Heart failure beyond the circulatory system
Cognitive and emotional changes in patients
For decades, the care of patients with heart failure has focused primarily on treating somatic symptoms, modifying pharmacotherapy, and optimizing hemodynamic parameters. However, contemporary research increasingly shows that heart failure is a disease whose consequences extend far beyond the cardiovascular system. It affects cognitive processes, emotions, and everyday behaviors that determine the effectiveness of self-care.
One of the latest and most comprehensive studies in this area is a prospective analysis conducted by an interdisciplinary team involving researchers from Wroclaw Medical University, Boston College, and centers in Italy, Spain, and the United Kingdom. The publication Analysis of changes in mental health, cognitive function and self-care behaviors in patients with heart failure, published in the journal of Wroclaw Medical University Advances in Clinical and Experimental Medicine, shows that within just six months, there are significant, systematic changes in the cognitive and emotional functioning of patients with HF, and the intensity of these changes clearly varies depending on the phenotype of the disease.
The co-author of the study, Maria Jędrzejczyk from the Department of Nursing at Wroclaw Medical University, emphasizes:
"In patients with HFpEF, we observe the most noticeable deterioration in cognitive function and worsening of depression symptoms within just six months. This phenotype cannot be considered ‘milder’. In daily practice, clinicians should regularly assess mental and cognitive status, even when cardiac parameters appear stable," she points out.
This observation is the starting point for redefining the way we think about heart failure as a disease that affects the ability to think, remember, organize one's life, and cope with emotions as much as it affects the heart.
The hidden dynamics of the disease
Heart failure often develops insidiously, and its cognitive and emotional consequences are sometimes interpreted as a normal part of aging. However, the study's results debunk this myth. Among the 162 patients observed for six months, there was a clear increase in mental and cognitive burden. And not only in the most clinically advanced phenotypes.
Patients with HFpEF (heart failure with preserved ejection fraction), although often considered clinically stable, showed the most dynamic deterioration in memory, executive function, and concentration. It may also be surprising that the severity of depression in this group increased faster than in patients with HFrEF (heart failure with reduced ejection fraction) or HFmrEF (heart failure with moderately reduced ejection fraction).
From the patients' perspective, this means a gradual weakening of one of the most important skills in managing the disease—self-care. From the system's perspective, it means an increased risk of hospitalization and costs, but above all, death.
Why does the heart affect thinking?
The authors of the study emphasize that cognitive decline in heart failure is not the result of a single process but rather a long-term, cumulative cascade of biological changes. A chronically ischemic brain works less efficiently, and the structures responsible for memory, attention, and planning become increasingly susceptible to overload. Added to this are metabolic stress, neurohormonal imbalances, and oxidative stress. Over time, all these factors cause subtle but progressive microdamage.
At the same time, depression, which is common in patients with heart failure, impairs executive functions and slows down information processing. A growing sense of fatigue, reduced motivation, pessimistic thinking, and difficulty concentrating create a vicious circle: the worse the mood, the more difficult it is to take care of oneself, and the more difficult it is to take care of oneself, the greater the risk of exacerbations of the disease and subsequent hospitalizations.
Maria Jędrzejczyk points out that in everyday practice, it is precisely these small, seemingly insignificant difficulties that can be the most dangerous:
“A patient with heart failure who starts to forget their medication doses or does not notice increasing shortness of breath is in real danger. And such signs often appear before clinical parameters deteriorate,” she emphasizes.
Maria Jędrzejczyk, MSc in Nursing, PhD candidate, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Poland.
Maria Jędrzejczyk, MSc in Nursing, PhD candidate, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Poland.
The patient's everyday life: changes in the course of the disease caused by cognitive impairment
In clinical practice, a patient who is unable to cope with everyday self-care tasks is considered high risk, regardless of test results.
A six-month observation showed that the ability to care for oneself and one's treatment deteriorated in patients with all types of heart failure, but correlated most strongly with memory impairment and increasing depression. As a result, patients were more likely to miss medication doses, respond later to symptoms of disease exacerbation, monitor their weight less frequently, and consult less often about concerning signs.
This is particularly dangerous because heart failure is a disease in which a quick response is often crucial. Early detection of edema or weight gain can prevent hospitalization. But only if the patient can register and interpret these signs.
The study also indicates that people who died between the first and second stages of observation had significantly lower cognitive test scores and higher levels of depression at the outset. This is a strong argument for treating cognitive and psychological conditions as full-fledged risk indicators in heart failure.
Prof Izabella Uchmanowicz, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Poland.
Prof Izabella Uchmanowicz, Department of Nursing, Faculty of Nursing and Midwifery, Wroclaw Medical University, Poland.
Podcast: Heart failure beyond the circulatory system
A new model of cardiac care
The research team emphasizes that patient care should move away from a model based primarily on physical symptom control and pharmacotherapy. The focus must be on cognitive processes, emotions, and the patient's ability to follow recommendations.
