Left atrial size is independently associated with cognitive function

Psychiatric symptoms in patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) is one of the leading causes of hospitalization and even death worldwide. Complex bidirectional associations have been suggested between psychiatric disorders and AF disease. This study was conducted to investigate the prevalence of psychiatric symptoms in a cohort of Egyptian population presented with symptomatic non-valvular AF (NVAF) and to identify the high-risk subjects in need for professional psychiatric consultation. A total of 100 eligible symptomatic NVAF patients were recruited in this cross-sectional study. Each patient was subjected to: (1) cardiac evaluation included electrocardiogram, trans-esophageal echocardiography, and the European Heart Rhythm Association (EHRA). (2) Psychiatric evaluation consisted of clinical psychiatric interviewing, Hospital Anxiety and Depression Scales (HADS), Mini–Mental State Examination (MMSE), type-D personality screening, and the short form-36 (SF-36) health survey for the assessment of health-related quality of life (HRQoL).

Results

Forty-four percent of our enrolled AF patients had anxiety symptoms, 32% had depressive symptoms, 24% had mild cognitive impairment, and 32% had type-D personality. Linear regression analysis demonstrated that the left atrial dimension (LAD) and the age were the main significant predictors of MMSE, while the main predictors of HADS were SF-36 (physical functioning and general health) and the age. Neither psychiatric symptoms, nor type-D personality was a significant predictor for the evaluated cardiac parameters.

Conclusions

Mild cognitive impairment as well as depressive and anxiety symptoms is not uncommon associates with NVAF patients. Assessment of cognitive function and HRQoL is strongly advised for AF patients presented with enlarged LAD particularly among old adults.

Normal left atrial diameter is associated with better performance on a cognitive screener among a cohort of ischemic stroke patients

Background

Cardiac structure is an important determinant of ischemic stroke (IS) etiology; however, whether an association between cardiac structural markers and cognition post-IS exists is not yet established. The aim of this study is to examine the association between LAD and LVEF with cognitive performance among IS patients.

Methods

IS patients admitted to the Johns Hopkins Hospital (2017-2019) underwent transthoracic echocardiography. IS was classified (TOAST) by a masked reviewer. Left atrial diameter (LAD) was evaluated as a non-linear continuous variable with one spline knot at 4 cm; left ventricle ejection fraction (LVEF) was dichotomized, then further evaluated as a non-linear continuous variable with spline knots at 50% and 70%. Patients were contacted by telephone on average 422 days post-stroke and administered the Six-Item Screener (SIS) to assess for dementia. SIS scores were dichotomized into low and high, imputing low scores for non-answerers. Multivariable logistic regression determined the association of SIS category with LAD or LVEF. A sensitivity analysis re-evaluated the association between SIS category and LAD, excluding participants with atrial fibrillation (AF).

Results

Participants (N = 108) were on average 61 years old (range = 18-89 years), 55% male, and 63% Black. Among patients considered to have a normal LAD (≤ 4 cm), a 1 mm larger LAD was associated with 1.20 greater odds (95%CI = 1.05-1.38) of scoring in the high SIS category in the final adjustment model. This association remained significant when excluding participants with prevalent AF. There was no association between a 1 mm larger LAD and SIS category among patients with a LAD >4 cm in both the primary analysis and the sensitivity analysis. There was no association between LVEF and SIS category.

Conclusions

In this prospective study, among ischemic stroke patients with a LAD within the normal range, a 1 mm increase in LAD was associated with higher scores on a telephone cognitive battery, without an association found among those with a LAD >4 cm.

Atrial cardiopathy and cognitive impairment

Cognitive impairment involves complex interactions between multiple pathways and mechanisms, one of which being cardiac disorders. Atrial cardiopathy (AC) is a structural and functional disorder of the left atrium that may be a substrate for other cardiac disorders such as atrial fibrillation (AF) and heart failure (HF). The association between AF and HF and cognitive decline is clear; however, the relationship between AC and cognition requires further investigation. Studies have shown that several markers of AC, such as increased brain natriuretic peptide and left atrial enlargement, are associated with an increased risk for cognitive impairment. The pathophysiology of cognitive decline in patients with AC is not yet well understood. Advancing our understanding of the relationship between AC and cognition may point to important treatable targets and inform future therapeutic advancements. This review presents our current understanding of the diagnosis of AC, as well as clinical characteristics and potential pathways involved in the association between AC and cognitive impairment.

Serum glial fibrillary acidic protein indicates memory impairment in patients with chronic heart failure

Aims

Cognitive dysfunction occurs frequently in patients with heart failure (HF), but early detection remains challenging. Serum glial fibrillary acidic protein (GFAP) is an emerging biomarker of cognitive decline in disorders of primary neurodegeneration such as Alzheimer's disease. We evaluated the utility of serum GFAP as a biomarker for cognitive dysfunction and structural brain damage in patients with stable chronic HF.

