Definitions and burden of heart failure
Heart failure and cognitive impairment – strength of association
Study
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Sample
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Population
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Median age in years (SD)
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Study methodology
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Inclusion criteria
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Exclusion criteria
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CV measures/criteria
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Cognitive assessment tool(s) used
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Results
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Zuccalà 1997 [6] | 57 HF pts | Consecutive admissions to hospital | 77 | Cross-sectional | Not specified | Co-morbid psychiatric or physical illness and previous diagnosis of CI | LVEF (mean EF 45%) NYHA II-III | MMSE, MDBandRCPM | 53% of HF pts showed global CI with MMSE less than 24 |
Callegari 2002 [7] | 64 HF pts, 321 healthy controls | Age <65 years and consecutive admissions to hospital | 52 (8) | Cross-sectional | Not specified | Co-morbid psychiatric or neurological illness. Previous diagnosis of CI and female sex | LVEF <50% | Multidomain neuropsychiatric battery | HF pts scored lower than control group in short-term verbal memory, short-term visuospatial memory and visual spatial logical ability |
NYHA I-III | |||||||||
Cardiopulmonary testing with treadmill | |||||||||
Right heart catheterisation | |||||||||
Trojano 2003 [8] | 149 HF NYHA II pts | Age >65 years and consecutive admissions to hospital | HF NYHA II: 75 (7) | Cross-sectional | Not specified | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | No measure of LV function | Multidomain neuropsychiatric battery | HF pts scored worse than those without HF in domains of: attention, verbal fluency, verbal learning |
159 HF NYHA III/IV | HF NYHA III/IV: 77 (7) | NYHA II-IV | No significant difference between pts with moderate or severe HF | ||||||
207 non-HF controls | Non-HF controls: 74 (7) | ||||||||
Zuccalà 2005 [9] | 1,511 HF pts, 11,790 control patients | All geriatric or general medical hospital admissions | 79 (9) | Cross-sectional | Not specified | Not specified | HF diagnosis based on discharge documentation | Hodkinson abbreviated mental test | 35% of HF pts showed global CI 29% of non-HF pts showed global CI |
Feola 2007 [10] | 60 HF-REF | Consecutive admissions to hospital | 66 | Cross-sectional | HF-REF: clinical HF, NYHA II-IV, LVEF ≤50% | Not specified | LVEF | Multidomain neuropsychiatric battery | 23% of HF pts showed global CI |
12 HF-PEF | HF-PEF: diagnosed based on E/A ratio, deceleration time and LV dilatation | NYHA II-IV | |||||||
BNP | |||||||||
Debette 2007 [11] | 83 HF pts | Consecutive admissions to hospital | 62 | Cross-sectional | Not specified | Hearing/visual impairment | LVEF <45% | MMSE | 61% of HF pts showed global CI |
NYHA I-IV | |||||||||
Dodson 2013 [12] | 282 decompensated HF pts | Age >65 years and non-consecutive admissions to hospital | 80 (8) | Prospective | English speaking | Co-morbid psychiatric illness | HF diagnosis based on documentation in medical records | MMSE | 25% of HF pts showed evidence of mild CI 22% of HF pts showed moderate to severe CI |
Schmidt 1991 [13] | 20 iDCM pts | Age <50 years and ambulatory outpatients only | iDCM: 38 (5) | Cross-sectional | Not specified | Co-morbid psychiatric, neurological or physical illness | LVEF 14-45% | LGT-3 and ALID | Systolic HF pts performed worse than the control group in domains of attention, learning and memory and reaction time |
20 healthy controls | Healthy controls: 41 (8) | NYHA II-IV | |||||||
Grubb 2000 [14] | 20 HF pts with CADs | Ambulatory outpatients only | HF: 68 | Cross-sectional | Not specified | Co-morbid psychiatric or neurological illness. Previous hospital admission within 6 months | HF: LVEF <40%, NYHA III/IV | RBMT and WMS | No difference between HF pts and control group |
