{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T03:11:32Z","timestamp":1785553892609,"version":"3.56.0"},"reference-count":50,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T00:00:00Z","timestamp":1776988800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Clinics and Practice"],"abstract":"<jats:p>Objectives: Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, and cardiometabolic comorbidity, have been increasingly associated with cognitive impairment and dementia. These associations, however, remain underexplored and underappreciated in middle-aged individuals with AF. This study aimed to explore the associations of early cognitive impairment with the presence of cardiometabolic comorbidities and potential associations with echocardiographic markers in middle-aged patients with and without AF. Methods: Between 2023\u20132024, fifty-six consecutive outpatients with a diagnosis of AF aged 45\u201365 years underwent clinical evaluation, transthoracic echocardiography, and comprehensive neuropsychological assessment using the Montreal Cognitive Assessment (MoCA) and the Consortium to Establish a Registry for Alzheimer\u2019s Disease battery (CERAD). A control group of 58 age group-matched individuals without known cardiometabolic disease was included in comparative cognitive analyses. Results: Patients with AF and cardiometabolic comorbidities demonstrated early cognitive deficits, particularly in episodic memory and visuospatial functions, detectable even in individuals with normal MoCA scores, compared with the control group. However, no associations were observed between cognitive performance and conventional echocardiographic parameters in the group with AF. Conclusions: This study corroborated prior evidence of an association between cardiometabolic impairment and subtle cognitive impairment, but did not identify a specific contribution of echocardiography markers. More extensive and sensitive biomarkers of left atrial structure and function may be required to detect harmful associations with subtle cognitive impairment in middle-aged individuals. Further prospective studies, with a more balanced control for comorbidities, are warranted to clarify the clinical relevance of atrial structural remodeling in this context.<\/jats:p>","DOI":"10.3390\/clinpract16050082","type":"journal-article","created":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T17:26:18Z","timestamp":1777051578000},"page":"82","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Exploring Associations Between Early Cognitive Impairment and Echocardiographic Markers in Middle-Aged Patients with Atrial Fibrillation and Cardiometabolic Comorbidities: A Pilot Study"],"prefix":"10.3390","volume":"16","author":[{"given":"Borislava","family":"Atanasova","sequence":"first","affiliation":[{"name":"Department of Neurology, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"},{"name":"UMHAT \u201cSv. Georgi\u201d EAD, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8144-6965","authenticated-orcid":false,"given":"Mariya","family":"Tokmakova","sequence":"additional","affiliation":[{"name":"UMHAT \u201cSv. Georgi\u201d EAD, 4002 Plovdiv, Bulgaria"},{"name":"First Department of Internal Diseases, Cardiology Section, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2540-5111","authenticated-orcid":false,"given":"Angel M.","family":"Dzhambov","sequence":"additional","affiliation":[{"name":"Environmental Health Division, Research Institute at Medical University of Plovdiv, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rafiela","family":"Chitak","sequence":"additional","affiliation":[{"name":"UMHAT \u201cSv. Georgi\u201d EAD, 4002 Plovdiv, Bulgaria"},{"name":"First Department of Internal Diseases, Cardiology Section, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Penka","family":"Atanassova","sequence":"additional","affiliation":[{"name":"Department of Neurology, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"},{"name":"UMHAT \u201cSv. Georgi\u201d EAD, 4002 Plovdiv, Bulgaria"},{"name":"Medical Speech Language Pathology Division, Research Institute at Medical University of Plovdiv, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1007\/s40471-018-0159-7","article-title":"Atrial Fibrillation, Cognitive Decline, and Dementia: An Epidemiologic Review","volume":"5","author":"Ding","year":"2018","journal-title":"Curr. Epidemiol. Rep."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"53","DOI":"10.5535\/arm.22027","article-title":"Dementia Epidemiology Fact Sheet 2022","volume":"46","author":"Shin","year":"2022","journal-title":"Ann. Rehabil. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"101580","DOI":"10.1016\/j.eclinm.2022.101580","article-title":"Global and regional projections of the economic burden of Alzheimer\u2019s disease and related dementias from 2019 to 2050: A value of statistical life approach","volume":"51","author":"Nandi","year":"2022","journal-title":"eClinicalMedicine"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1016\/j.tcm.2023.01.005","article-title":"Atrial fibrillation and the risk of early-onset dementia and cognitive decline: An updated review","volume":"34","author":"Kogelschatz","year":"2024","journal-title":"Trends Cardiovasc. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e01","DOI":"10.15420\/aer.2022.29","article-title":"This is Your Brain, and This is Your Brain on Atrial Fibrillation: The Roles of Cardiac Malperfusion Events and Vascular Dysfunction in Cognitive Impairment","volume":"12","author":"Zenger","year":"2023","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1697","DOI":"10.1016\/j.amjcard.2019.08.027","article-title":"Circulating levels of biomarkers of cerebral injury in patients with atrial fibrillation","volume":"124","author":"Galenko","year":"2019","journal-title":"Am. J. