The incidence of dementia and cardiovascular disease (CVD) increases with age. Current evidence supports the role for both atherosclerosis and arteriosclerosis as a common pathophysiological ground ...

A major role for cardiovascular burden in age-related cognitive decline

CONTEXT\nCoronary artery bypass graft (CABG) surgery is associated with a decline in cognitive function, which has largely been attributed to the use of cardiopulmonary bypass (on-pump procedures). Cardiac stabilizers facilitate CABG surgery without use of cardiopulmonary bypass (off-pump procedures) and should reduce the cognitive decline associated with on-pump procedures.\n\n\nOBJECTIVE\nTo compare the effect of CABG surgery with (on-pump) and without (off-pump) cardiopulmonary bypass on cognitive outcome.\n\n\nDESIGN AND SETTING\nRandomized controlled trial conducted in the Netherlands of CABG surgery patients enrolled from March 1998 through August 2000, with 3- and 12-month follow-up.\n\n\nPARTICIPANTS AND INTERVENTION\nPatients scheduled for their first CABG surgery (mean age, 61 years; n = 281) were randomly assigned to off-pump surgery (n = 142) or on-pump surgery (n = 139).\n\n\nMAIN OUTCOME MEASURES\nCognitive outcome at 3 and 12 months, which was determined by psychologists (blinded for randomization) who administered 10 neuropsychological tests before and after surgery. Quality of life, stroke rate, and all-cause mortality at 3 and 12 months were secondary outcome measures.\n\n\nRESULTS\nCognitive outcome could be determined at 3 months in 248 patients. Cognitive decline occurred in 21% in the off-pump group and 29% in the on-pump group (relative risk [RR], 0.65; 95% confidence interval [CI], 0.36-1.16; P =.15). The overall standardized change score (ie, improvement of cognitive performance) was 0.19 in the off-pump vs 0.13 in the on-pump group (P =.03). At 12 months, cognitive decline occurred in 30.8% in the off-pump group and 33.6% in the on-pump group (RR, 0.88; 95% CI, 0.52-1.49; P =.69). The overall standardized change score was 0.19 in the off-pump vs 0.12 in the on-pump group (P =.09). No statistically significant differences were observed between the on-pump and off-pump groups in quality of life, stroke rate, or all-cause mortality at 3 and 12 months.\n\n\nCONCLUSION\nPatients who received their first CABG surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months.

Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: A randomized trial☆

Background Coronary artery bypass grafting (CABG) is known to improve heart function and quality of life, while rates of surgery-related mortality are low. However, delirium and cognitive decline are common complications. We sought to identify preoperative, intraoperative, and postoperative risk or protective factors associated with delirium and cognitive decline (across time) in patients undergoing CABG. Methods and Results We conducted a systematic search of Medline, PsycINFO, EMBASE, and Cochrane (March 26, 2019) for peer-reviewed, English publications reporting post-CABG delirium or cognitive decline data, for at least one risk factor. Random-effects meta-analyses estimated pooled odds ratio for categorical data and mean difference or standardized mean difference for continuous data. Ninety-seven studies, comprising data from 60 479 patients who underwent CABG, were included. Moderate to large and statistically significant risk factors for delirium were as follows: (1) preoperative cognitive impairment, depression, stroke history, and higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) score, (2) intraoperative increase in intubation time, and (3) postoperative presence of arrythmia and increased days in the intensive care unit; higher preoperative cognitive performance was protective for delirium. Moderate to large and statistically significant risk factors for acute cognitive decline were as follows: (1) preoperative depression and older age, (2) intraoperative increase in intubation time, and (3) postoperative presence of delirium and increased days in the intensive care unit. Presence of depression preoperatively was a moderate risk factor for midterm (1-6 months) post-CABG cognitive decline. Conclusions This meta-analysis identified several key risk factors for delirium and cognitive decline following CABG, most of which are nonmodifiable. Future research should target preoperative risk factors, such as depression or cognitive impairment, which are potentially modifiable. Registration URL: https://www.crd.york.ac.uk/prosp​ero/; Unique identifier: CRD42020149276.

/pdf/risk-factors-for-delirium-and-cognitive-decline-following-340ms5wfv2.pdf

Risk Factors for Delirium and Cognitive Decline Following Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta‐Analysis

Approximately a quarter of a billion people undergo surgery every year hoping that the operation will alleviate symptoms, cure diseases, and improve quality-of-life. A concern has arisen that, despite the benefits of surgery, elderly patients might suffer neurological injury from surgery and general anaesthesia leading to persistent cognitive decline. However, many studies of postoperative cognition have had methodological weaknesses, including lack of suitable control groups, dissociation of cognitive outcomes from surgical outcomes, sub-optimal statistical techniques, and absence of longitudinal preoperative cognitive assessments. Emerging evidence suggests that after early cognitive decline, most patients return to their preoperative cognitive trajectories within 3 months of surgery; some even experience subsequent cognitive improvement. In this review, we summarize the scientific literature on perioperative cognition. We propose that the most important determinants of the postoperative cognitive trajectory are the preoperative cognitive trajectory, the success of the surgery, and events in the perioperative period. Postoperative complications, ongoing inflammation, and chronic pain are probably modifiable risk factors for persistent postoperative cognitive decline. When surgery is successful with minimal perioperative physiological perturbations, elderly patients can expect cognition to follow its preoperative course. Furthermore, when surgery alleviates symptoms and enhances quality-of-life, postoperative cognitive improvement is a possible and desirable outcome.

Perioperative cognitive trajectory in adults

The growing number of publications concerning postoperative cognitive decline (POCD) after cardiac surgery is indicative of the health-related and economic-related importance of this intriguing issue. Significantly, the reported POCD incidence over the years has remained steady due to various unresolved challenges regarding the examination of this multidisciplinary topic. In particular, a universally accepted POCD definition has not been established, and the pathogenesis is still vaguely understood. However, numerous recent studies have focused on the role of the inflammatory response to a surgical procedure in POCD occurrence. Therefore, this traditional narrative review summarizes and evaluates the latest findings, with special attention paid to the difficulties of defining POCD as well as the involvement of inflammation in POCD development. We searched the MEDLINE, Scopus, PsycINFO and CENTRAL databases for the best evidence, which was classified according to the Oxford Centre for Evidence-based Medicine. To our knowledge, this is the first narrative review that identified class-1 evidence (systematic review of randomized trials), although most evidence is still at class-2 or below. Furthermore, we revealed that defining POCD is a very controversial matter and that the inflammatory response plays an important role in the mutually overlapping processes included in POCD development. Thus, developing the definition of POCD represents an absolute priority in POCD investigations, and the inflammatory response to cardiac surgery merits further research.

/pdf/postoperative-cognitive-decline-after-cardiac-surgery-a-14bq9qx1on.pdf

Postoperative Cognitive Decline After Cardiac Surgery: A Narrative Review of Current Knowledge in 2019.

Cognitive Outcome After On- and Off-Pump Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis☆☆☆★

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Cognitive Outcome After On- and Off-Pump Coronary Artery Bypass Grafting Surgery: A Systematic Review and Meta-Analysis☆☆☆★