20 CAD control | CAD controls: 67 | CAD controls: LVEF >55%, no CHF | |||||||
Riegel 2002 [15] | 42 HF pts | Ambulatory outpatients only | 75 (12) | Cross-sectional | English speaking | Co-morbid physical or psychiatric illness | No measure of LV function | MMSE and CIMS | 29% of HF pts showed evidence of global CI |
NYHA I-IV | |||||||||
Vogels 2007 [16] | 62 HF pts | Age >50 years and ambulatory outpatients only | HF: 69 (9)) | Case control | HF pts: diagnosis of HF >6 months and stable on medication >4 weeks | Co-morbid physical, neurological or psychiatric illness. Previous diagnosis of CI | LVEF <40% | Multidomain neuropsychiatric battery | HF pts scored lower than the healthy control group in all domains |
53 CAD controls | CAD controls: 69 (10) | CAD controls: IHD but no clinical CHF and EF >40% | NYHA II-IV | HF pts scored lower than the IHD control group in domains of memory and mental speed | |||||
42 healthy controls | Healthy controls: 67 (9 | IHD control group scored lower than the healthy control group in language only | |||||||
Hoth 2008 [17] | 31 HF pts | Age >55 years and ambulatory outpatients only | HF: 69 (9) | Cross-sectional | English speaking | Co-morbid physical, neurological or psychiatric illness. Previous diagnosis of CI | LVEF <40% | Multidomain neuropsychiatric battery | Systolic HF pts scored lower than the IHD control group in domains of executive function and cognitive flexibility |
31 CAD controls | CAD controls: 69 (9) | Minimum of 8th grade education | NYHA II-IV | ||||||
CAD controls: angina/previous MI/PCI/PVD and HF excluded on basis of clinical examination | |||||||||
Beer 2009 [18] | 31 HF pts | Ambulatory outpatients only | HF: 54 (11) | Case control | Not specified | Co-morbid neurological illness or previous diagnosis of CI | LVEF <40% | Block design, CVLT and 'F,A,S test' | Systolic HF pts scored lower than control group in all cognitive domains |
24 healthy controls | Healthy controls: 56 (8) | NYHA II | |||||||
LWHFQ | |||||||||
Stanek 2009 [19] | 40 HF pts, 35 CAD controls | Ambulatory outpatients only | 70 (8) | Prospective | English speaking | Co-morbid psychiatric or neurological illness. Previous diagnosis of CI | NYHA II-III | DRS | No difference between systolic HF pts and CAD control patients in all domains |
CAD controls: history of MI, CAD, cardiac surgery, hypertension | CO <4 L/minute on echo | ||||||||
Sauvé 2009 [20] | 50 HF pts 50 healthy controls | Age >30 years in HF pts and >55 years in controls. Ambulatory outpatients only | HF: 63 (14) Healthy controls: 63 (14) | Case control | Diagnosis of HF >6 months | Co-morbid psychiatric or neurological illness | LVEF ≤40% NYHA II-IV | Multidomain neuropsychiatric battery | Systolic HF pts scored lower than control group in domain of verbal memory |
Pressler 2010 [21] | 249 HF pts | Ambulatory outpatients only | HF: 63 (15) | Cross-sectional | HF: LVEF ≤40% and clinical HF | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | NYHA | Multidomain neuropsychiatric battery | HF group performed worse than healthy and general medical groups in domains of memory, executive function and psychomotor speed |
63 healthy controls | Healthy controls: 53 (17) | Healthy controls: absence of any medical condition or controlled CV risk factors | LVEF | ||||||
102 general medical pts | Medical group: 63 (12) | Medical group: major chronic disorder other than HF | |||||||
Bauer 2012 [22] | 51 HF-REF, 29 HF-PEF | Age >21 years and ambulatory outpatients only | 72 (12) | Cross-sectional | HF-REF: history of HF-REF >6 months, stable on medication >4 weeks, LVEF ≤40% | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | LVEF | Multidomain neuropsychiatric battery | HF-REF and HF-PEF pts performed worse than age- and educated-adjusted healthy control groups in executive function, attention, language, memory and psychomotor speed |
