Special ArticleRelationship between Cognitive Impairment and Echocardiographic Parameters: A Review
Section snippets
Clinical Determinants of Cognitive Impairment
The main clinical factors associated with cognitive impairment are advanced age, hypertension, diabetes mellitus, high plasma cholesterol levels, obesity, tobacco smoking, and the presence of atherosclerotic vascular disease.9, 10, 11, 12, 13, 14 In addition to these risk factors, hyperhomocysteinemia, diets comprising high levels of saturated fats, excessive alcohol consumption, and physical inactivity increase the risk for developing Alzheimer's disease.15 These risk factors are also
Cognitive Impairment Risk Evaluation Models
It is now accepted that a preclinical phase exists in dementia, hence the early identification of patients at risk for developing the disease is likely to be a key step.2 In 2006, Kivipelto et al.26 proposed a cognitive impairment risk evaluation model, the Cardiovascular Risk Factors, Aging and Dementia risk score, to predict the 20-year risk for dementia in middle-aged people. This model stratifies patients by age, sex, education, hypertension, body weight, physical activity, hyperlipidemia,
Conventional Echocardiographic Parameters of the Left Ventricle and Cognitive Impairment
The presence of a heart disease may alter left ventricular (LV) function, leading to a reduction in cerebrovascular blood flow causing subclinical brain injury and cognitive impairment.42, 43, 44, 45 It was described previously that patients with severe chronic heart failure may have reduced cerebral blood flow, by approximately 30%, despite the activation of physiologic neurohormonal counterregulatory mechanisms such as the renin-angiotensin system and the sympathetic nervous system.46
Left Atrial Enlargement Parameters and Cognitive Impairment
Left atrial (LA) function can be considered as a three-component model.66 The first component occurs during LV systole and is called the reservoir phase, in which the left atrium receives blood from the pulmonary veins. The second component is called the passive conduit phase, occurring during LV early diastole and diastasis. The LA contraction phase is the third component, in which the left atrium acts as a contractile pump during late diastole LV filling, contributing to the increase in LV
Cardiac Output and Cognitive Impairment
The exact mechanism governing the link between cognitive impairment and reduced CO remains unknown.43, 67, 81 It has previously been reported that counterregulatory mechanisms contribute to the increase of cerebral blood flow during acute periods of reduced CO.82 However, chronic CO reduction may decrease cerebral blood flow, overwhelming autoregulatory phenomena and leading to brain injury, particularly in elderly individuals with hypertension, in whom a shift of the cerebral autoregulation
Left Ventricular Mass and Cognitive Impairment
The main hypothesis linking cognitive impairment to increased LV mass is the fact that LV mass may be a reflection of chronic exposure to high blood pressure, a recognized risk factor for dementia.91, 92 Table 4 details the main studies that investigated the link between LV mass and cognitive impairment. Scuteri et al.92 found that an increased LV mass index was associated with cognitive impairment and a higher probability of developing dementia independently of blood pressure in a population
Aortic Root Diameter and Cognitive Impairment
Paul et al.51 found that an increased aortic root diameter was associated with both impaired cognitive function and cerebral abnormalities on brain MRI, including white matter lesions and whole-brain volume. The relationship between ischemic brain infarction and aortic arch morphology has been described previously.96, 97, 98, 99, 100 This link may be explained by the fact that dilation of the aorta has been associated with the presence of atherosclerotic plaques in the vessel, which are known
Epicardial Fat Thickness and Cognitive Impairment
Recently, a growing amount of interest has been focused on the link between the amount of visceral adiposity and cognition.102 The epicardial adipose tissue is a recognized index of visceral adiposity,103 a marker of cardiovascular risk,104 and has been associated with inflammation modulators that may play a role in coronary atherosclerosis and in vasculopathic effects mediated by systemic inflammation.105 Considering that chronic inflammation is associated with systemic vasculopathy and
Is There Enough Evidence to Integrate Echocardiography Into a Preventive Strategy?
In this review, we found strong evidence in favor of the existence of an association between echocardiographic parameters and cognitive impairment. One of the most interesting, but arduous, questions that subsequently arises focuses on the nature of the underlying mechanisms governing this relationship. Echocardiographic evidence such as LA enlargement, systolic and/or diastolic LV dysfunction, and increased LV mass may simply reflect an underlying cardiac condition that predisposes to
Conclusions
Dementia is an increasingly important public health challenge, and no curative treatment has thus far been identified. Focusing on the detection of preclinical signs announcing the onset of the disease is, however, highly important in view of the possibility that starting preventive measures early in the course of the disease may prove beneficial. The inclusion of echocardiography may further improve currently used risk assessment models by allowing the detection of subclinical cardiac
Acknowledgments
Sophie Rushton-Smith, PhD, provided editorial support for the final version of this review and was funded by the authors.
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Dr Tzourio has received fees from Fondation de Recherche sur l’Hypertension Artérielle for participating in a scientific committee. Dr Cohen has received a research grant from RESICARD (research nurses) and consulting and lecturing fees from AstraZeneca, Bayer Pharma, Boehringer Ingelheim, Daiichi-Sankyo, GlaxoSmithKline, and Sanofi. All other authors report no conflicts of interest.