI, 1.22-5.59]). Conclusions- We have demonstrated a significant association between a marker of left ventricular structure and elevated florbetapir standardized uptake value ratio, identified using positron emission tomography. Ongoing prospective work will help determine if changes in cardiac structure and function either precede, or occur simultaneously with deposition of amyloid.

Cognitive Function and Atrial Fibrillation: From the Strength of Relationship to the Dark Side of Prevention. Is There a Contribution from Sinus Rhythm Restoration and Maintenance?

Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia with an increasing prevalence over time mainly because of population aging. It is well established that the presence of AF increases the risk of stroke, heart failure, sudden death, and cardiovascular morbidity. In the last two decades several reports have shown an association between AF and cognitive function, ranging from impairment to dementia. Ischemic stroke linked to AF is a well-known risk factor and predictor of cognitive decline. In this clinical scenario, the risk of stroke might be reduced by oral anticoagulation. However, recent data suggest that AF may be a predictor of cognitive impairment and dementia also in the absence of stroke. Cerebral hypoperfusion, reduced brain volume, microbleeds, white matter hyperintensity, neuroinflammation, and genetic factors have been considered as potential mechanisms involved in the pathogenesis of AF-related cognitive dysfunction. However, a cause-effect relationship remains still controversial. Consequently, no therapeutic strategies are available to prevent AF-related cognitive decline in stroke-free patients. This review will analyze the potential mechanisms leading to cognitive dysfunction in AF patients and examine the available data on the impact of a sinus rhythm restoration and maintenance strategy in reducing the risk of cognitive decline.

Cognitive dysfunction in atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia in adults, and its incidence and prevalence increase with age. The risk of cognitive impairment and dementia also increases with age, and both AF and cognitive impairment or dementia share important risk factors. In meta-analyses of published studies, AF is associated with a 2.4-fold and 1.4-fold increase in the risk of dementia in patients with or without a history of stroke, respectively. This association is independent of shared risk factors such as hypertension and diabetes mellitus. Neuroimaging has illustrated several potential mechanisms of cognitive decline in patients with AF. AF is associated with increased prevalence of silent cerebral infarcts, and more recent data also suggest an increased prevalence of cerebral microbleeds with AF. AF is also associated with a pro-inflammatory state, and the relationship between AF-induced systemic inflammation and dementia remains to be investigated. Preliminary reports indicate that anticoagulation medication including warfarin can reduce the risk of cognitive impairment in patients with AF. Catheter ablation, increasingly used to maintain sinus rhythm in patients with AF, is associated with the formation of new silent cerebral lesions. The majority of these lesions are not detectable after 1 year, and insufficient data are available to evaluate their effect on cognition. Large prospective studies are urgently needed to confirm the association between AF and dementia, to elucidate the associated mechanisms, and to investigate the effect of anticoagulation and rhythm control on cognition.

Association of sickle cell trait with measures of cognitive function and dementia in African Americans

OBJECTIVE

The incidence and prevalence of cognitive decline and dementia are significantly higher among African Americans compared with non-Hispanic Whites. The aim of this study was to determine whether inheritance of the sickle cell trait (SCT) i.e. heterozygosity for the sickle cell mutation increases the risk of cognitive decline or dementia Among African Americans.

METHODS

We studied African American participants enrolled in the Atherosclerosis Risk in Communities study. SCT genotype at baseline and outcome data from cognitive assessments at visits 2, 4 and 5, and an MRI performed at visit 5 were analyzed for the association between SCT and risk of cognitive impairment and/or dementia.

RESULTS

There was no significant difference in risk factors profile between participants with SCT (N = 176) and those without SCT (N = 2532). SCT was not independently associated with a higher prevalence of global or domain-specific cognitive impairment at baseline or with more rapid cognitive decline. Participants with SCT had slightly lower incidence of dementia (HR = 0.63 [0.38, 1.05]). On the other hand, SCT seems to interact with the apolipoprotein E ε4 risk allele resulting in poor performance on digit symbol substitution test at baseline (z-score = -0.08, Pinteraction = 0.05) and over time (z-score = -0.12, Pinteraction = 0.04); and with diabetes mellitus leading to a moderately increased risk of dementia (HR = 2.06 [0.89, 4.78], Pinteraction = 0.01).

CONCLUSIONS

SCT was not an independent risk factor for prevalence or incidence of cognitive decline or dementia, although it may interact with and modify other putative risk factors for cognitive decline and dementia.

