Howard A. Fink, MD, MPH; Laura S. Hemmy, PhD; Roderick MacDonald, MS; Maureen H. Carlyle, MPH; Carin M. Olson, MD, MS; Maurice W. Dysken, MD; J. Riley McCarten, MD; Robert L. Kane, MD; Santiago A. Garcia, MD; Indulis R. Rutks, BS; Jeannine Ouellette; Timothy J. Wilt, MD, MPH
Disclaimer: The topic of this review was nominated to AHRQ by the Coverage and Analysis Group at the CMS. This article is based on research conducted by the Minnesota Evidence-based Practice Center under contract to AHRQ, U.S. Department of Health and Human Services. The authors of this article are responsible for its content. Statements in the article should not be construed as endorsement by AHRQ, the CMS, or the U.S. Department of Health and Human Services.
Grant Support: By AHRQ, U.S. Department of Health and Human Services (contract 290-2007-100641).
Disclosures: Dr. Fink reports grants from AHRQ during the conduct of the study. Dr. Hemmy reports grants from AHRQ during the conduct of the study. Dr. Olson reports grants from AHRQ during the conduct of the study. Dr. Garcia reports grants from AHRQ during the conduct of the study and grants from Veterans Affairs Office of Research and Development outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2793.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Howard A. Fink, MD, MPH, Geriatric Research Education & Clinical Center, Veterans Affairs Health Care System (11-G), One Veterans Drive, Minneapolis, MN 55417; e-mail, Howard.email@example.com.
Current Author Addresses: Drs. Fink, Hemmy, Dysken, and McCarten: Geriatric Research Education & Clinical Center, Veterans Affairs Health Care System (11-G), One Veterans Drive, Minneapolis, MN 55417.
Mr. MacDonald and Dr. Wilt: Center for Chronic Disease Outcomes Research (111-0), Veterans Affairs Health Center, One Veterans Drive, Minneapolis, MN 55417.
Ms. Carlyle: Optum Health, 12125 Technology Drive, Eden Prairie, MN 55344.
Dr. Olson: Veterans Affairs Health Care System, Building 9, Room 211, One Veterans Drive, Minneapolis, MN 55417.
Dr. Kane and Ms. Ouellette: University of Minnesota School of Public Health, 420 Delaware Street SE, Mayo D351, MMC 197, Minneapolis, MN 55455.
Dr. Garcia: Division of Cardiology, Veterans Affairs Health Care System, One Veterans Drive (111-C), Minneapolis, MN 55417.
Mr. Rutks: Center for Chronic Disease Outcomes Research (152), Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN 55417.
Author Contributions: Conception and design: H.A. Fink, L.S. Hemmy, R.L. Kane, S.A. Garcia, J. Ouellette.
Analysis and interpretation of the data: H.A. Fink, L.S. Hemmy, R. MacDonald, M.W. Dysken, J.R. McCarten, R.L. Kane, S.A. Garcia, T.J. Wilt.
Drafting of the article: L.S. Hemmy, J. Ouellette.
Critical revision of the article for important intellectual content: H.A. Fink, L.S. Hemmy, R. MacDonald, C.M. Olson, M.W. Dysken, J.R. McCarten, R.L. Kane, S.A. Garcia, T.J. Wilt.
Final approval of the article: H.A. Fink, L.S. Hemmy, C.M. Olson, M.W. Dysken, J.R. McCarten, R.L. Kane, S.A. Garcia, I.R. Rutks, T.J. Wilt.
Provision of study materials or patients: R. MacDonald, I.R. Rutks.
Statistical expertise: R. MacDonald, T.J. Wilt.
Obtaining of funding: H.A. Fink, L.S. Hemmy, R.L. Kane, T.J. Wilt.
Administrative, technical, or logistic support: H.A. Fink, R. MacDonald, M.H. Carlyle, R.L. Kane, I.R. Rutks, T.J. Wilt.
Collection and assembly of data: L.S. Hemmy, R. MacDonald, M.H. Carlyle, C.M. Olson, I.R. Rutks.
Risks for intermediate- and long-term cognitive impairment after cardiovascular procedures in older adults are poorly understood.
To summarize evidence about cognitive outcomes in adults aged 65 years or older at least 3 months after coronary or carotid revascularization, cardiac valve procedures, or ablation for atrial fibrillation.
MEDLINE, Cochrane, and Scopus databases from 1990 to January 2015; ClinicalTrials.gov; and bibliographies of reviews and eligible studies.
English-language trials and prospective cohort studies.
One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and strength of evidence (SOE).
17 trials and 4 cohort studies were included; 80% of patients were men, and mean age was 68 years. Cognitive function did not differ after the procedure between on- and off-pump coronary artery bypass grafting (CABG) (n = 6; low SOE), hypothermic and normothermic CABG (n = 3; moderate to low SOE), or CABG and medical management (n = 1; insufficient SOE). One trial reported lower risk for incident cognitive impairment with minimal versus conventional extracorporeal CABG (risk ratio, 0.34 [95% CI, 0.16 to 0.73]; low SOE). Two trials found no difference between surgical carotid revascularization and carotid stenting or angioplasty (low and insufficient SOE, respectively). One cohort study reported increased cognitive decline after transcatheter versus surgical aortic valve replacement but had large selection and outcome measurement biases (insufficient SOE).
Mostly low to insufficient SOE; no pertinent data for ablation; limited generalizability to the most elderly patients, women, and persons with substantial baseline cognitive impairment; and possible selective reporting and publication bias.
Intermediate- and long-term cognitive impairment in older adults attributable to the studied cardiovascular procedures may be uncommon. Nevertheless, clinicians counseling patients before these procedures should discuss the uncertainty in their risk for adverse cognitive outcomes.
Agency for Healthcare Research and Quality.
Appendix Table 1. Risk of Bias in RCTs
Appendix Table 2. Risk of Bias in Prospective Cohort Studies
Appendix Table 3. Strength of Evidence
Appendix Table 3.—Continued
Summary of evidence search and selection.
* Some references were identified in several databases. Sixty-five additional references were identified by hand searching; 61 of them were excluded at the title and abstract review stage, and 4 were excluded after full-text review. Ninety studies were identified from ClinicalTrials.gov. Among studies not already included in the review, 2 seemed possibly eligible: 1 (NCT02108093) that was still enrolling patients and the other (NCT01743456) that is listed as completed but for which no results appear reported.
† Included 21 unique studies.
Appendix Table 4. Individual Study Definitions of Incident Cognitive Impairment Based on Combining Results of Individual Neuropsychological Tests
Table 1. Coronary Artery Revascularization: Comparison of Intermediate- and Long-Term Postprocedure Cognitive Outcomes Between Treatment Groups
Table 2. Carotid Artery Revascularization: Comparison of Intermediate- and Long-Term Postprocedure Cognitive Outcomes Between Treatment Groups
Table 3. Cardiac Valve Replacement or Repair: Comparison of Intermediate- and Long-Term Postprocedure Cognitive Outcomes Between Treatment Groups
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Howard A. Fink, Laura S. Hemmy, Roderick MacDonald, Maureen H. Carlyle, Carin M. Olson, Maurice W. Dysken, et al. Intermediate- and Long-Term Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review. Ann Intern Med. 2015;163:107–117. doi: 10.7326/M14-2793
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Published: Ann Intern Med. 2015;163(2):107-117.
Cardiology, Coronary Heart Disease, Geriatric Medicine.
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