Methods and results

Using bead‐based single molecule immunoassays, we quantified serum levels of GFAP in patients with HF participating in the prospective Cognition.Matters‐HF study. Participants were extensively phenotyped, including cognitive testing of five separate domains and magnetic resonance imaging (MRI) of the brain. Univariable and multivariable models, also accounting for multiple testing, were run. One hundred and forty‐six chronic HF patients with a mean age of 63.8 ± 10.8 years were included (15.1% women). Serum GFAP levels (median 246 pg/mL, quartiles 165, 384 pg/mL; range 66 to 1512 pg/mL) did not differ between sexes. In the multivariable adjusted model, independent predictors of GFAP levels were age (T = 5.5; P < 0.001), smoking (T = 3.2; P = 0.002), estimated glomerular filtration rate (T = −4.7; P < 0.001), alanine aminotransferase (T = −2.1; P = 0.036), and the left atrial end‐systolic volume index (T = 3.4; P = 0.004). NT‐proBNP but not serum GFAP explained global cerebral atrophy beyond ageing. However, serum GFAP levels were associated with the cognitive domain visual/verbal memory (T = −3.0; P = 0.003) along with focal hippocampal atrophy (T = 2.3; P = 0.025).

Conclusions

Serum GFAP levels are affected by age, smoking, and surrogates of the severity of HF. The association of GFAP with memory dysfunction suggests that astroglial pathologies, which evade detection by conventional MRI, may contribute to memory loss beyond ageing in patients with chronic HF.

Expanding the horizon of research into the pathogenesis of the white matter diseases: Proceedings of the 2021 Annual Workshop of the Albert Research Institute for White Matter and Cognition

White matter pathologies are critically involved in the etiology of vascular cognitive impairment-dementia (VCID), Alzheimer's disease (AD), and Alzheimer's disease and related diseases (ADRD), and therefore need to be considered a treatable target ( Roseborough A, Hachinski V, Whitehead S. White matter degeneration - a treatable target? Roseborough et al. JAMA Neurol [Internet]. 2020 Apr 27;77(7):793-4, [1] . To help address this often-missed area of research, several workshops have been sponsored by the Leo and Anne Albert Charitable Trust since 2015, resulting in the incorporation of "The Albert Research Institute for White Matter and Cognition" in 2020. The first annual "Institute" meeting was held virtually on March 3-4, 2021. The Institute provides a forum and workspace for communication and support of the advancement of white matter science and research to better understand the evolution and prevention of dementia. It serves as a platform for young investigator development, to introduce new data and debate biology mechanisms and new ideas, and to encourage and support new research collaborations and directions to clarify how white matter changes, with other genetic and health risk factors, contribute to cognitive impairment. Similar to previous Albert Trust-sponsored workshops (Barone et al. in J Transl Med 14:1-14, [2]; Sorond et al. in GeroScience 42:81-96, [3]), established expert investigators were identified and invited to present. Opportunities to attend and present were also extended by invitation to talented research fellows and younger scientists. Also, updates on institute-funded research collaborations were provided and discussed. The summary that follows is a synopsis of topics and discussion covered in the workshop.

Frequent Premature Atrial Contractions Are Associated With Poorer Cognitive Function in the Atherosclerosis Risk in Communities (ARIC) Study

OBJECTIVE

To evaluate the association of premature atrial contraction (PAC) frequency with cognitive test scores and prevalence of dementia or mild cognitive impairment (MCI).

MATERIALS AND METHODS

We conducted a cross-sectional analysis using Atherosclerosis Risk in Communities study visit 6 (January 1, 2016, through December 31, 2017) data. We included 2163 participants without atrial fibrillation (AF) (age mean ± SD, 79±4 years; 1273 (58.9%) female; and 604 (27.97.0% Black) who underwent cognitive testing and wore a leadless, ambulatory electrocardiogram monitor for 14 days. We categorized PAC frequency based on the percent of beats: less than 1%, minimal; 1% to <5%, occasional; greater than or equal to 5%, frequent. We derived cognitive domain-specific factor scores (memory, executive function, language, and global z-score). Dementia and MCI were adjudicated.

RESULTS

During a mean analyzable time of 12.6±2.6 days, 339 (15.7%) had occasional PACs and 107 (4.9%) had frequent PACs. Individuals with frequent PACs (vs minimal) had lower executive function factor scores by 0.30 (95% CI, -0.46 to -0.14) and lower global factor scores by 0.20 (95% CI, -0.33 to -0.07) after multivariable adjustment. Individuals with frequent PACs (vs minimal) had higher odds of prevalent dementia or MCI after multivariable adjustment (odds ratio, 1.74; 95% CI, 1.09 to 2.79). These associations were unchanged with additional adjustment for stroke.