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"392","DOI":"10.1161\/CIRCULATIONAHA.121.055018","article-title":"Atrial fibrillation and dementia: A report from the AF-SCREEN International Collaboration","volume":"145","author":"Rivard","year":"2022","journal-title":"Circulation"},{"key":"ref_8","unstructured":"Anand, S., and Schoo, C. (2024). Mild cognitive impairment. StatPearls, StatPearls Publishing."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1016\/S0140-6736(24)01296-0","article-title":"Dementia prevention, intervention, and care: 2024 report of the Lancet Standing Commission","volume":"10","author":"Livingston","year":"2024","journal-title":"Lancet"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"859","DOI":"10.26599\/1671-5411.2025.10.006","article-title":"Cognitive function disparities among atrial fibrillation patients with varying comorbidities","volume":"22","author":"Zhao","year":"2025","journal-title":"J. Geriatr. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1590\/1980-5764-dn-2021-0097","article-title":"Forty-five years of the Mini-Mental State Examination: A perspective from Ibero-America","volume":"16","author":"Gallegos","year":"2022","journal-title":"Dement. Neuropsychol."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Lee, Y.C., Lee, S.C., and Chiu, E.C. (2022). Practice effect and test\u2013retest reliability of the Mini-Mental State Examination-2 in people with dementia. BMC Geriatr., 22.","DOI":"10.1186\/s12877-021-02732-7"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Yang, H., Yim, D., and Park, M.H. (2021). Converting from the Montreal Cognitive Assessment to the Mini-Mental State Examination-2. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0254055"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"61","DOI":"10.15420\/aer.2020.13","article-title":"Atrial myopathy underlying atrial fibrillation","volume":"9","author":"Rivner","year":"2020","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Ekholm, M., and Kahan, T. (2021). The Impact of the Renin-Angiotensin-Aldosterone System on Inflammation, Coagulation, and Atherothrombotic Complications, and to Aggravated COVID-19. Front. Pharmacol., 12.","DOI":"10.3389\/fphar.2021.640185"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Valentini, A., Heilmann, R.M., K\u00fchne, A., Biagini, L., Bellis, D.D., and Rossi, G. (2025). The renin\u2013angiotensin\u2013aldosterone system beyond cardiovascular regulation. Vet. Sci., 12.","DOI":"10.3390\/vetsci12080777"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"8","DOI":"10.15420\/aer.2018.75.2","article-title":"Atrial fibrillation and dementia: Exploring the association, defining risks and improving outcomes","volume":"8","author":"Bunch","year":"2019","journal-title":"Arrhythmia Electrophysiol. Rev."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1489","DOI":"10.1016\/j.amjcard.2018.07.031","article-title":"The Impact of Gender on Atrial Fibrillation Incidence and Progression to Dementia","volume":"122","author":"Golive","year":"2018","journal-title":"Am. J. Cardiol."},{"key":"ref_19","unstructured":"Chompalov, K. (2017). Neurological and Neuropsychological Study of the Risk of Cerebrovascular Disease in the Age of 45\u201355. [Ph.D. Dissertation, Medical University of Plovdiv]."},{"key":"ref_20","first-page":"613","article-title":"An ultra-brief screening scale for anxiety and depression: The PHQ-4","volume":"50","author":"Kroenke","year":"2009","journal-title":"Psychosomatics"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s13195-020-00603-8","article-title":"Enhanced diagnostic accuracy for neurocognitive disorders: A revisedcut-off approach for the Montreal Cognitive Assessment","volume":"12","author":"Thomann","year":"2020","journal-title":"Alzheimers Res. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3233\/JAD-230026","article-title":"CERAD (Consortium to Establish a Registry for Alzheimer\u2019s Disease) neuropsychology assessment battery: 35 years and counting","volume":"93","author":"Fillenbaum","year":"2023","journal-title":"J. Alzheimer\u2019s Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2181","DOI":"10.1111\/jgs.12541","article-title":"Criterion and convergent validity of the Montreal Cognitive Assessment with screening and standardized neuropsychological testing","volume":"61","author":"Lam","year":"2013","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"3235","DOI":"10.1002\/alz.13040","article-title":"Accuracy of the Montreal Cognitive Assessment tool for detecting mild cognitive impairment: A systematic review and meta-analysis","volume":"19","author":"Islam","year":"2023","journal-title":"Alzheimers Dement."