Heart failure and cognitive impairment: a narrative review

Heart failure (HF) is a major global health burden affecting more than 64 million individuals worldwide, and is associated with substantial morbidity, mortality, and healthcare expenditure. Cognitive impairment (CI) is a prevalent and clinically consequential comorbidity, affecting approximately 40%-50% of patients with HF across both reduced and preserved ejection fraction phenotypes. Despite its high prevalence and adverse prognostic implications, CI remains systematically underdiagnosed and insufficiently addressed in routine clinical practice. The pathophysiological mechanisms linking HF and CI are multifactorial and incompletely understood, encompassing cerebral hypoperfusion secondary to reduced cardiac output, systemic neuroinflammation driven by pro-inflammatory cytokines, oxidative stress, neurohumoral dysregulation, and cerebrovascular injury. Shared cardiovascular risk factors, including atrial fibrillation, hypertension, diabetes mellitus, and obesity, further compound the risk of cognitive decline. CI exerts a profound impact on clinical outcomes in HF, independently predicting increased all-cause mortality, higher rates of hospitalization and 30-day readmission, impaired self-care capacity, and reduced medication adherence. Early and systematic identification is a reasonable clinical priority that may support optimized clinical management and informed shared decision-making. This review synthesizes current evidence on the epidemiology, pathophysiology, clinical assessment, prognostic significance, and therapeutic implications of CI in HF, and highlights key controversies and priorities for future research.