Systematic psychological and cognitive screening plays a particularly important role here, which, as Maria Jędrzejczyk argues, does not require sophisticated tools or a lot of time:
"A few minutes and a simple set of assessments are enough. The most important thing is to do it regularly. HF patients may lose cognitive function faster than their general well-being or hemodynamic parameters would indicate”, she points out.
The study also indicates that the most effective therapeutic strategies are those that simplify patients' lives. This is particularly important in heart failure with preserved ejection fraction, where deteriorating memory and concentration can be very subtle and yet extremely dangerous.
“Two areas have the greatest impact on patient safety: early detection and reporting of symptoms, and regular medication intake. For people with cognitive deficits, simple and repetitive solutions, short instructions, checklists, daily schedules, and reminders on their phones are most effective,” adds the young researcher.
A new understanding of heart failure
The results of the study paint a picture of heart failure as a condition that affects not only the organs but also the way people think, feel, and organize their daily lives. Patients face not only physical difficulties, but also increasing cognitive and emotional frailty.
This approach paves the way for more holistic, realistic, and effective care, in which drug treatment goes hand in hand with cognitive assessment, emotional support, and simple tools to enhance self-care.
One of the key messages of the study is that HFpEF requires special vigilance. It is in this group — paradoxically more stable in cardiological terms — that the most dynamic deterioration of brain function occurs.
At the same time, the entire population of patients with heart failure may experience a silent, insidious decline in the abilities that determine survival.
A. Hasiak
FAQ: Heart failure and cognitive and emotional changes in patients
Are cognitive impairments in heart failure inevitable?
No. Although many patients experience deterioration in memory, concentration, or executive function, the rate and severity of these changes vary greatly. Early diagnosis, treatment of depression, patient education, and simplification of therapeutic recommendations can significantly slow their development and limit their impact on daily functioning.
Why are patients with heart failure particularly vulnerable to cognitive decline?
Heart failure often progresses with apparent hemodynamic stability, which can lull clinical vigilance. At the same time, these patients are usually older and burdened with multiple comorbidities that exacerbate chronic cerebral ischemia, metabolic disorders, and inflammatory processes, promoting faster cognitive decline.
What symptoms should a doctor or caregiver pay attention to?
Alarming signs include frequent forgetfulness about medications, difficulty planning the day, confusion about recommendations, depressed mood, apathy, and lack of response to increasing somatic symptoms such as shortness of breath or edema. These are often the first signs of deteriorating self-care.
Is depression in heart failure a “natural reaction” to the disease?
It should not be treated as such. Depression is a common but clinically significant complication of HF that affects cognitive function, motivation, and adherence to recommendations. If left untreated, it increases the risk of hospitalization and death, and therefore requires active diagnosis and treatment.
How can cognitive function be assessed in a patient with heart failure in everyday practice?
Extensive neuropsychological testing is not necessary. Brief screening tools and regular assessment of mood and self-care abilities are sufficient. Consistency and observation of changes over time are key, rather than a single measurement.
Does cognitive decline affect prognosis?
Yes. The study shows that lower cognitive test scores and higher levels of depression were associated with a higher risk of death. Cognitive function and mental status should be considered important risk indicators, on par with cardiac parameters.
What interventions are most effective in patients with cognitive deficits?
Simple and repeatable solutions are most effective: simplified treatment regimens, short instructions, checklists, a fixed daily schedule, phone reminders, and involving loved ones in the care process. The goal is to reduce the patient's cognitive load.
What does this study mean for the future model of care for patients with heart failure?
It points to the need for a holistic approach, in which pharmacological treatment is complemented by regular assessment of cognitive function, mental health, and self-care abilities. Only such a model can realistically improve patient safety and treatment effectiveness.
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About the journal:
(Adv Clin Exp Med) is an international, peer-reviewed journal that highlights the full translational pathway of biomedical research – from laboratory discoveries (“bench”), through clinical application (“bedside”), to real-world practice and policy (“implementation”). It welcomes original research articles, reviews/meta-analyses, clinical recommendations/guidelines, research-in-progress reports, research letters, and study protocols authored by recognized experts in the fields of clinical and experimental medicine. The journal is indexed in several databases, including Scopus, PubMed and Index Copernicus, as well as (since 2007) in Thomson Reuters databases – Science Citation Index Expanded and Journal Citation Reports/Science Edition. It has its Journal Impact Factor (JIF) calculated since the 2009 release of the Journal Citation Reports™. The journal “Advances in Clinical and Experimental Medicine" is owned and published monthly by Wroclaw Medical University.
This material is based on the article:
Maria Jędrzejczyk, Christopher S. Lee, Ercole Vellone, Anna Gozdzik, Remigiusz Szczepanowski, Michał Czapla, Izabella Uchmanowicz
Advances in Clinical and Experimental Medicine
DOI: 10.17219/acem/202773
Web. A. Maj
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