Baseline cognitive functioning in LVAD patients and anticoagulation time in range
Bryce K, Peterson E, Cowger J, Liu B, Chamogeorgakis T, Lanfear DE. Baseline cognitive functioning in LVAD patients and anticoagulation time in range. J Am Coll Cardiol. 2018;71(11)
J Am Coll Cardiol
Background: Left ventricular assist devices (LVAD) are accepted therapy for end stage heart failure, but optimal patient selection remains challenging. Our group and others have shown that baseline cognitive impairment is associated with worse outcomes post LVAD, particularly an increased risk of hospitalization. The mechanism(s) underlying this association is unknown, but it has been suggested that cognitive impairment is associated with poor medical adherence post-LVAD. The purpose of this study was to explore the impact of cognitive impairment on adherence, specifically anticoagulation time in range. Methods: A retrospective review was conducted on 100 consecutive patients who received continuous fow LVADS over a three year period (2011 and 2014) who were administered The Montreal Cognitive Assessment (MoCA) at the time of their pre-surgical psychological evaluation. Those who did not survive to discharge were excluded. Demographic information, MoCA scores and all International Normalized Ratio (INR) values between 1 month and 1 year post-implantation were collected. The primary endpoint of interest was time in therapeutic INR range (2-3). We tested the association of MoCA score (dichotomized at the median) with time in range. Results: The average age was 55.6 (± 12.29), 22 patients were female, 42 were non-white race and 69 were destination therapy. Median MoCA was 24 (IQR 22-26). MoCA did not differ by race, gender, or INTERMACS, but did differ by indication (22.8 vs. 24.2 for DT vs. BTT, p=0.049). Patients with MoCA scores below the median had a lower percentage of days within therapeutic INR range than those with higher scores (56% vs. 66%, p=0.045), representing approximately 15% less likelihood of being therapeutic. Conclusion: LVADpatients with lower baseline cognitive functioning are less likely to maintain therapeutic INR levels. This suggests that adherence to medical regimen is a key mediator of the association between poor cognitive status and worse clinical outcomes after LVAD. Interventions to improve attention and adherence in these high-risk patients are needed.