Atrial fibrillation is associated with impaired cerebral perfusion and cognitive decline, especially in heart failure patients, though evidence certainty is low.
Does atrial fibrillation impair cerebral perfusion and cognitive function compared to sinus rhythm?
Current evidence suggests atrial fibrillation may impair cerebral perfusion and contribute to cognitive decline, though conclusions are limited by methodological heterogeneity and high risk of bias.
Created in BioRender. BORCH, P. (2026) https://BioRender.com/yvbfpip . Abbreviations: AF, atrial fibrillation; HF, heart failure; SR, sinus rhythm; GRADE, Grades of Recommendation, Assessment, Development, and Evaluation. • AF may impair cerebral perfusion and contribute to cognitive decline. • Most studies found reduced brain perfusion in AF compared with sinus rhythm. • AF was associated with impaired cognitive performance in multiple studies. • Limited evidence suggests greater perfusion decline in AF with heart failure. Atrial fibrillation (AF) has been associated with cognitive impairment. Impaired cerebral perfusion is a proposed mechanism, though evidence remains inconclusive, particularly in patients with concomitant heart failure (HF). We conducted a systematic review in accordance with PRISMA 2020 guidelines. PubMed and EMBASE were searched from database inception to May 9, 2025 for adult studies comparing cerebral perfusion in AF and sinus rhythm (SR). Risk of bias was assessed using ROBINS-E and ROBINS-I; certainty of evidence was graded using GRADE. Twenty-three studies were included (11 interventional, 1 observational, 11 cross-sectional). Measurement methods and effect sizes were heterogeneous. Most studies had serious/critical risk of bias, and certainty of evidence was low. Twenty-two studies concluded that AF may impair cerebral perfusion, while one found no such effect. Nine studies reported cognitive testing, and five demonstrated impaired performance in AF or improvement following SR restoration. In HF subgroup analyses (2 studies), perfusion was lower in HF patients with AF than those in SR. A third study found higher pulsatile index in HF patients with AF than those without HF, but no difference in peak, mean or diastolic cerebral blood flow velocities. Current clinical evidence suggests that AF may impair cerebral perfusion and contribute to cognitive decline. However, methodological limitations and heterogeneity limit the conclusions, and further longitudinal studies with standardized perfusion metrics are needed, including in concomitant HF where data are scarce.
Borch et al. (2026) studied this question. Atrial fibrillation is associated with impaired cerebral perfusion and cognitive decline, especially in heart failure patients, though evidence certainty is low.