Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration

Abstract

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.

Association of Catheter Ablation and Reduced Incidence of Dementia among Patients with Atrial Fibrillation during Long-Term Follow-Up: A Systematic Review and Meta-Analysis of Observational Studies

“…The present analysis, despite using general terms to maximize sensitivity, retrieved a low number of studies. In fact, the AF-SCREEN International Collaboration has recently [ 14 ] highlighted the urge for dedicated research to establish the role of AF treatment strategies in preventing dementia. The effect of sinus rhythm maintenance has been investigated especially in regard to hard clinical endpoints, whereas evidence on cognitive impairment is limited and burdened by heterogeneity in the scale adopted to measure cognitive function.…”

“…Among the possible therapeutic strategies for AF management, catheter ablation (AFCA) is the most effective in achieving rhythm control and improving quality of life [ 11 , 12 , 13 ]. Lately, the possible role of rhythm control strategies in preventing cognitive decline has been investigated [ 14 , 15 , 16 , 17 , 18 , 19 ]; however, the effect of AFCA on dementia occurrence, a highly relevant medical and socio-economical event, has rarely been studied and remains matter of debate.…”

Clinical significance, challenges and limitations in using artificial intelligence for electrocardiography-based diagnosis

“…While there is still limited supporting evidence for systematic screening for AF, as well as associated cost implications [26], targeted screening, systemic opportunistic screening or smartphone algorithms, may be a more cost-effective option when using AI-enhanced ECG systems. With an increasing consumer adoption of wearable healthcare technologies [27,28], the incorporation of AIenhanced algorithms for AF screening [29][30][31][32] would be expected to AF-related morbidities in the long-term [33,34].…”

Atrial cardiopathy and cognitive impairment

“…However, other studies have reported that the AF-related risk of dementia can be explained by brain infarcts, with the majority of infarcts being silent ( Sposato et al, 2017 ; Kühne et al, 2022 ). AF and dementia share multiple risk factors, and while many studies adjust for these risk factors at baseline, they have short follow-up times and are not always reassessed ( Rivard et al, 2022 ). Further, subclinical AF could be a confounding cause of dementia in patients with AC.…”