Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.
Bibliographical noteFunding Information:
Within the past 3 years, AF-SCREEN received funding for holding its annual meetings from BMS/Pfizer, Bayer, Medtronic, iRhythm, Daiichi-Sankyo, Zenicor, Servier, Boehringer Ingelreim, Biotel, C-SPIN (Canadian Stroke Prevention Intervention Network), and Omron. The sponsors played no role in setting the agenda or the programs for the annual meetings and had no role in drafting, reviewing, or submitting this document for publication. Dr Rivard is supported by FRSQ (Fonds de Recherche Santé du Québec).
Dr Rivard reports research grants from Bayer Inc, Heart and Stroke Foundation, and FRSQ (Fonds de Recherche Santé du Québec). Dr Berge reports speaker fees from Bayer, Boehringer Ingelheim, BMS, and Pfizer. Dr Boriani reports speaker’s fees of small amounts from Bayer, Boehringer, Boston, and Medtronic. Dr Brandes reports research grants from the Region of Southern Denmark and Theravance and has been a speaker for Bayer, Boehringer Ingelheim, BMS/Pfizer, and MSD. Dr Camm reports consulting fees from Bayer, Daiichi Sankyo, Boehringer Ingelheim, Boston Scientific, and Abbott; and research funding from Bayer, Daiichi Sankyo, Boehringer Ingelheim, Pfizer BMS, Boston Scientific, and Abbott. Dr Conen holds a McMaster University Department of Medicine Mid-Career Research Award and reports honoraria from Servier Canada and Roche Diagnostics, both outside of the current work. Dr Elkind reports receiving study drug in kind from the BMS-Pfizer Alliance for Eliquis® and ancillary funding from Roche for an National Institutes of Health–funded trial of stroke prevention; royalties from UpToDate; and serving as an unpaid Officer of the American Heart Association. Dr Engdahl reports lecture or consultant fees from Pfizer, Bristol Myers Squibb, Merck Sharpe & Dome, Medtronic, Boehringer Ingelheim, and Roche Diagnostics. Dr Hankey reports personal fees from the American Heart Association (as Associate Editor for Circulation) and speaker and consulting fees from Bayer and Medscape. Dr Häeusler reports speaker honoraria, consulting fees, lecture honoraria, and/or study grants from Abbott, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Edwards Lifescience, Medtronic, Pfizer, Portola, Premier Research, Sanofi, and WL Gore and Associates. Dr Wang reports research grants from National Natural Science Foundation of China (grants 91639203 and 82070435), Beijing, and the Shanghai Commission of Science and Technology (grant 19DZ2340200), Shanghai, China, and lecture and consulting fees from Novartis, Omron, Servier, and Takeda. Dr Kirchhof is partially supported by European Union BigData@Heart (grant agreement EU IMI 116074 and Horizon 2020 AFFECT-EU, 847770), British Heart Foundation (FS/13/43/30324; PG/17/30/32961 and PG/20/22/35093; AA/18/2/34218), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK), and Leducq Foundation; has received honoraria from companies active in atrial fibrillation and cognitive function in the past, but not in the past 3 years; and is listed as inventor on 2 patents held by the University of Birmingham (Atrial fibrillation therapy WO 2015140571 and Markers for atrial fibrillation WO 2016012783). Dr Lip reports honoraria from Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi-Sankyo and speaking for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo; no fees are directly received personally. Dr Madhavan reports a significant research grant from BMS/Pfizer. Dr Montaner reports research funding from Fundación Marató de TV3: “Atrial Fibrillation Research in Catalonia (AFRICAT): Sequential Clinic-Electro-Biological Screening Among High Risk Individuals,” code 20152830, and H2020 program (AFFECT-EU grant agreement 847770) for digital, risk-based screening for atrial fibrillation in the European community. Dr Ntaios reports speaker fees/advisory boards/research support from Abbott, Amgen, Bayer, Boehringer-Ingelheim, BMS, and Pfizer. Drs Rienstra and Van Gelder report research grants from the Netherlands Cardiovascular Research Initiative: An Initiative With Support of the Dutch Heart Foundation: CVON 2014–9: Reappraisal of Atrial Fibrillation: Interaction Between Hypercoagulability, Electric Remodelling, and Vascular Destabilisation in the Progression of AF (RACE V) and grant support from Medtronic to the institution outside this work. Dr Sandhu reports research grants from Servier and BMS/Pfizer. Dr Schnabel reports research grants from the European Research Council under the European Union’s Horizon 2020 research and innovation program under grant agreements 648131 and 847770 (AFFECT-EU), the German Center for Cardiovascular Research (DZHK eV; 81Z1710103), the German Ministry of Research and Education (BMBF 01ZX1408A), and ERACoSysMed3 (031L0239) and has received lecture fees and advisory board fees from BMS/Pfizer outside this work. The other authors report no conflicts.
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- atrial fibrillation
- cognitive dysfunction
PubMed: MeSH publication types
- Journal Article
- Research Support, Non-U.S. Gov't