Cognitive impairment often coexists with heart failure, and this condition can negatively impact patient prognosis and impede patients’ independence and ability to fully participate in their treatment. A new scientific statement from the Heart Failure Association of America (HFSA) will help clinicians do their part by screening for any disorders and taking steps to address them when they are discovered. It is an object.

The paper’s lead author, Eilan Z. Gorodeski, MD, of University Hospitals in Cleveland, Ohio, told TCTMD that the document was prepared at the request of the HFSA. Their interest in this topic, outside of the drugs, devices and procedures that often receive the most attention, supports the idea that cognitive impairment plays an important role in the management of heart failure, he commented. did.

“There is a growing recognition that the overwhelming majority of patients with heart failure have some element of cognitive impairment,” Dr. Gorodeski said. In extreme cases, the disorder is obvious, but for most patients it is mild and “may not be detected unless tested,” he noted.

Whether the disorder is invisible to clinicians or not, “it certainly has an impact on what happens next for the patient, the outcome, the course,” he said. Patients with cognitive impairment may not be able to understand what their doctor has said, how to practice self-care, or how to deal with other aspects of managing their disease.

Additionally, there is now “extensive literature spanning several decades” on the interplay between heart failure and mental acuity and advances in managing this dual condition, he added.

“Here’s why [the paper is] It is timely and the Association is committed to providing information on it to guide and raise awareness of clinicians in the field, to teach them how to diagnose, and what first steps they need to take to make a diagnosis. I was hoping for a more definitive piece of writing. Do something about it,” Gorodeski said.

The statement, led by Dr. Parag Goyal (Weill Cornell Medicine, New York, NY), was published online yesterday. heart failure journal.

Why the overlap?

Heart failure patients can develop cognitive impairment for a variety of complex reasons, Gorodeski said. “It may be directly related to heart failure itself, especially in patients with more advanced heart failure who have low blood flow to the brain or very high filling pressures,” he explained. Some people who are hospitalized with heart failure experience changes in behavior or mental status after stabilization.

But beyond this, Gorodeski noted that a variety of CV and non-CV comorbid conditions can cause cognitive impairment in a patient’s “complex ecology.” “For example, one of the most commonly unrecognized things is that the vast majority of heart failure patients have sleep apnea, which is known to worsen cognitive function. Thromboembolism can cause subclinical infarctions in the brain that affect a patient’s ability to think clearly, and cognitive function can also be affected by diabetes and chronic kidney disease; Fibrillation is also thought to be involved.

In any patient, “we may not know what the primary cause is,” he acknowledged. “But to be honest, for someone like me, a real-world cardiovascular clinician who treats patients with heart failure, I’m not a neurologist or a psychiatrist, and that doesn’t really interest me.” Much of it lies in the reasons. I’m interested in: Is it there? And if it is there, what am I going to do about it? ”

Diagnosis and future developments

Importantly, Mr. Gorodeski emphasized: “You can’t just walk into a room and look at someone and diagnose them. . . . We shouldn’t look at cognitive impairment.”

To this end, the HFSA Scientific Statement addresses three options for screening. The Mini-Cog, Mini Mental State Exam, and MoCA stand out “in terms of usefulness, practicality, recognition/recognition, and prediction,” the paper states. “The tools used in routine clinical practice should be selected based on available time and personnel. However, clinicians should also be aware of differences in diagnostic performance. Mini-Cog can be administered in 3 minutes. MoCA may be better at detecting mild cognitive impairment, although it may not be sensitive enough to detect mild cognitive impairment. [it]However, it takes 10 minutes to administer (or longer for people with cognitive impairments). ”

However, the authors added that it is also worth noting that other symptoms, such as mood and sleep disorders, delirium, and sensory disturbances, can also mimic cognitive impairment.

for Gorodeski, Minicog is less sensitive, but stands out for its convenience. “It’s like taking your blood pressure. [which] It will probably take a minute and a half to two minutes. “The cognitive impairment check will probably take him a minute and a half to him two minutes,” he said.

We should not focus on cognitive impairment. Eilan Z. Gorodeski

Once cognitive impairment is identified, it is important to view the management of heart failure through that “prism,” the statement said.

“That’s probably the most important thing to do about it,” he said. Gorodeski“It’s about considering what kind of accommodations the patient needs.”

Before being discharged from the hospital, patients with decompensated heart failure are given a long list of things to do, including taking numerous medications, weighing and recording their weight daily, eating a low-salt diet, and following a scheduled schedule. You will be instructed to return to the clinic for an examination. “People with cognitive impairments can’t do that. They want what’s best for themselves, but they’re going to make a lot of mistakes.” This is because their ability to do things and problem-solve are all weakened. Gorodeski He explained.

Clinicians can address these issues by making the patient’s social circle aware that, although it may not be obvious, the patient has cognitive problems due to the disease, he advised. Friends and relatives can help with things like managing your pillbox and making sure you’re on time for appointments.

Care teams should also investigate whether there are other factors contributing to cognitive impairment and control them as much as possible, the HFSA statement said.

And finally, another area to consider is how to make difficult decisions when a patient’s mental acuity is impaired. “Given its impact on self-care and life expectancy, incorporating cognitive impairment into clinical decision-making is a complex but important part of the care of adults with heart failure and cognitive impairment,” Goyal et al. writing. Although both advanced care planning and the choice to pursue treatments such as left ventricular assist devices and heart transplantation are particularly difficult in this setting, this statement aims to provide patient-centered care and It provides strategies on how to communicate.

The authors note that many gaps remain in understanding the pathophysiological mechanisms and how best to screen for and potentially reverse cognitive impairment. “By addressing these gaps, the field has an opportunity to further improve the care provided. [to] “They are one of the most vulnerable segments of the population,” they conclude.