HF-PEF: history of HF-PEF >6 months, stable on medication >4 weeks, LVEF >41% | NYHA | ||||||||
Festa 2011 [23] | 169 HF-REF, 38 HF-PEF | Age >17 years and ambulatory outpatients only | 69 | Retrospective | On medical treatment for HF | Co-morbid neurological illness | LVEF | Multidomain neuropsychiatric battery | Low EF was associated with poor memory in pts over 63 years old |
Haemodynamically stable | Pts <63 years old had preserved memory function regardless of EF. | ||||||||
Not receiving mechanical circulatory support | |||||||||
Steinberg 2011 [24] | 55 HF pts | Ambulatory outpatients only | 55 (8) | Cross-sectional | Stable clinical status | Co-morbid neurological or physical illness. Previous diagnosis of CI | LVEF ≤45% | Multidomain neuropsychiatric battery | 44% of HF pts showed evidence of global CI |
NYHA I-III | |||||||||
6 minute walk test | |||||||||
Jefferson 2011 [25] | 1,114 pts from Framingham Heart Study | Age >40 and <89 years and ambulatory outpatients only | 67 (9) | Cross-sectional | Not specified | Co-morbid neurological illness or previous diagnosis of CI | LVEF | Multidomain neuropsychiatric battery | U-shaped association between LVEF and cognitive performance |
Cardiac MRI | |||||||||
Miller 2012 [26] | 140 HF pts | Age >50 and <85 years and ambulatory outpatients only | 69 (9) | Cross-sectional | English speaking | Co-morbid psychiatric or neurological illness | No measure of LV function | Multidomain neuropsychiatric battery | 62% of HF pts showed evidence of global CI |
No NYHA classification | |||||||||
2 minute step test | |||||||||
Almeida 2012 [27] | 35 HF pts | Age >45 years and ambulatory outpatients only | HF: 69 (9) | Cross-sectional | HF: EF <40%, clinical HF ≥6 months, English speaking, NYHA I-III | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | LVEF | Multidomain neuropsychiatric battery | HF pts scored lower than the healthy control group in domains of immediate/long-term memory and psychomotor speed |
56 CAD controls | CAD controls: 67 (10) | CAD controls: previous MI, English speaking, EF ≥60%, no clinical HF | NYHA | No difference between the HF group and IHD control group in cognition | |||||
64 healthy controls | Healthy controls: 69 (11) | Healthy controls: English speaking, no previous MI/angina, EF ≥60% | |||||||
Hawkins 2012 [28] | 251 HF pts | Ambulatory outpatients only | 66 (10) | Cross-sectional | English speaking | Co-morbid psychiatric illness. Previous diagnosis of CI | LVEF ≤40% | Multidomain neuropsychiatric battery | 58% of HF pts had CI with poor scores in the domains of verbal learning and verbal memory |
Bratzke-Bauer 2013 [29] | 47 HF-REF | Age >50 years and ambulatory outpatients only | HF-REF: 75 (9) | Cross-sectional | History of HF >6 months | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | LVEF | Multidomain neuropsychiatric battery | 23% of the HF-REF cohort showed evidence of CI |
33 HF-PEF | HF-PEF: 68 (15) | Stable on medication ≥4 weeks | NYHA | 3% of the HF-PEF cohort showed evidence of CI | |||||
HF-PEF based on AHA criteria | |||||||||
Huijts 2013 [30] | 491 HF-REF | Age >60 years and ambulatory outpatients only | 77 (8) | Prospective | HF-REF: hospitalization within past year | Co-morbid physical illness | HF-REF: LVEF <45%, NYHA II-IV, NT-proBNP >400 pg/ml | AMT | 8% of HF-REF group showed evidence of severe CI (AMT ≤7) |
120 HF-PEF | HF-PEF: NT-proBNP ≥400 pg/ml if pt <75 years or ≥800 pg/ml if pt ≥75 years | HF-PEF: LVEF ≥45% | 13% of HF-PEF group showed evidence of severe CI (AMT ≤7) | ||||||
Kindermann 2012 [31] | 20 decompensated HF pts | Decompensated HF: non-consecutive admissions to hospital | Decompensated HF: 60 (16) | Prospective | Decompensated HF: caused by ischaemic or DCM, symptomatic HF for ≥6 months, clinical signs of decompensation, for example, raised JVP | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | LVEF <45% | Multidomain neuropsychiatric battery | Decompensated HF group scored lower than stable HF group in domains of memory, executive control and processing speed |