CONCLUSION

In community-dwelling older adults without AF, frequent PACs were cross-sectionally associated with lower executive and global cognitive function and greater prevalence of dementia or MCI, independently of stroke. Our findings lend support to the notion that atrial cardiomyopathy may be a driver of AF-related outcomes. Further research to confirm these associations prospectively and to elucidate underlying mechanisms is warranted.

Neuropsychological Assessment and Screening in Heart Failure: a Meta-Analysis and Systematic Review

A variety of neuropsychological changes secondary to heart failure have been documented in the literature. However, what remains unclear are which neuropsychological abilities are the most impacted by heart failure and what tests have the sensitivity to measure that impact. Eight databases were searched for articles that examined the neuropsychological functioning of patients with heart failure. Some of the inclusion criteria were articles had to have a heart failure group with a demographically comparable control group and standardized neuropsychological testing. Exclusion criteria included articles with a heart failure group with any other type of major organ failure, or comparisons that were between different classes of heart failure rather than between a heart failure and non-heart failure group. A total of 33 articles met the inclusion criteria (total heart failure sample n = 8900) and provided effect size data for 20 neuropsychological domains. All observed domain-level differences between heart failure and non-heart failure groups were statistically significant, except for simple motor functioning and confrontation naming. The greatest differences in performance were in executive functioning, global cognition, complex psychomotor speed, and verbal memory. The highest effect sizes came from Trail-Making Test-Part B, CAMCOG, Symbol Digit Modality Test, and California Verbal Learning Test. The neuropsychological patterns of heart failure suggested diffuse cognitive involvement, with higher-level processes being most affected. It is important to track neurocognition in this clinical population since neuropsychological impairment is prevalent, and screening measures appear to be reliable. Such screening and further assessment would inform future medical treatment and may improve patient care management.

Different associations between left atrial size and 2.5-year clinical outcomes in patients with anterior versus non-anterior wall ST-elevation myocardial infarction

Objective

To investigate associations between left atrial diameter (LAD) and long-term outcomes in patients with anterior or non-anterior wall ST-elevation myocardial infarction (STEMI).

Methods

Patients with STEMI were included in this secondary analysis of data from a prospective cohort study in which the primary outcome was major adverse cardiovascular event (MACE) occurrence during a 2.5-year follow-up. A LAD cut-off value was obtained through receiver operating characteristic curve analysis. Kaplan-Meier curve and Cox regression analyses were applied. Subgroup Cox regression analysis was also performed, with patients stratified based on left ventricular diastolic diameter (LVEDD, > 55 mm and ≤55 mm). The relationship between LAD and outcomes in patients with anterior or non-anterior wall STEMI was explored using restricted cubic spline functions.

Results

Out of 464 patients, adjusted Cox regression showed that dichotomous (>40 mm) LAD was significantly associated with MACE (hazard ratio 2.978, 95% confidence interval 1.763, 5.030) in patients with anterior wall but not non-anterior wall STEMI. The association was not different between normal and enlarged LVEDD groups.

Conclusions

A left atrium > 40 mm may indicate higher risk of MACE in patients with anterior wall STEMI, even in patients with normal left ventricular structure. This relationship was not observed in patients with non-anterior wall STEMI.

Hemodynamic Instability in Heart Failure Intensifies Age-Dependent Cognitive Decline

This review attempts to examine two key elements in the evolution of cognitive impairment in the elderly who develop heart failure. First, major left side heart parts can structurally and functionally deteriorate from aging wear and tear to provoke hemodynamic instability where heart failure worsens or is initiated; second, heart failure is a major inducer of cognitive impairment and Alzheimer's disease in the elderly. In heart failure, when the left ventricular myocardium of an elderly person does not properly contract, it cannot pump out adequate blood to the brain, raising the risk of cognitive impairment due to the intensification of chronic brain hypoperfusion. Chronic brain hypoperfusion originates from chronically reduced cardiac output which progresses as heart failure worsens. Other left ventricular heart parts, including atrium, valves, myocardium, and aorta can contribute to the physiological shortfall of cardiac output. It follows that hemodynamic instability and perfusion changes occurring from the aging heart's blood pumping deficiency will, in time, damage vulnerable brain cells linked to specific cognitive regulatory sites, diminishing neuronal energy metabolism to a level where progressive cognitive impairment is the outcome. Could cognitive impairment progress be reversed with a heart transplant? Evidence is presented detailing the errant hemodynamic pathways leading to cognitive impairment during aging as an offshoot of inefficient structural and functional heart parts and their contribution to heart failure.

