Correlation between Cognitive Impairment and Prognostic Parameters in Patients with Congestive Heart Failure

doi:10.1016/j.arcmed.2006.10.004

Archives of Medical Research

Volume 38, Issue 2, February 2007, Pages 234-239

https://doi.org/10.1016/j.arcmed.2006.10.004 Get rights and content

Background

Cognitive impairment has been observed in patients with congestive heart failure (CHF). We analyzed in-hospital CHF patients with neuropsychological tests attempting to correlate the results with prognostic parameters.

Methods

All subjects underwent a mini-mental state examination (MMSE), memory and learning tests (Corsi Block-tapping test, Verbal Span test, Prose Memory test, Visual Search), anxiety and depression scale test. New York Hospital Association (NYHA) class, brain natriuretic peptide (BNP) and left ventricular ejection fraction (LVEF) were evaluated.

Results

Sixty patients (mean age 65.5 years) were analyzed. NYHA class was 2.9 ± 0.9, LVEF was 32.9 ± 13.7%, BNP plasma level 683.3 ± 864.3 pg/mL. In 23.3% of cases a pathological MMSE score emerged; memory and learning test results were abnormal in 3.4–37%.

A positive correlation between MMSE and age (r = 0.18, p = 0.01), BNP (r = 0.25, p = 0.02) was observed but not between MMSE and years of education, NYHA class and LVEF. The Corsi Block-tapping test was related to educational duration (r = 0.12, p = 0.02) with a positive trend for BNP (r = 0.2, p = 0.07). The Prose Memory test and Visual Search were influenced by the patients' educational level (r = 0.36, p = 0.0001; r = 0.27, p = 0.0001).

Conclusions

CHF patients manifest an impairment of MMSE and memory and learning test performance. In our population MMSE correlates to plasma BNP and advanced age.

Introduction

Chronic heart failure is a major health problem, which is growing as the population ages. Recurrent hospitalizations occur in about half of the subjects within 6 months after the initial admission (1). Several co-morbidities usually coexist in these patients (2). In spite of its clinical importance, the relationship between cognitive impairment and clinical status in chronic heart failure patients has not always been considered in studies and in clinical interventions regarding patients with congestive heart failure (CHF) (3). Cognitive impairments could lead to relevant difficulties in the management of cardiac patients who may have problems in understanding their disease and in adhering to pharmacological treatment and medical advice. Previous studies have addressed the neuropsychological sequelae of cardiac arrest (4); on the whole, a high prevalence of cognitive deficits from moderate to severe was found (5). A recent review (6) on this field demonstrated a prevalence rate of cognitive impairment ranging from 30% to 80% in patients with CHF. In most patients only a mild deterioration emerged, although as many as one-fourth could manifest moderate to severe cognitive impairment. Additionally, in a multicenter observational study (7), Trojano et al. observed an abnormal performance during neuropsychological tests according to the worsening of CHF (57.9% in severe CHF vs. 43% in moderate CHF). Nevertheless, a clear relationship between cognitive impairment and severity of CHF has still not been well explored.

The aim of this observational study was to analyze the prevalence of cognitive impairment in an in-hospital CHF population trying to correlate the cognitive deficit with simple prognostic parameters that reflected the severity of hemodynamic deterioration.

Section snippets

Subjects and Methods

From May 2004 to February 2005, CHF patients admitted to our Department for worsening CHF were requested to enter the study. Subjects of any age, etiology, and severity of symptoms were recruited. All patients underwent a complete medical, psychological and neuropsychological examination. Patients included in this study fulfilled 1, 2, 3 the following criteria: 1) manifest symptoms of CHF, according to the criteria commonly accepted in medical literature (8), namely, the presence of two major

Results

Seventy two CHF patients were admitted to S. Croce Department of Cardiovascular Diseases and 60 (83.3%) (44 males and 16 females) agreed to enter this observational study. The mean age was 65.5 years (range 24–87; Table 1). The mean NYHA class was 2.9 ± 0.9, but we included NYHA class II, III and IV patients. Eighteen (30%) CHF patients were found to be in NYHA class IV and 70% were in II–III. LVEF ranged from 15 to 70% and the mean LVEF was 32.9% ± 13.7; 43.3% patients reported an LVEF <30%.

