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Cognitive impairment during cardiac rehabilitation: although to a lesser extent, outcome affected

comment by Marco Ambrosetti, EAPC Secondary Prevention and Rehabilitation Section

Cardiovascular Rehabilitation

Besides strong association to cardiovascular diseases, cognitive impairment is an emerging determinant of the efficacy of Cardiac Rehabilitation (CR) programmes also. However, there is still controversial about what CR component is mostly affected by this condition, as far as long-term effects.

In the present study (1), 401 patients (54.5±6.3 years, 80% men) referred to CR after an acute coronary syndrome and/or coronary surgery (CABG), were tested using the Montreal Cognitive Assessment (MoCA) tool by trained study nurses, and grouped according to the presence of mild cognitive impairment (MCI) or not. Patients’ disease-related knowledge, focused on medical knowledge and healthy lifestyle/behaviour, was then evaluated at a 6-month follow-up.

Globally, 36% of the examined patients were affected by MCI. During CR, disease-related knowledge was significantly increased in both groups, even though MCI patients displayed lower attendance rates to educational sessions. At follow-up, the average level of medical knowledge was significantly reduced, especially in CABG patients, while lifestyle knowledge remained at a stable level. The maintenance of knowledge after CR was predominantly predicted by prior knowledge cognitive performance.

The study is relevant first of all because it provides a reliable estimate of the prevalence of cognitive impairment – particularly of MCI, which is less easily detectable than manifest dementia – in the setting of CR. Considering that up to one third of patients referred to CR may display MCI, this could lead to appropriate routine screening and pathways of care for positive subjects. According to the study by Salzwedel et al (1), the adoption of the MoCA tool could represent a feasible solution, particularly in those contexts were a structured psychological intervention could not be delivered during the CR programme, or a psychologist is not included within the CR staff.

Second, because it highlights that patients’ education is not an indivisible package, and fortunately, CR really works better on lifestyle and behavioural aspects, just those recognized as major determinants of cardiovascular prognosis. On the other hand, the CR community has to be cautioned against the risk of mitigation given by cognitive impairment on the educational process during the rehabilitation programme, to be considered like a “drug resistance phenomenon” or, at the very least, as a potential cause of non-adherence.

Third, the role of cognitive impairment –even though at a lesser extent – after the end of the CR intervention, which should now be closely considered and monitored during structured follow-up programmes, interventional trials, and observational studies.

Of course, further research is needed, both in appreciating the role of cognitive impairment in different target groups for CR (i.e. chronic heart failure patients) and different CR phases (i.e. during long-term phase III interventions). The influence of cognitive impairment on other major core components of CR (i.e. physical training or dietary intervention) should also be evaluated in a omni-comprehensive perspective, in order to produce evidence-based guidelines to all CR health operators.


Note: The content of this article reflects the personal opinion of the author and is not necessarily the official position of the European Society of Cardiology. 


Marco Ambrosetti commented on this article:

  1. Salzwedel A, et al. Impact of cognitive performance on disease-related knowledge six months after multi-component rehabilitation in patients after an acute cardiac event. Eur J Prev Cardiol 2019, Vol. 26(1) 46–55.