• acute coronary syndromes

The link between cognitive impairment and cardiovascular diseases has been firmly established by a number of studies. However, there is a worrying shortage of studies exploring the role of cognitive impairment in affecting patients’ survival in the specific setting of the early phase of an acute coronary syndrome (ACS).

In their Heart paper, Briet et al 1 start to shed some light on this area. In a prospective study on 600 older patients consecutively admitted with ACS to a tertiary centre, the authors found that 29% had cognitive impairment already present on admission, of whom 153 (25.5%) had abnormal scores at the Mini-Mental State Examination (MMSE) and 19 (3.2%) had delirium, as assessed with the Confusion Assessment Method (CAM). Death rate at three different time points (ie, in-hospital, 3 months and 1 year) was much higher in those with cognitive impairment and there was a significant association with both 3-month and 1-year all-cause mortality (adjusted hazards ratio, 2.4, 95% CI 1.53 to 3.62, p<0.001), independent of other covariables. The association between cognitive impairment and in-hospital death was significant at the univariate (HR 2.93, 95% CI 1.04 to 8.22) but not at the multivariate analysis (HR 3.4, 95% CI 0.9 to 12.5), likely as the result of a low proportion of patients who actually died during hospitalisation. Cognitive impairment was also independently associated with higher rates of in-hospital bleeding as well as cardiovascular-related and heart failure-related rehospitalisation.

One interpretation for the increased risk of poor outcome in patients with cognitive impairment may be that it represents a marker of frailty in older patients, that is, of an increased susceptibility to develop complications and other negative outcomes after a critical event. There are studies supporting the notion that delirium and dementia are strongly related to frailty and that this association can lead to various negative outcomes.2 3 However, other …