20 stable HF pts | Stable HF: outpatients | Stable HF: 61 (17) | Stable HF pts: CHF of ischaemic or DCM, NYHA III-IV, no clinical signs/history of decompensation for ≥3 months | NYHA III/IV | Stable HF group scored lower than the healthy control group in domains of intelligence and episodic memory | ||||
20 healthy controls | Healthy controls: 62 (15) |
Study
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Sample
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Population
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Median age in years (SD)
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Study methodology
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Inclusion criteria
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Exclusion criteria
|
CV measures
|
Cognitive assessment tool used
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Follow-up period
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Results
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Karlsson 2005 [32] | 146 CHF pts | Age >60 years and outpatients | 76 (8) | Prospective | EF <45% | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | LVEF | MMSE | 6 months | 12% of HF patients had MMSE scores <24 at baseline |
NYHA II-IV | NYHA | And 4% had MMSE scores <24 at 6 months | ||||||||
Tanne 2005 [33] | 20 CHF underwent exercise programme 5 CHF pts as control pts | Outpatients | 63 (13) | Prospective | EF ≤35% | Co-morbid psychiatric, neurological or physical illness | LVEF | Multidomain neuropsychiatric battery | 18 weeks | Improvement in executive function post-exercise programme |
NYHA III | NYHA | |||||||||
History of HF for ≥6 months | Mod-Bruce ETT | No change in cognition in control group with time | ||||||||
Stable on medication ≥6 weeks | 6 minute walk test | |||||||||
Stanek 2009 [19] | 40 HF pts, 35 CAD controls | Age >53 and <84 years. Outpatients | 70 (8) | Prospective | HF: English speaking | Co-morbid psychiatric or neurological illness. Previous diagnosis of CI | NYHA | DRS | 12 months | HF patients improved at 12 months, particularly in attention |
NYHA II or III | ||||||||||
CO <4 L/minute | CO | Cardiac controls stable at 12 months | ||||||||
CAD controls: CO ≥4 L/minute, history of MI/CAD | ||||||||||
Almeida 2013 [34] | 77 HF pts | Age >45 years and outpatients | HF: 68 (10) | Prospective | HF: EF <40%, English speaking | Co-morbid psychiatric or neurological illness. Previous diagnosis of CI | NYHA | Multidomain neuropsychiatric battery | 2 years | CHF group showed cognitive decline compared with CAD and healthy controls |
73 CAD controls | CAD controls: 68 (10) | CAD controls: previous MI and EF >60%, English speaking | LVEF | |||||||
81 healthy controls | Healthy controls: 69 (11) | Healthy controls: no history of CAD, English speaking | 6 minute walk test | |||||||
Hjelm 2011 [35] | 95 HF pts 607 non-CHF controls | Age >80 years and outpatients | 84 (3) | Prospective | Not specified | Not specified | HF diagnosis based on documentation in medical records | Multidomain neuropsychiatric battery | 10 years | HF patients showed significant decline in episodic memory and spatial performance compared with controls |
Riegel 2012 [36] | 279 consecutive HF pts (HF-REF and HF-PEF) | Age <80 years and outpatients | 62 (12) | Prospective | Stage C HF and English speaking | Co-morbid psychiatric or physical illness. Previous diagnosis of CI | NYHA I-IV | Multidomain neuropsychiatric battery | 6 months | No significant change in cognition over 6 months (HF-REF and HF-PEF) |
LVEF | Minimal improvement in DSST in both groups (likely due to learned effect) | |||||||||
Higher LVEF associated with lower DSST score | ||||||||||
Huijts 2013 [30] | 491 HF-REF 120 HF-PEF | Age >60 years and outpatients | 77 (8) | Prospective | HF-REF: hospitalization within past year | Co-morbid physical illness | HF-REF: LVEF <45%, NYHA II-IV, NT-proBNP >400 pg/ml | AMT | 18 months | HF-REF: 23% of HF pts showed decline of ≥1 point in AMT over 18 months |