Risk factors for predicting progression from normal cognition to mild cognitive impairment: protocol for a systematic review and meta-analysis of cohort studies

INTRODUCTION

Mild cognitive impairment (MCI) often represents the earliest stage of Alzheimer's disease. There has been considerable research investigating specific risk factors regarding the progression from normal cognition to MCI. However, different studies have come to different conclusions on the impact of particular risk factors. Therefore, it is necessary to conduct a meta-analysis of the risk factors that predict cognitive disruption in individuals based on associations with MCI.

METHODS AND ANALYSIS

We will search seven electronic databases without time limit, including MEDLINE, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Wan Fang Database and China Biology Medicine. Two researchers will independently screen for eligibility and perform data extraction. Data were extracted from cohort studies meeting the inclusive criteria according to the Newcastle Ottawa Scale (NOS) methods. A third member of the research team will be contacted when a consensus cannot be reached. Any disagreement will be settled by consensus. The NOS will be used to assess the quality of the studies. All analyses were performed using Stata V.15.1.

ETHICS AND DISSEMINATION

We will report this review in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. We will disseminate our findings through a publication in a peer-reviewed journal. This systematic review does not require ethical approval as no primary data are collected.

PROSPERO REGISTRATION NUMBER

CRD42018109099.

Atrial Fibrillation and Risk of Dementia: Epidemiology, Mechanisms, and Effect of Anticoagulation

Atrial fibrillation (AF) is one of the cardiovascular risk factors for dementia. Several longitudinal studies have reported an association between AF and dementia independently of stroke history. Although the mechanisms underlying this association are not fully understood, proposed mechanisms include cerebral hypoperfusion, inflammation, genetic factors, cerebral microbleeds, and recurrent silent cerebral ischemia. Oral anticoagulation can be used to minimize risk of cognitive decline and dementia, given that brain insults can be caused by chronic microemboli or microbleeds. However, controversy on the effects of warfarin and direct oral anticoagulants on this risk exists. This article will address these aspects, with data on the studies already published and a critical view on this subject.

Atrial Fibrillation and Objective Sleep Quality by Slow Wave Sleep

BACKGROUND

Self-reported poor sleep quality has been suggested in patients with AF. Slow wave sleep (SWS) is considered the most restorative sleep stage and represents an important objective measure of sleep quality. The aim of this study was to compare quantity of SWS between patients with and without AF.

METHODS AND RESULTS

We included patients with and without a documented history of AF by reviewing clinically indicated polysomnography data from a single sleep center. Patients on medications with potential influence on sleep architecture were excluded. Logistic regression was performed to determine the association between AF and SWS time (low vs. high) adjusting for age, gender, body mass index, and sleep apnea. In a 2:1 case-control set-up, a total of 205 subjects (139 with AF, 66 without AF) were included. Mean age was 62 (SD: 14.3) years and 59% were men. Patients with AF had lower SWS time (11.1 vs. 16.6 min, p=0.02). In multivariable analysis, prevalent AF was associated with low SWS independent of sleep apnea and other potential confounders (OR 2.5 [1.3, 5.0], p=0.006). Limiting the analysis to patients whose total sleep time was greater than 4 hours (by excluding N=31) resulted in more robust results (OR 3.9 [1.7, 9.7]. p=0.002).

CONCLUSION

AF is associated with more impaired sleep quality as indicated by lower quantity of SWS. More studies are needed to explore the mechanistic interactions between AF and sleep.

Latent classes of mild cognitive impairment are associated with clinical outcomes and neuropathology: Analysis of data from the National Alzheimer's Coordinating Center

Given the importance of identifying prodromes of dementia with specific etiologies, we assessed whether seven latent classes of mild cognitive impairment (MCI), defined empirically based on cognitive, functional, and neuropsychiatric information at initial visit, are associated with distinct clinical outcomes and neuropathological features. We separated 6034 participants with a baseline diagnosis of MCI into seven latent classes using previously defined criteria. We found that these latent classes of MCI differed significantly in their clinical outcomes, survival time, and neuropathology. Two amnestic multi-domain subgroups, as well as two other subgroups with functional impairments and neuropsychiatric disturbances, were at higher risk of not only a 'pure' form of Alzheimer's disease (AD) pathology, but also a 'mixed' pathology consisting of both AD and vascular features. Moreover, the seven latent classes had different risks of Lewy bodies, hippocampal sclerosis, and frontotemporal lobar degeneration (FTLD). This study indicates that data-driven subgroups of MCI are clinicopathologically informative and, with refinement, could lead to targeted interventions focused on each etiology.