Ischemic Heart Disease and Cognitive Prognosis in the First Year after Stroke

ImportanceCognitive impairment is the greatest single source of unmet need identified by stroke survivors. Knowledge of the factors that influence cognitive prognosis will lead to better preventive and rehabilitation strategies. ObjectiveTo identify the factors that influence general cognitive function, memory and executive function in the first year after ischemic stroke. DesignSingle centre longitudinal observational study. SettingHospital stroke service. ParticipantsA cohort of 179 patients identified within 7 days of first symptomatic ischaemic stroke were enrolled into a longitudinal cognitive study, STRATEGIC. General cognitive function, episodic memory and executive function were assessed in the first three months and again at one year after stroke. Lesion topography was defined by imaging (n=152) performed in the acute period. Cognitive evaluation was repeated at one year in 141 participants. Main Outcome MeasuresMontreal Cognitive Assessment (MoCA) score at 1 year. Verbal free recall (Free and Cued Selective Reminding Test) and Digit Symbol Substitution Score provided secondary outcome measures of episodic memory and executive function respectively. ResultsAt 50{+/-}19 days after stroke, diabetes mellitus and smoking were associated with MoCA score independent of other risk and demographic factors. Lesion vascular territory was independently associated with memory while white matter lesion burden was associated with executive function. In contrast to other risk factors, ischaemic heart disease was associated with change in cognitive scores and MoCA score at one year but not MoCA score at 3 months. IHD was the only factor significantly associated with change over time. This association was significant independent of other factors. Conclusions and RelevanceAssociations between post-stroke cognition - and age, diabetes, smoking and white matter lesions - are likely to reflect the general effects of these factors on brain structure and function. These risk factors are not associated with change in cognitive function between 3 months and one year. In contrast, pre-existing ischemic heart disease was associated specifically with change in cognition over time. On average, patients with IHD showed decline in MoCA scores between 3 and 12 months while those free of IHD showed improvement. Intervention for IHD, alongside best-care stroke rehabilitation, merits investigation as a strategy to improve cognitive prognosis after stroke. Key PointsO_ST_ABSQuestionC_ST_ABSWhat factors predict cognitive prognosis after stroke? FindingsIn this hospital-based cohort, diabetes mellitus and smoking were associated with Montreal Cognitive Assessment scores at both 3 months and 1 year after first symptomatic ischemic stroke. Ischemic heart disease (IHD), in contrast to other factors, was associated with change in cognitive scores. Participants with a history of IHD showed worsening cognition on average; those free of IHD improved. MeaningMultiple factors contribute to cognitive function after stroke. IHD is associated with change between 3 and 12 months. The nexus between heart and brain in neurologic recovery requires further exploration.