Association of Abnormal P-Wave Indices With Dementia and Cognitive Decline Over 25 Years: ARIC-NCS (The Atherosclerosis Risk in Communities Neurocognitive Study)

Background Abnormal P-wave indices (PWIs)-reflecting underlying left atrial abnormality-are associated with increased risk of stroke independent of atrial fibrillation. We assessed whether abnormal PWIs are associated with incident dementia and greater cognitive decline, independent of atrial fibrillation and ischemic stroke. Methods and Results We included 13 714 participants (mean age, 57±6 years; 56% women; 23% black) who were followed for dementia through the end of 2015. (Abnormal P-wave terminal force in lead V1, ≥4000 μV×ms), abnormal P-wave axis (>75° or <0°), prolonged P-wave duration (>120 ms), and advanced interatrial block were determined from ECGs at visits 2 to 4. Dementia was adjudicated by an expert panel using data from cognitive tests and hospitalization International Classification of Diseases codes. Cognitive function was measured longitudinally using 3 neuropsychological tests. Cox proportional hazards models were used to assess the association between time-dependent abnormal PWIs with incident dementia. Linear regression models were used to evaluate PWIs with cognitive function over time. At the conclusion of the study, 19%, 16%, 28%, and 1.9% of participants had abnormal P-wave terminal force in lead V1, abnormal P-wave axis, prolonged P-wave duration, and advanced interatrial block, respectively. During mean follow-up of 18 years, there were 1390 (10%) dementia cases. All abnormal PWIs except advanced interatrial block were associated with an increased risk of dementia even after adjustment for incident atrial fibrillation and stroke: multivariable hazard ratio of abnormal P wave terminal force in lead V1=1.60, 95% CI, 1.41 to 2.83; abnormal P-wave axis, hazard ratio =1.36, 95% CI, 1.17 to 2.57; prolonged P-wave duration, hazard ratio=1.60, 95% CI, 1.42 to 1.80. Only abnormal P-wave terminal force in lead V1 was associated with greater decline in global cognition. Conclusions Abnormal PWIs are independently associated with an increased risk of dementia. This novel finding should be replicated in other cohorts and the underlying mechanisms should be evaluated.

Association of Left Atrial Enlargement and Atrial Fibrillation With Cognitive Function and Decline: The ARIC-NCS

Background Atrial fibrillation (AF) is associated with cognitive decline. Whether left atrial enlargement (LAE), a critical substrate for AF, is also associated is less well established. Therefore, we assessed the association of LAE and AF with cognitive decline in the ARIC-NCS (Atherosclerosis Risk in Communities Neurocognitive Study). Methods and Results Participants (n=3391; mean age, 75±5 years; 59% women) underwent cognitive tests and 2-dimensional echocardiograms at visit 5 (2011-2013) and follow-up cognitive tests at visit 6 (2016-2017). LAE was defined as left atrium volume index ≥34 mL/m2. AF was ascertained using study ECGs and hospitalization discharge codes. We assessed the association of AF and LAE with (a) cognitive domain scores at visit 5 and (b) cognitive domain score changes between visit 5 and visit 6. At visit 5, compared with the reference group (without AF, normal left atrium), participants with LAE and AF had significantly lower global cognition (Z score, -0.24; 95% CI, -0.38 to -0.10), whereas participants with AF and without LAE and participants with LAE and without AF did not have lower global cognition. In longitudinal analysis, compared with the reference group, participants with AF but without LAE had significantly greater decline in global cognition (Z score, -0.13; 95% CI, -0.21 to -0.06). However, LAE, with or without AF, was not associated with greater cognitive decline. Conclusion Although LAE with AF was significantly associated with lower cognitive function in cross-sectional analysis, LAE, with or without AF, was not associated with greater cognitive decline over 5 years, highlighting the importance of evaluating longitudinal cognitive function. Future studies should have longer follow-up and evaluate left atrium function.

Genome Wide Meta-Analysis identifies common genetic signatures shared by heart function and Alzheimer's disease

Echocardiography has become an indispensable tool for the study of heart performance, improving the monitoring of individuals with cardiac diseases. Diverse genetic factors associated with echocardiographic measures have been previously reported. The impact of several apoptotic genes in heart development identified in experimental models prompted us to assess their potential association with human cardiac function. This study aimed at investigating the possible association of variants of apoptotic genes with echocardiographic traits and to identify new genetic markers associated with cardiac function. Genome wide data from different studies were obtained from public repositories. After quality control and imputation, a meta-analysis of individual association study results was performed. Our results confirmed the role of caspases and other apoptosis related genes with cardiac phenotypes. Moreover, enrichment analysis showed an over-representation of genes, including some apoptotic regulators, associated with Alzheimer's disease. We further explored this unexpected observation which was confirmed by genetic correlation analyses. Our findings show the association of apoptotic gene variants with echocardiographic indicators of heart function and reveal a novel potential genetic link between echocardiographic measures in healthy populations and cognitive decline later on in life. These findings may have important implications for preventative strategies combating Alzheimer's disease.