Discussion

Patients with CHF show a range of care and global therapeutic management problems (14). Cognitive impairment in patients with CHF is frequent and emerges in the reduction of MMSE and in the performance obtained in memory and learning tests. The extent of the problem is remarkably underdiagnosed: it is calculated that >50% of older patients with CHF have an MMSE score within the dementia range (MMSE ≤24/30) (15). Pathophysiological determinants of cognitive impairment in CHF patients remain

References (22)

M.J. Garcia et al.
New Doppler echocardiographic applications for the study of diastolic function
J Am Coll Cardiol
(1998)
M.F. Folstein et al.
Mini-Mental State. A practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975)
G. Zuccalà et al.
Correlates of cognitive impairment among patients with heart failure: results of a multicenter survey
Am J Med
(2005)
J.M. Vinson et al.
Early readmission of elderly patients with congestive heart failure
J Am Geriatr Soc
(1990)
A. Di Lenarda et al.
Heart failure programs and comprehensive management in heart failure
Monaldi Arch Chest Dis
(2002)
S. Callegari et al.
Relationship between cognitive impairment and clinical status in chronic heart failure patients
Monaldi Arch Chest Dis
(2002)
R.O. Roine et al.
Neuropsychological sequelae of cardiac arrest
JAMA
(1993)
M.E. Farmer
Cognitive deficits related to major organ failure: the potential role of neuropsychological testing
Neuropsychol Rev
(1994)
S. Bennett et al.
Cognitive deficits in patients with heart failure: a review of the literature
J Cardiovasc Nursing
(2003)
L. Trojano et al.
Cognitive impairment: a key feature of congestive heart failure in the elderly
J Neurol
(2003)

P.A. McKee et al.

The natural history of CHF. The Framingham study

N Engl J Med

(1971)

Cited by (40)

