ReviewMechanisms, Clinical Significance, and Prevention of Cognitive Impairment in Patients With Atrial Fibrillation
Section snippets
Cognitive Impairment and AF
Cognition encompasses several essential brain functions including memory, language, intuition, judgement, and the capacity to learn. Cognitive disorders range from mild impairment, such as a decline in memory and mental functions that does not affect daily life, to outright dementia, which exerts a toll on normal activities and relationships. Numerous longitudinal and cross-sectional studies have addressed the link between AF and cognitive impairment and dementia (Table 1). Most have reported a
Silent cerebral ischemia
Multiple studies have reported a positive association between AF and silent cerebral ischemia. In a recent meta-analysis, AF was associated with a greater than twofold increase in the odds of having silent cerebral ischemia as detected in imaging studies. These seemingly subclinical events appear to bear clinical relevance. For example, in the Cardiovascular Health Study, silent cerebral ischemia was associated with mild cognitive impairment and, in the Rotterdam Scan Study, it more than
Anticoagulation
Figure 3 and Table 2 provide an overview of therapeutic modalities studied in the prevention of cognitive dysfunction in patients with AF. Several observational studies, including post hoc analyses of clinical trials, have assessed the association between anticoagulation therapy and silent cerebral ischemia or neurocognitive outcomes in patients with AF. The most recent data come from the Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Strokes in Atrial Fibrillation Patients Who Have
AF Ablation
Whether or not AF ablation can prevent cognitive decline on long-term follow-up remains unknown. From the prospective Intermountain AF study, Bunch et al. compared 4212 consecutive patients who underwent AF ablation with 16,848 control participants with AF (matched for age and sex).56 Dementia, defined according to ICD-9 codes, occurred in 0.2% of patients with AF ablation compared with 0.9% of control participants (P < 0.0001). The Early Treatment of Atrial Fibrillation for Stroke Prevention T
Conclusions
Numerous observational studies have described an association between AF and cognitive dysfunction ranging from mild impairment to overt dementia. The association appears to be independent of manifest stroke and of the several risk factors common to both entities. The most convincing pathophysiological mechanism linking AF to cognitive impairment is silent cerebral ischemia due to microembolization. Cerebral hypoperfusion and inflammation might likewise play a role. Genetic predisposing factors
Clinical Perspective
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Observational studies suggest that AF is independently associated with a ≥ 40% higher risk for dementia, with a stronger association in younger patients (ie, younger than 70-75 years).
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Proposed pathophysiological mechanisms linking AF to cognitive dysfunction include silent cerebral ischemia, cerebral hypoperfusion, inflammation, reduction in hippocampal brain volume, and genetic factors.
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Although catheter ablation of AF is associated with an acutely heightened risk for cognitive decline, some
Disclosures
Drs Rivard and Khairy are lead investigators of the BRAIN-AF trial, of which the pilot phase was supported in part by an investigator-initiated grant from Bayer Inc, Canadian Stroke Prevention Network and the Montreal Heart Institute Foundation.
References (68)
- et al.
Prevalence of atrial fibrillation in elderly subjects (the Cardiovascular Health Study)
Am J Cardiol
(1994) - et al.
Epidemiology and mechanism of atrial fibrillation and atrial flutter
Am J Cardiol
(1996) - et al.
A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study
Am J Med
(2002) - et al.
The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study
Am J Med
(1995) - et al.
Dementia in western Europe: epidemiological evidence and implications for policy making
Lancet Neurol
(2016) - et al.
Atrial fibrillation is independently associated with senile, vascular, and Alzheimer's dementia
Heart Rhythm
(2010) - et al.
Prevalence of silent cerebral ischemia in paroxysmal and persistent atrial fibrillation and correlation with cognitive function
J Am Coll Cardiol
(2013) - et al.
Atrial fibrillation is associated with lower cognitive performance in the Framingham Offspring men
J Stroke Cerebrovasc Dis
(2006) - et al.
Association of atrial fibrillation and focal neurologic deficits with impaired cognitive function in hospitalized patients >or=65 years of age
Am J Cardiol
(2006) - et al.
Atrial fibrillation and risk of dementia in non-demented elderly subjects with and without mild cognitive impairment (MCI)
Arch Gerontol Geriatr
(2007)
Prevalence, functional impact, and mortality of atrial fibrillation in an older Italian population (from the Pro.V.A. study)
Am J Cardiol
Atrial fibrillation, stroke and dementia in the very old: a population-based study
Neurobiol Aging
Atrial fibrillation (AF) and cognitive impairment in the elderly: a case-control study
Arch Gerontol Geriatr
Association between cognitive impairment and atrial fibrillation: a systematic review
J Stroke Cerebrovasc Dis
Atrial fibrillation, cognitive impairment, and neuroimaging
Alzheimers Dement
Diastolic blood pressure, subclinical myocardial damage, and cardiac events: implications for blood pressure control
J Am Coll Cardiol
Soluble CD40 ligand, platelet surface CD40 ligand, and total platelet CD40 ligand in atrial fibrillation: relationship to soluble P-selectin, stroke risk factors, and risk factor intervention
Chest
Dementia in subjects with atrial fibrillation: hemostatic function and the role of anticoagulation
J Thromb Haemost
Subtle post-procedural cognitive dysfunction after atrial fibrillation ablation
J Am Coll Cardiol
Long-term population-based cerebral ischemic event and cognitive outcomes of direct oral anticoagulants compared with warfarin among long-term anticoagulated patients for atrial fibrillation
Am J Cardiol
Statins and the risk of dementia in patients with atrial fibrillation: a nationwide population-based cohort study
Int J Cardiol
Functional status in rate- versus rhythm-control strategies for atrial fibrillation: results of the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Functional Status Substudy
J Am Coll Cardiol
Effect of apixaban on brain infarction and microbleeds: AVERROES-MRI assessment study
Am Heart J
Risk and prediction of dementia in patients with atrial fibrillation–a nationwide population-based cohort study
Int J Cardiol
Improving outcomes in patients with atrial fibrillation: rationale and design of the Early treatment of Atrial fibrillation for Stroke prevention Trial
Am Heart J
Atrial fibrillation as an independent risk factor for stroke: the Framingham Study
Stroke
Impact of atrial fibrillation on the risk of death: the Framingham Heart Study
Circulation
Impact of atrial fibrillation on mortality, stroke, and medical costs
Arch Intern Med
Declining incidence of stroke and dementia: coincidence or prevention opportunity?
JAMA Neurol
Antihypertensive treatment can prevent stroke and cognitive decline
Nat Rev Neurol
Increased risk of cognitive and functional decline in patients with atrial fibrillation: results of the ONTARGET and TRANSCEND studies
CMAJ
Atrial fibrillation and incidence of dementia: a systematic review and meta-analysis
Neurology
Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: data from a community-based cohort
Eur Heart J
Atrial fibrillation in stroke-free patients is associated with memory impairment and hippocampal atrophy
Eur Heart J
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2021, HeartRhythm Case ReportsCitation Excerpt :Both procedure-related strokes and silent microemboli have been reported in interventional cardiac procedures, including LAA closure.8 Microemboli may lead to long-term cognitive decline.9 Thus, strategies to reduce stroke and embolic risk are of interest in an appendage closure population.
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