Cognitive screening for cardiovascular risk stratification in stable coronary artery disease: a prospective cohort study

Background While cognitive impairment is prevalent in patients with stable coronary artery disease (CAD), its prognostic significance in stable CAD patients remains unclear. Purpose To investigate the impact of baseline cognitive impairment on the risk of major adverse cardiovascular events (MACE) and unplanned revascularisation in a large cohort of patients with stable CAD. Methods In this prospective cohort study of 6,130 stable CAD patients, baseline cognitive function was assessed using the Montreal Cognitive Assessment (MoCA). The primary outcome was MACE, comprising all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Unplanned revascularisation was specified as a secondary outcome. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess the prognostic impact of cognitive impairment. The robustness of the findings was tested via subgroup analyses, propensity score matching, and sensitivity analyses. Results During a median follow-up of 546 days, MACE occurred in 123 (2.0%) and unplanned revascularisation in 315 (5.1%) of the included patients (mean age 61.2 years, 75.8% male). Cognitive impairment (MoCA score < 24) was highly prevalent among older adults (44.8%), females (50.6%), and patients with lower educational attainment or a high cardiometabolic burden. Patients with cognitive impairment exhibited a significantly higher cumulative incidence of MACE (Log-rank P=0.001), all-cause mortality (P=0.020), and the composite of nonfatal myocardial infarction and stroke (P=0.021), whereas no difference was observed for unplanned revascularisation (P=0.791). In fully adjusted multivariable Cox regression models, baseline cognitive impairment remained a strong independent predictor of MACE (hazard ratio [HR]: 1.58; 95% confidence interval [CI]: 1.06–2.37; P=0.026). The stability of these findings was confirmed across three sensitivity analysis strategies: using PSM to adjust for confounders, applying standard educational adjustments to MoCA scores, and excluding patients with baseline stroke. Subgroup analyses demonstrated consistent risks across most clinical strata, except in patients with low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L, where the adverse prognostic impact of cognitive impairment was attenuated (HR: 0.99; 95% CI: 0.45–2.17; P=0.973).Subgroup analyses demonstrated consistent risks across most clinical strata, except in patients with low-density lipoprotein cholesterol (LDL-C) < 1.8 mmol/L, where the adverse prognostic impact of cognitive impairment was attenuated (HR: 0.99; 95% CI: 0.45–2.17; P=0.973). Conclusion Baseline cognitive impairment is a robust and independent predictor of MACE in patients with stable CAD.Figure 1Figure 2