Risk evaluation of cognitive impairment in patients with heart failure: A call for action
2022, IJC Heart and Vasculature
Cognitive impairment (CI) is common in patients with heart failure (HF) and impacts treatment adherence and other aspects of patient life in HF. Recognition of CI in patients with HF is therefore important. We aimed to develop a risk model with easily available patient characteristics, to identify patients with HF who are at high risk to be cognitively impaired and in need for further cognitive investigation.
The risk model was developed in 611 patients ≥ 60 years with HF from the TIME-CHF trial. Fifty-six (9 %) patients had CI (defined as Hodkinson Abbreviated Mental Test ≤ 7). We assessed the association between potential predictors and CI with least-absolute-shrinkage-and-selection-operator (LASSO) regression analysis. The selected predictors were: older age, female sex, NYHA class III or IV, Charlson comorbidity index ≥ 6, anemia, heart rate ≥ 70 bpm and systolic blood pressure ≥ 145 mmHg. A model that combined these variables had a c-statistic of 0.70 (0.63–0.78). The model was validated in 155 patients ≥ 60 years with HF from the ECHO study. In the validation cohort 51 (33 %) patients had CI (defined as a Mini Mental State Exam ≤ 24). External validation showed an AUC of 0.56 (0.46–0.66).
This risk model with easily available patient characteristics has poor predictive performance in external validation, which may be due to case-mix variation. These findings underscore the need for active screening and standardized assessment for CI in patients with HF.
Cognitive Impairment and Heart Failure: Systematic Review and Meta-Analysis
2017, Journal of Cardiac Failure
Cognitive impairment and dementia are associated with a range of cardiovascular conditions, including hypertension, coronary artery disease, and atrial fibrillation. We aimed to describe the association with heart failure, summarizing published data to give estimates of prevalence, incidence, and relative risk of cognitive impairment/dementia in heart failure.
We searched multidisciplinary databases including MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), PsychINFO (EBSCO), Web of Science (Thomson Reuters), and CENTRAL (Cochrane Library) from inception until May 31, 2015. All relevant studies looking at cognitive impairment/dementia in heart failure were included. Studies were selected by 2 independent reviewers using prespecified inclusion/exclusion criteria. Where data allowed, we performed meta-analysis and pooled results using random effects models.
From 18,000 titles, 37 studies were eligible (n = 8411 participants). Data from 4 prospective cohorts (n = 2513 participants) suggest greater cognitive decline in heart failure compared with non-heart failure over the longer term. These data were not suitable for meta-analysis. In case control studies describing those with and without heart failure (n = 4 papers, 1414 participants) the odds ratio for cognitive impairment in the heart failure population was 1.67 (95% confidence interval 1.15–2.42). Prevalence of cognitive impairment in heart failure cohorts (n = 26 studies, 4176 participants) was 43% (95% confidence interval 30–55).
This review suggests a substantial proportion of patients with heart failure have concomitant cognitive problems. This has implications for planning treatment and services. These data do not allow us to comment on causation, and further work is needed to describe the underlying pathophysiology.
Hemodynamic and serum cardiac markers and risk of cognitive impairment and dementia
2017, Alzheimer's and Dementia
Cardiac function is a key player in maintaining energy homeostasis in the brain. Heart failure is closely related to higher risk of neurocognitive disorders. Recent evidence shows that this relationship might not be limited to patients with advanced heart failure, and even suboptimal cardiac functioning is associated with accelerated brain aging. Hence, hemodynamic and serum cardiac markers may provide valuable information about the risk of dementia.
We provide an overview on the link between cardiac markers and cognitive function by a systematic search in five databases. Furthermore, we discuss the pathophysiological aspects of this link and highlight the pertinent clinical and public health implications.
Increasing evidence supports the associations of hemodynamic and serum cardiac markers with accelerated cognitive decline.
Hemodynamic and serum cardiac markers are closely linked with risk of cognitive impairment. This highlights the significance of the heart–brain connection in reducing the burden of dementia.
Depression predicts mortality and hospitalization in heart failure: A six-years follow-up study
2016, Journal of Affective Disorders
Citation Excerpt :
Similarly to the results found by other authors (Parissis et al., 2008), in our study depressed patients had increased BNP plasma levels; higher functional class NHYA but no association was found between depression and ejection fraction. Instead, other authors did not found a relation between psychological factors as depression, anxiety, negative affectivity, social inhibition, type D personality and natriuretic peptide levels (Feola et al., 2007; Gottlieb et al., 2004; Krista et al., 2011; Redwine et al., 2007). The evidences relative to the relation between psychological factors and systemic aspects of HF, as BNP levels, produced mixed results but the scientific evidence points to the conclusion that these factors are minimally related.
The aim of this study is to evaluate the prevalence of depressive symptoms (DS) and its relation on hospitalization for cardiovascular (CV) causes and all-cause mortality risk among outpatients with HF.
A prospective study was conducted on 130 adult outpatients with HF. The Beck Depression Inventory Scale–second edition (BDI–II) was used to screen for DS. All-cause mortality and hospitalization for CV causes were registered over 6 years. Logistic regression and multinomial logistic regression analysis were used to evaluate the independent prognostic value of DS on mortality and hospitalization for CV causes after adjustment for clinical risk factors.