HF-PEF: NT-proBNP ≥400 pg/ml if pt <75 years or ≥800 pg/ml if pt ≥75 years | 120 HF-PEF: LVEF ≥45% | HF-PEF: 24% of HF pts showed improvement of ≥1 point in AMT over 18 months |
Study
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Sample
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Population
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Median age in years (SD)
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Study methodology
|
Inclusion criteria
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Exclusion criteria
|
Measures
|
Results
|
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Zuccalà 2003 [37] | 1511 HF pts 11,790 controls | All geriatric or general medical admissions | 79 (9) | Prospective | Not specified | Not specified | Hodkinson abbreviated mental test | Mean length of hospital stay: pts with CI = 15 ± 10 days; pts without CI = 15 ± 9 days |
Length of hospital stay | Inpatient mortality: pts with CI, 18%; pts without CI, 3% | |||||||
1 year mortality | 1-year mortality: pts with CI, 27%; pts without CI, 15% | |||||||
Karlsson 2005 [32] | 146 CHF pts | Age >60 years and outpatients | 76 (8) | Prospective | LVEF <45% | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | HF self-care | Self-care scores were significantly higher in those with MMSE >24 compared to those ≤24 |
NYHA II–IV | questionnaire | |||||||
MMSE | ||||||||
Riegel 2007 [38] | 29 CHF pts | Outpatients | 64 (10) | Cross-sectional | LVSD on echo | Co-morbid psychiatric or physical illness. Previous diagnosis of CI | Self-care of HF index | CI was worse in the poor self-care group compared to the good and expert self-care groups but did not reach level of significance |
Clinical HF | DSST | |||||||
English speaking | Probed memory recall | |||||||
Cameron 2009 [39] | 50 CHF pts | Age >45 years and consecutive hospital admissions | 73 (11) | Cross-sectional | Clinical CHF | Co-morbid neurological illness. Previous diagnosis of CI | Self-care of HF index | CI was not a predictor of self-care |
LVSD on echo | Cardiac depression scale | |||||||
English speaking | MMSE | |||||||
Cameron 2010 [40] | 93 CHF pts | Age >45 years and consecutive hospital admissions | 73 (11) | Cross-sectional | Clinical CHF | Co-morbid neurological illness. Previous diagnosis of CI | Self-care HF index | CI and self-care management were significantly associated (t = 2.7; P < 0.01) |
LVSD on echo | MMSE | |||||||
English speaking | MoCA | |||||||
Pulignano 2010 [41] | 93 CHF pts | Consecutive outpatients | 77 (6) | Cross-sectional | Not specified | Not specified | The European heart failure self-care behaviour scale | MMSE was negatively correlated with self-care behavioural scores (r = 0.58, P < 0.001) |
MMSE | ||||||||
Alosco 2013 [42] | 110 CHF pts | Age >50 years and <85 years. Outpatients | 70 (9) | Prospective | NYHA II-IV | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | Lawton-Brody instrumental activities of daily living | Poorer performance on 3MS was associated with worse total activities of daily living performance |
English speaking | Modified MMSE (3MS) | |||||||
Harkness 2013 [43] | 100 CHF pts | Age >55 years and outpatients | 72 (10) | Cross-sectional | Confirmed HF using the Boston criteria | Co-morbid psychiatric illness or previous diagnosis of CI | MoCA | MoCA score of <26 was significantly associated with worse self-care management |
LVEF ≤45% | Self-care in HF index | |||||||
Change in symptoms on previous 3 months | Geriatric Depression Scale | |||||||
English speaking | ||||||||
Alosco 2013 [42] | 175 CHF pts | Age >50 years and <85 years. Outpatients | 68 (10) | Cross-sectional | NYHA II-IV | Co-morbid psychiatric, neurological or physical illness. Previous diagnosis of CI | Lawton-Brody instrumental activities of daily living | Poorer executive function was independently associated with poorer total activities of daily living performance |
English speaking | Executive function assessed by FAB and LNS |