Background Minimising risk factors through secondary prevention behaviour is challenging for patients following an acute coronary syndrome. Cognitive impairment can potentially make these changes more difficult. However, cognitive impairment prevalence in acute coronary syndrome patients is poorly understood. Design This study was based on a systematic review. Methods A systematic review was conducted of PubMed, Medline, PsycINFO and Cochrane databases up to March 2019, to identify studies reporting the prevalence of cognitive impairment in acute coronary syndrome patients. Predefined inclusion criteria were specified, including use of a validated cognitive impairment screening tool. Studies were excluded if patients had diagnosed dementia or coronary artery bypass graft surgery. Strengthening The Reporting of Observational Studies in Epidemiology and Cochrane Risk of Bias tools were used to assess quality. Results From 747 potential studies, nine were included. The total sample size was 6457 (range 53–2174), mean age range was 51.3–77.4 years, and range of proportions of males was 57–100%. Reported cognitive impairment prevalence rates varied substantially (9–85%) with no clear pattern over time. From the two studies which examined domains, verbal fluency, memory and language were affected the most. Meta-analysis could not be undertaken due to diverse screening tools ( n = 9), cut-off scores and screening timepoints. Conclusions Cognitive impairment in acute coronary syndrome patients is currently poorly described, and likely affects a substantial number of acute coronary syndrome patients who remain undetected and have the potential to develop to dementia in the future. As domains are most affected, this could impact understanding and retention of health education. Research is needed to accurately determine the prevalence of cognitive impairment in acute coronary syndrome patients and create suitable standardised measures and thresholds.

Background Cognitive impairment may limit the uptake of secondary prevention in acute coronary syndrome patients, but is poorly understood, including in cardiac rehabilitation participants. Aim The aim of this study was to explore cognitive impairment in relation to psychological state in acute coronary syndrome patients over the course of cardiac rehabilitation and follow-up. Methods Acute coronary syndrome patients without diagnosed dementia were assessed on verbal learning, processing speed, executive function and visual attention, at cardiac rehabilitation entry, completion and follow-up and scores adjusted using normative data. The hospital anxiety and depression scale measured psychological state. Results Participants ( n = 40) had an average age of 66.2 (±8.22) years and were 70% men. Mild cognitive impairment occurred at cardiac rehabilitation entry in single 62.5% and multiple 22.5% domains but was significantly less prevalent by cardiac rehabilitation completion (52.5% and 15.0%) and follow-up (32.5% and 7.0%). Domains most often impaired were verbal learning (52.5%) and processing speed (25.6%), again decreasing significantly with time (verbal learning cardiac rehabilitation completion 42.5%, follow-up 22.5%; processing speed cardiac rehabilitation completion 15.0%, follow-up 15.0%). A small group of patients had persistent multiple domain cognitive impairment. At cardiac rehabilitation entry patients with cognitive impairment in processing speed, a single domain or multiple domains had more depression, and patients with cognitive impairment in executive function had more depression and anxiety. Conclusions At cardiac rehabilitation entry, mild cognitive impairment is very common in post-acute coronary syndrome patients and worse in patients who have depression or anxiety symptoms. Cognitive impairment decreases significantly by cardiac rehabilitation follow-up. A small proportion of patients has persistent, multiple domain cognitive impairment flagging potential long-term changes and the need for further investigations and cognitive rehabilitation.

Background: Cognitive impairment (CI) may contribute to difficulties in understanding and implementing secondary prevention behavior change after acute coronary syndrome (ACS), but the association is poorly understood. Objectives: The aim of this study was to explore the prevalence of CI in patients 4 weeks post ACS and the association with health literacy and secondary prevention. Methods: Patients with ACS who were free from visual deficits, auditory impairment, and dementia diagnoses were recruited and assessed 4 weeks post discharge for cognitive function (Montreal Cognitive Assessment and Hopkins Verbal Learning Test), health literacy (Newest Vital Sign), depression (Patient Health Questionnaire), physical activity (Fitbit Activity Tracker and Physical Activity Scale for the Elderly), and medication knowledge and adherence. Results: Participants (n = 45) had an average age of 65 ± 11 years, 82% were male, 64% were married/partnered, and 82% had high school education or higher. Overall CI was identified in 28.9% (n = 13/45) of the patients 4 weeks after discharge, which was composed of patients detected on both the Montreal Cognitive Assessment and Hopkins Verbal Learning Test (n = 3), patients detected on Montreal Cognitive Assessment alone (n = 6), and patients detected on Hopkins Verbal Learning Test alone (n = 4). Fewer patients with CI had adequate health literacy (61.4%) than patients with normal cognition (90.3%, P = .024). Significant correlations were found between Hopkins Verbal Learning Test scores and medication knowledge (0.4, P = .008) and adherence (0.33, P = .029). Conclusions: In this exploratory study, 30% of patients with ACS demonstrated CI at 4 weeks post discharge. Two screening instruments were required to identify all cases. Cognitive impairment was significantly associated with health literacy and worth further investigation.

Aims This study aimed to determine the sensitivity and specificity of the National Institute of Neurological Disorders and Stroke (NINDS) and the Canadian Stroke Network (CSN) brief (5 min) screen composed of three items of the Montreal Cognitive Assessment (MoCA), in acute coronary syndrome (ACS) patients during hospital admission, relative to the full MoCA and potential alternative combinations of other items. Methods and results Participants were consecutively recruited during ACS admission and administered the MoCA before discharge. The three NINDS–CSN screen items were extracted, collated and compared to the full MoCA. Receiver operator characteristic (ROC) curves were created to determine the sensitivity, specificity, and appropriate cut-off scores of the screens. The mean age of the sample (n = 81) was 63.49 [standard deviation (SD) 10.85] years and 49.4% screened positive for cognitive impairment. The NINDS–CSN mean score was 9.22 (SD 2.09 of the potential range 0–12). Area under the ROC (AUC) indicated high accuracy levels for screening for cognitive impairment (AUC = 0.89, P < 0.01, 95% confidence interval 0.82, 0.96) with none of the alternative combination screens performing better on both sensitivity and specificity. A cut-off score of ≤10 on the NINDS–CSN protocol provided 83% sensitivity and 80% specificity for classifying cognitive impairment. Conclusion The NINDS–CSN protocol presents an accurate, feasible screen for cognitive impairment in patients following ACS for use at the bedside and potentially also for telephone screens. Diagnostic accuracy should be confirmed using a neurocognitive battery.