During a mean follow-up of 6 years, 44% of patients were classified as having DS. Sixty-two participants died for all causes, representing 61% of those with DS and 37% of those without (p=0.006); Forty-nine participants (38%) were hospitalized for CV causes, representing 49% of those with DS and 29% of those without (p=0.027).
Logistic regression analysis indicated that DS predicted all-cause mortality (OR: 2.905; 95% CI:1.228–6.870; p=0.006) and multinomial logistic regression indicated that DS were predictive of hospitalization for CV causes (OR: 3.169; 95% CI: 1.230–8.164; p=0.027). These associations were independent of conventional risk factors.
Only outpatient sample; measure of DS only at baseline; cause of death was not known.
This study, first held in a portuguese population, showed that DS are independent predictors of death and hospitalization for CV causes among HF patients and its impact persists over 6 years.
The independent association of hypertension with cognitive function among older adults with heart failure
2012, Journal of the Neurological Sciences
Citation Excerpt :
Consistent with past work, cognitive impairment was common in the current sample of older adults with HF. Previous work suggests reduced cardiac pumping efficiency and its resulting inadequate cerebral perfusion to be an important mechanism for cognitive impairment in HF [36–38], although some studies question the shape or even the existence of the relationship between cardiac and cognitive functioning [12,39]. The present study extends such work and identifies hypertension as an important contributor to cognitive dysfunction in this population.
Hypertension is the most common comorbidity among heart failure (HF) patients and has been independently linked with cognitive impairment. Cognitive impairment is prevalent among HF patients, though the extent to which hypertension contributes to cognitive function in this population is unclear.
116 HF patients (31.0% women, 67.68 ± 11.16 years) completed neuropsychological testing and impedance cardiography. History of physician diagnosed hypertension, along with other medical characteristics, was ascertained through a review of participants' medical charts.
69.8% of the HF patients had a diagnostic history of hypertension. After adjustment for demographic and medical characteristics (i.e., cardiac index, medication status, and resting blood pressure), hypertension was independently associated with attention/executive function/psychomotor speed (ΔF(1,103) = 10.85, ΔR² = .07, p < .01) and motor functioning (ΔF(1,103) = 4.46, ΔR² = .04, p < .05). HF patients with a diagnosed history of hypertension performed worse in these domains than those without such history.
The current findings indicate that diagnostic history of hypertension is an important contributor to cognitive impairment in HF. Hypertension frequently precedes HF and future studies should examine whether sustained hypertension compromises cerebral autoregulatory mechanisms to produce brain damage and exacerbate cognitive impairment in this population.
The complex interplay of cardiovascular system and cognition: How to predict dementia in the elderly?
2011, International Journal of Cardiology
Citation Excerpt :
This speculation is backed up by a study by Zuccala et al. [59], where low systolic blood pressure was associated with poor cognitive performance in heart failure patients. B-type natriuretic peptide has been associated with cognitive dysfunction in heart failure patients [60,61]. We recently found B-type natriuretic peptide to be an independent predictor of cognitive dysfunction and dementia in an elderly general population when cardiovascular co-morbidities, including heart failure and hypertension, and other several risk markers were taken into account.
Prevalence of dementing illnesses is expected to grow due to aging of the population throughout the world. Vascular dementia and Alzheimer's disease share several risk factors and are nowadays considered two ends of a continuum rather than two distinct entities. Traditional cardiovascular risk markers such as diabetes, dyslipidemia, hypertension, metabolic syndrome and adiposity in mid-life are harbingers of cognitive decline, Alzheimer's disease and vascular dementia later in life. In aged populations, only diabetes has been more constantly associated with the development of cognitive dysfunction, while other risk markers have shown more mixed results. Normal aging, co-morbidities and other changes connected to cognitive decline make the interpretation of the risk markers in the elderly challenging and probably explain these contradictory findings. Control of cardiovascular risk factors has been linked to beneficial effects in terms of cognition in cross-sectional and prospective follow up studies, but the results of interventional trials have been disappointing. More research in this area is needed, specifically, placebo-controlled randomized trials in both mid-life and late-life with cognitive dysfunction as a primary endpoint.

View all citing articles on Scopus

View full text

Original articleClinicalCorrelation between Cognitive Impairment and Prognostic Parameters in Patients with Congestive Heart Failure

Background

Methods

Results

Conclusions

Introduction

Section snippets

Subjects and Methods

Results

Discussion

J Am Coll Cardiol

J Psychiatr Res

Am J Med

Early readmission of elderly patients with congestive heart failure

J Am Geriatr Soc

Heart failure programs and comprehensive management in heart failure

Monaldi Arch Chest Dis

Relationship between cognitive impairment and clinical status in chronic heart failure patients

Monaldi Arch Chest Dis

Neuropsychological sequelae of cardiac arrest

JAMA

Cognitive deficits related to major organ failure: the potential role of neuropsychological testing

Neuropsychol Rev

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

J Cardiovasc Nursing

Cognitive impairment: a key feature of congestive heart failure in the elderly

J Neurol

The natural history of CHF. The Framingham study

N Engl J Med

Original article
Clinical
Correlation between Cognitive Impairment and Prognostic Parameters in Patients with Congestive Heart Failure