Cognitive assessment in heart failure: clinical value, timing, and practical tools

This narrative review examines the clinical value of cognitive assessment in heart failure, highlighting optimal timing, practical tools, and the epidemiology, pathophysiology, and clinical implications of cognitive impairment. The relationship between heart failure (HF) and cognitive impairment (CI) increasingly represents a growing challenge at the intersection of the heart and brain. Current hypotheses suggest a bidirectional relationship driven by multifactorial mechanisms, including chronic cerebral hypoperfusion, blood-brain barrier disruption, neuroinflammation, while shared proteinopathy remains a preliminary and unconfirmed hypothesis. Although CI affects approximately 41% of patients with HF, it remains frequently underdiagnosed in routine practice. The neurocognitive phenotype in HF is characterised predominantly by deficits in executive function, attention, and memory, which critically undermine patient self-management and medication adherence. We critically evaluate available screening modalities, highlighting the limitations of tools like the Mini-Mental State Examination (MMSE) in detecting executive dysfunction. This review emphasises screening cognitive impairment in stable heart failure and atrial fibrillation as early as possible with appropriate screening tools in order to be referred to CDAMS or memory clinics for prompt management. Rather than identifying a single superior tool, this review emphasises that the overarching clinical priority is the routine application of multidomain cognitive assessments sensitive to these specific deficits. The review concludes that integrating routine cognitive assessment into HF management is essential for accurate risk stratification, individualised therapeutic planning, and ultimately reducing the neurocognitive burden in this population.