Cognitive impairment and 1-year outcomes in patients hospitalized for acute heart failure: insights from the OFICA2 cohort

Introduction

Cognitive impairment is frequent in elderly patients with heart failure (HF) and is consistently associated with adverse outcomes. However, standard cognitive assessments are often time-consuming or poorly suited to acute hospitalization. The Cognitive Disorders Examination (CODEX) is a simple, rapid, and validated bedside tool that classifies patients into four categories (A–D), enabling pragmatic risk stratification.

Purpose

We aimed to investigate the association between CODEX-defined cognitive impairment and 1-year prognosis in patients hospitalized for acute heart failure (AHF) in the OFICA2 cohort. Secondary objectives were to identify factors independently associated with cognitive impairment and to assess adherence to HF treatment using linkage with the French National Health Data System.

Methods

This analysis was based on the nationwide prospective OFICA2 cohort conducted in France across 80 centers (March–April 2021). Among 1251 patients hospitalized for AHF who underwent CODEX assessment after clinical stabilization, cognitive impairment was defined as an abnormal CODEX result (categories C or D). Factors associated with cognitive impairment were assessed using multivariable logistic regression. Treatment adherence was evaluated using the proportion of days covered (PDC), and defined as PDC ≥80%. The primary outcome was 1-year all-cause mortality, evaluated using Cox proportional hazards models.

Results

Of the 1251 patients included (mean age 75.8 years, 39.1% women), 524 (36.6%) had cognitive impairment. These patients were older, more frequently women, less often in sinus rhythm, and had a higher prevalence of prior stroke or depression (all p<0.05). They also reported lower educational levels and lower use of smartphones or the internet (all p<0.001). On multivariable analysis, increasing age was independently associated with cognitive impairment (p<0.001).

At 1-year follow-up, 451 patients (31.5%) had died. Cognitive impairment was associated with a higher risk of 1-year all-cause mortality (CODEX C/D: 39.9% vs A/B: 25.6%, p<0.001), remaining significant after multivariable adjustment (HR 1.46, 95% CI 1.13–1.89, p=0.004). Patients with cognitive impairment had lower 1-year rates of consultation with a general practitioner or cardiologist (16.2% vs 25.4%, p<0.001). Among patients with HF-rEF (n=449), those with cognitive impairment were less likely to receive guideline-directed medical therapy at discharge, while 1-year adherence to HF treatment was similar between groups.

Conclusion

Cognitive impairment detected by an abnormal CODEX result in patients hospitalized for AHF was independently associated with higher 1-year all-cause mortality. Optimization of HF therapy appears warranted in these patients, especially as treatment adherence was not lower. Early identification of cognitive impairment during hospitalization may support tailored discharge planning and follow-up.1-year survival according to cognitive statusFactors associated with 1-year mortality