European Heart Rhythm Association (EHRA)/Heart Rhythm Society (HRS)/Asia Pacific Heart Rhythm Society (APHRS)/Latin American Heart Rhythm Society (LAHRS) expert consensus on arrhythmias and cognitive function: What is the best practice?

Abstract

Keywords: European Heart Rhythm Association, Heart Rhythm Society, Asia Pacific Heart Rhythm Society, Latin American Heart Rhythm Society, Cognitive, Arrythmias, Dementia Table of Contents Introduction 1400 Evidence review 1400 Relationships with industry and other conflicts 1400a Decline of cognitive function: terminology and epidemiology 1400a Terminology: cognitive decline, mild cognitive impairment, and dementia 1400a Epidemiology of dementia 1400a Methods for assessment of cognitive function 1400b Role of imaging 1400c Atrial fibrillation and cognitive function 1400c Atrial fibrillation, overt stroke, and cognitive function 1400c Atrial fibrillation, silent stroke, and cognitive function 1400e Atrial fibrillation and cognitive function in the absence of stroke 1400g Assessment of cognitive function in atrial fibrillation patients in clinical practice 1400g Prevention of cognitive dysfunction in atrial fibrillation patients 1400h Other arrhythmias and cognitive dysfunction 1400j Cognitive dysfunction in patients with regular supraventricular tachycardias 1400j Cognitive impairment after cardiac arrest 1400j Cardiac implantable electronic devices and cognitive dysfunction 1400k Catheter ablation 1400k Implications for electrophysiological procedures and cognitive function 1400l Current knowledge gaps, future directions, and areas for research 1400m Recommendations 1400m Introduction This expert consensus statement of the European Heart Rhythm Association (EHRA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), and the Latin American Heart Rhythm Society (LAHRS) summarizes the consensus of the international writing group and is based on a thorough review of the medical literature regarding cognitive function in arrhythmias. The document is intended to describe the impact of different types of arrhythmias on cognitive function, to highlight possible risk markers for cognitive decline and to formulate implications for clinical practice regarding follow-up methods, prevention and treatment strategies. Our objective is to raise awareness of cognitive function among physicians treating patients with arrhythmias and to provide them with practical proposals that may lead to improvement of patient care in this regard. This document reviews terminology and the epidemiology of cognitive dysfunction, methods for assessment of cognitive function and the role of imaging. Recent studies have suggested possible associations between cognitive decline and atrial fibrillation (AF). We review the reported literature on AF and cognitive function, including the scenarios of AF with overt stroke, silent stroke, or no stroke, and then make recommendations for assessment of cognitive function and prevention of cognitive decline in patients with AF in clinical practice. The document also reviews the association of other arrhythmias and cognitive dysfunction, including settings such as post-cardiac arrest, cardiac implantable devices, such as implantable cardioverter-defibrillators (ICDs) and pacemakers, or ablation procedures. Implications for electrophysiological procedures and cognitive function are discussed. Long QT syndrome and cognitive function is not addressed in the document. For quick reference, sub-chapters are followed by a short section on consensus recommendations. The document concludes with a summary of consensus statements, current knowledge gaps, and future directions of research. Evidence review Members of the Task Force were asked to perform a detailed literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes for which data exist. Patient-specific modifiers, co-morbidities, and issues of patient preference that might influence the choice of particular tests or therapies are considered, as are frequency of follow-up and cost-effectiveness. In controversial areas, or with regard to issues without evidence other than usual clinical practice, a consensus was achieved by agreement of the expert panel after thorough deliberations. This document was prepared by the Task Force with representation from EHRA, HRS, APHRS, and LAHRS. The document was peer-reviewed by official external reviewers representing EHRA, HRS, APHRS, and LAHRS. Consensus statements are evidence-based and derived primarily from published data or determined through consensus opinion if data are not available. Current systems of ranking level of evidence are becoming complicated in a way that their practical utility might be compromised.1 In contrast to guidelines, we opted for an easier and user-friendly system of ranking using ‘coloured hearts’ that should allow physicians to easily assess the current status of the evidence and consequent guidance (Table ​Table11). This EHRA grading of consensus statements does not have separate definitions of the level of evidence. This categorization, used for consensus statements, must not be considered as directly similar to that used for official society guideline recommendations, which apply a classification (Class I–III) and level of evidence (A, B, and C) to recommendations used in official guidelines. Table 1 Scientific rationale of recommendations*