Curriculum in Cardiology
Atrial fibrillation: A major risk factor for cognitive decline

https://doi.org/10.1016/j.ahj.2014.12.015Get rights and content

Atrial fibrillation is a common disease of the elderly, conferring considerable morbidity and mortality related to cardiovascular effects and thromboembolic risks. Anticoagulation, antiarrhythmic medications, and rate control are the cornerstone of contemporary management, whereas ablation and evolving surgical techniques continue to play important secondary roles. Growing evidence shows that atrial fibrillation is also a risk factor for significant cognitive decline through a multitude of pathways, further contributing to morbidity and mortality. At the same time, cognitive decline associated with cryptogenic strokes may be the first clue to previously undiagnosed atrial fibrillation. These overlapping associations support the concept of cognitive screening and rhythm monitoring in these populations. New research suggests modulating effects of currently accepted treatments for atrial fibrillation on cognition; however, there remains the need for large multicenter studies to examine the effects of novel oral anticoagulants, rhythm and rate control, and left atrial appendage occlusion on long-term cognitive function.

Section snippets

Background

Twenty-five percent of people >40 years of age will develop atrial fibrillation (AF).1 Atrial fibrillation has been clearly established as a cause of embolic stroke from thrombus primarily originating in the atrial appendage.2, 3 Evidence is emerging to suggest that AF may also contribute to less dramatic but equally devastating neurologic decline. Treatment modalities for AF target various aspects, including control of heart rate, conversion of heart rhythm, and elimination of either the nidus

Methods

A systematic electronic literature search was conducted using Medline for studies published from January 1, 2004, to July 1, 2014, including the search phrases: atrial fibrillation, cognitive impairment, and cognitive decline. Articles not in the English language were excluded. Hand-selected references from articles were also reviewed. Studies were categorized into 3 categories based on topic: epidemiology, pathophysiology, and treatment (Figure 1). Further review of epidemiologic studies was

Epidemiology

Numerous studies have been conducted examining the association between AF and cognitive impairment, with diverse populations ranging from case series of acute stroke inpatients to community-dwelling population-based longitudinal studies. Because of the heterogeneity of populations, methods, and analysis of the literature, 4 reviews4, 5, 6, 7and 3 meta-analyses8, 9, 10 (Table I) were reviewed, whereas prospective cohort and cross-sectional studies were excluded. In general, studies support a

Hemodynamics

As noted in many of the epidemiologic studies, patients with AF often have concurrent diagnoses such as hypertension, previous stroke, and other cardiovascular diseases that confound the association and delineation of underlying mechanism. Atrial fibrillation decreases cardiac output secondarily to loss of atrioventricular synchrony and impairment of left ventricular filling.12 As a result of this decreased cardiac output, cerebral hypoperfusion may occur, particularly in the elderly in whom

Anticoagulation

Oral anticoagulation (OAC) has been the mainstay treatment of AF and has documented benefit in stroke reduction.41 People with AF have twice the risk of dying,42 and only anticoagulation therapy has been demonstrated to reduce AF-related deaths.43 Prescribing practices in “real-world” studies have shown a significant rate of anticoagulant omission, ranging from 34%44 to 59%.45 Although a number of clinical factors and bleeding risk characteristics may contribute to the low prescribing rate, no

Cognitive screening and future directions

Recognizing and preventing mild cognitive impairment as persons age is important. Persons with mild cognitive impairment are more likely to forget to take their medicines, have a greater propensity to falling, have worse outcomes after a major adverse event such as surgery, and die earlier.71, 72, 73 In addition, approximately a third of persons with mild cognitive impairment will develop Alzheimer disease 3 years after diagnosis.74

In a population-based study of 6,584 participants between ages

Acknowledgements

No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this review.

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