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Published on: April 23, 2021
The pathophysiology of cognitive impairment in individuals with heart failure: a systematic review
Reine Sam Shi Ni1, Hanis Qarissa Mohamed Raffi1, Yanhong Dong1
1Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
Insights
Heart failure and cognitive impairment are linked through various brain and systemic changes. Understanding these pathophysiological mechanisms is key to improving patient management and exploring new interventions.
Area of Science:
- Cardiology
- Neurology
- Pathophysiology
Background:
- Heart failure and cognitive impairment are increasingly prevalent and interconnected conditions.
- Existing reviews highlight the relationship but lack depth in exploring underlying pathophysiological mechanisms.
- Current research often focuses on prevalence and interventions like cardiac rehabilitation, leaving a gap in understanding the 'why'.
Purpose of the Study:
- To systematically review and summarize existing evidence on the pathophysiological mechanisms linking heart failure and cognitive impairment.
- To consolidate findings on how cardiac dysfunction impacts brain health and vice versa.
- To identify research gaps and guide future investigations into the brain-heart axis in these conditions.
Main Methods:
- A systematic review was conducted using eight electronic databases and grey literature, with reference hand-searching.
- Specific inclusion criteria were applied for population, exposures, and outcomes.
- Data from 32 studies were synthesized using narrative synthesis, with JBI critical appraisal tools for quality assessment.
Main Results:
- Cognitive impairment in heart failure stems from brain changes (atrophy, white/grey matter alterations, neuroinflammation) and systemic/cardiac factors (inflammation, oxidative stress, biomarkers, heart rhythm).
- Seven studies reported negative findings, suggesting complexity or potential bi-directional influences.
- Identified limitations include the inclusion of non-human studies and a high number of cross-sectional designs.
Conclusions:
- Future research should investigate the bi-directional relationship between the brain and heart, moving beyond the current focus on cardiac effects on the brain.
- A deeper understanding of pathophysiological mechanisms can improve heart failure patient management and prognosis.
- Developing interventions to slow or reverse cognitive impairment is crucial to reduce the overall disease burden.
Introduction:
Heart Failure and Cognitive Impairment are both on the rise and shown to be interlinked. Despite existing reviews delineating a relationship between heart failure and cognitive impairment, the underlying pathophysiology is not researched in great depth. Current literature proposed varying pathophysiological mechanisms and focused heavily on the prevalence of cognitive impairment and treatment interventions such as cardiac rehabilitation. In view of the limitations of previous reviews, this systematic review summarized the best existing evidence concerning different pathophysiological mechanisms behind cognitive impairment in individuals with heart failure.
Methods:
Eight electronic databases including PubMed, Cochrane Library and EMBASE etc., two grey literatures (ProQuest Theses and Dissertations and Mednar) and hand-searching of references were performed using specific criteria regarding population, exposures and outcomes, before duplicate removal and screening using Endnote and Rayyan respectively. JBI critical appraisal tools for non-randomized studies were used for appraisal. Data extraction was performed using two modified forms from JBI Manual for Evidence Synthesis.
Results:
Narrative synthesis was performed to summarize the data from 32 studies. There were three main themes-cognitive impairment due to changes in the brain: brain atrophy, alterations in grey matter and white matter, cerebral alterations, pathway or axis changes, neuroinflammation and hippocampal gene changes; cognitive impairment due to changes in the heart or systemic circulation: inflammation, oxidative stress and changes in serum biomarkers or proteins and the riser rhythm; cognitive impairment due to changes in both the brain and the heart, with seven studies obtaining negative results. There are some limitations such as having non-human studies and large numbers of cross-sectional studies etc.
Discussion:
Considering the findings, future research should examine the bi-directional relationship between the brain and the heart as most of the existing research is about the effect of the heart on the brain. By understanding the different pathophysiological mechanisms, the management and prognosis of heart failure patients will be ameliorated. Interventions that slow down or even reverse cognitive impairment can be explored so that these two common issues will not add to the already aggravating disease burden.
Systematic Review Registration:
This review is registered under PROSPERO. Identifier: CRD42022381359.
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