Background: Mild cognitive impairment (MCI) has been reported after acute coronary syndrome (ACS), but it is uncertain who is at risk, particularly during inpatient admission. Objective: In this study, we aimed to explore the prevalence and cognitive domains affected in MCI during ACS admission and determine factors that identify patients most at risk of MCI. Methods: Inpatients with ACS were consecutively recruited from 2 tertiary hospital cardiac wards and screened with the Montreal Cognitive Assessment and the Hopkins Verbal Learning Test. Screening included health literacy (Newest Vital Sign), depressive symptoms (Patient Health Questionnaire-9), and physical activity (Physical Activity Scale for the Elderly). Factors associated with MCI were determined using logistic regression. Results: Participants (n = 81) had a mean (SD) age of 63.5 (10.9) years, and 82.7% were male. In total, MCI was identified in 52.5%, 42.5% with 1 screen and 10% with both. Individually, the Montreal Cognitive Assessment identified MCI in 48.1%, and the Hopkins Verbal Learning Test identified MCI in 13.8%. In Montreal Cognitive Assessment screening, the cognitive domains in which participants most frequently did not achieve the maximum points available were delayed recall (81. 5%), visuospatial executive function (48.1%), and attention (30.9%). Accounting for education, depression, physical activity, and ACS diagnosis, the likelihood of an MCI positive screen increased by 11% per year of age (odds ratio, 1.11; 95% confidence interval, 1.04-1.18) and by 3.6 times for those who are unmarried/unpartnered (odds ratio, 3.61; 95% confidence interval, 1.09-11.89). Conclusion: An estimated half of patients with ACS screen positive for MCI during admission, with single and older patients most at risk. Multiple areas of thinking were affected with potential impact on capacity for learning heart disease management.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the Vanguard Grant, Heart Foundation Background Cognitive impairment (CI) following acute coronary syndrome (ACS) is poorly understood. Purpose We aimed to explore the prevalence of CI in ACS patients four weeks post hospitalisation, the association with secondary prevention capacity and behaviours. Methods ACS inpatients who were free from visual deficits and dementia diagnoses were recruited. The post four weeks hospitalisation assessments included cognitive screening (Montreal Cognitive Assessment [MoCA], and Hopkins Verbal Learning Test [HVLT]), health literacy (Newest Vital Sign), depression (Patient Health Questionnaire-9), physical activity (Physical Activity Scale for the Elderly and Fitbit-Flex activity tracker), medication knowledge and adherence, sociodemographic and clinical factors. Results Participants (n = 45) had an average age of 65.07 ± 11.21 years, 82.2% were male, 64.4% were married/partnered and 82.2% had high school education or higher. CI occurred in 28.9% using either instrument, 20% using MoCA only and 15.6% using HVLT ­only. Cognitive domains affected were delayed recall (median = 5, range = 0-6) and new verbal learning and memory (15.6%). Adequate health literacy was less common in patients with CI (61.4%) than patients with normal cognition (90.3%, p = 0.024). Furthermore, patients with CI had trends for lower levels of secondary prevention capacity and behaviours, including fewer patients with high medication adherence, unlikely to be married or have an intimate partner, more depressive symptoms and lower levels of physical activity. Conclusions CI occurs in almost 30% of ACS patients four weeks post discharge, however a single screening tool is not sufficient to identify all cases. CI affected delayed recall, new verbal learning and memory; was associated with worse health literacy and may have potential implications for secondary prevention capacity.

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D ementia is a leading contributor to the global burden of disease due to progressive and unrelenting deterioration of the capacity of an individual to live independently. Vascular etiology is the second most common cause of dementia 1 and cardiovascular disease (CVD) results in faster decline. 2 Mild cognitive impairment (MCI), which may indicate early dementia, occurs frequently in acute coronary syndrome (ACS) patients. 3 Prevalence rates vary widely (9-85%), depending on timing and assessment method used. A recent report indicated 63% had MCI on screening 4 4-wk post-ACS. Data based on full neurocognitive assessment when recovery has progressed (4-mo post-ACS) are required for confirmation and to inform inpatient screening that reliably predicts MCI. Early detection of MCI enables timely intervention to potentially slow the progression of MCI to dementia and enable customizing of education and support. METHODSWe recruited consecutive ACS inpatients from two university hospitals in metropolitan Sydney, Australia. Included patients were free from dementia and proficient in English. Inpatient screening for MCI was undertaken using the Montreal Cognitive Assessment (MoCA) 5 and the Hopkins Verbal Learning Test (HVLT). 6 Together, these tests are sensitive to the cognitive decline common in vascular cognitive impairment. Mild cognitive impairment was classified as MoCA score <26 and/or HVLT ≥ −1 z-score. Participants were then assessed 4-mo post-ACS using a full neurocognitive battery conducted by qualified neuropsychologists in an accredited testing center (see Supplemental Digital Content Table 1, available at: http://links.lww.com/JCRP/A432). Testing determined if patients met clinical criteria for MCI, as well as classification of amnestic and nonamnestic MCI