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1801137","DOI":"10.1183\/13993003.01137-2018","article-title":"Detection of mild cognitive impairment in middle-aged and older adults with obstructive sleep apnoea","volume":"52","author":"Gagnon","year":"2018","journal-title":"Eur. Respir. J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1212\/01.wnl.0000167607.63000.38","article-title":"A total score for the CERAD neuropsychological battery","volume":"65","author":"Chandler","year":"2005","journal-title":"Neurology"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1093\/ehjci\/jev014","article-title":"Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"16","author":"Lang","year":"2015","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1321","DOI":"10.1093\/ehjci\/jew082","article-title":"Recommendations for the evaluation of left ventricular diastolic function by echocardiography: An update from the American Society of Echo-cardiography and the European Association of Cardiovascular Imaging","volume":"17","author":"Nagueh","year":"2016","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_29","first-page":"461","article-title":"Association of midlife cardiovascular risk factors with risk of dementia in later life","volume":"317","author":"Freund","year":"2017","journal-title":"JAMA"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2672","DOI":"10.1161\/STR.0b013e3182299496","article-title":"Vascular contributions to cognitive impairment and dementia: A statement for healthcare professionals from the American Heart Association\/American Stroke Association","volume":"42","author":"Gorelick","year":"2011","journal-title":"Stroke"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e265","DOI":"10.1016\/S2666-7568(23)00054-5","article-title":"Cardiometabolic multimorbidity, lifestyle behaviours, and cognitive function: A multicohort study","volume":"4","author":"Jin","year":"2023","journal-title":"Lancet Healthy Longev."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"991","DOI":"10.1161\/HYPERTENSIONAHA.123.21356","article-title":"Hypertension, Neurodegeneration, and Cognitive Decline","volume":"81","author":"Pacholko","year":"2024","journal-title":"Hypertension"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Zhao, Y., Wang, H., Tang, G., Wang, L., Tian, X., and Li, R. (2025). Risk factors for mild cognitive impairment in type 2 diabetes: A systematic review and meta-analysis. Front. Endocrinol., 16.","DOI":"10.3389\/fendo.2025.1617248"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"37","DOI":"10.3233\/JAD-201176","article-title":"Association between low-density lipoprotein cholesterol levels, statin use, and dementia in patients followed in German General Practices","volume":"79","author":"Zingel","year":"2021","journal-title":"J. Alzheimers Dis."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1001\/archneurol.2008.582","article-title":"Midlife and late-life obesity and the risk of dementia: Cardiovascular health study","volume":"66","author":"Fitzpatrick","year":"2009","journal-title":"Arch. Neurol."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Hasanein, D., Lighezan, D.F., \u021aunea, O.E., Ciobotaru, V.G., and Ba\u0219a, N.S. (2026). Atrial Fibrillation and Cognitive Decline: Mechanisms, Evidence, and Preventive Strategies-A Narrative Review. J. Clin. Med., 15.","DOI":"10.3390\/jcm15051899"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1253\/circj.CJ-22-0224","article-title":"Association Between Atrial Fibrillation and Domain-Specific Cognitive Decline\u2014Insights From the Systolic Blood Pressure Intervention Trial","volume":"87","author":"Zhao","year":"2022","journal-title":"Circ. J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1527802","DOI":"10.3389\/fcvm.2025.1527802","article-title":"Atrial fibrillation and cognitive impairment: Mechanisms, influencing factors, and prospects","volume":"12","author":"Huang","year":"2025","journal-title":"Front. Cardiovasc. Med."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"100453","DOI":"10.1016\/j.clinsp.2024.100453","article-title":"Risk factors of atrial fibrillation complicated with cognitive impairment and the relationship between cardiac function parameters and the degree of cognitive impairment","volume":"79","author":"Liao","year":"2024","journal-title":"Clinics"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1590\/S1980-57642009DN20200002","article-title":"Subcortical ischemic vascular disease and cognition: A systematic review","volume":"2","author":"Alves","year":"2008","journal-title":"Dement. Neuropsychol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"795","DOI":"10.1093\/qjmed\/hct129","article-title":"Atrial fibrillation as a risk factor for cognitive impairment: A semi-systematic review","volume":"106","author":"Udompanich","year":"2013","journal-title":"QJM Int. J. Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1662","DOI":"10.1161\/STROKEAHA.119.027815","article-title":"Association Between Atrial Fibrillation and Cognitive Impairment in Individuals With Prior Stroke: A Meta-Analysis and Meta-Regression Analysis","volume":"51","author":"Kokkinidis","year":"2020","journal-title":"Stroke"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.echo.2014.11.009","article-title":"Relationship between cognitive impairment and echocardiographic parameters: A review","volume":"28","author":"Arangalage","year":"2015","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1138","DOI":"10.1001\/jama.2022.2518","article-title":"Association of Echocardiographic Measures of Left Atrial Function and Size With Incident Dementia","volume":"327","author":"Wang","year":"2022","journal-title":"JAMA"},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Myers, S.J., Jim\u00e9nez-Ruiz, A., Sposato, L.A., and Whitehead, S.N. (2022). Atrial cardiopathy and cognitive impairment. Front. Aging Neurosci., 14.","DOI":"10.3389\/fnagi.2022.914360"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"e025646","DOI":"10.1161\/JAHA.121.025646","article-title":"Risk of Dementia Associated With Atrial Cardiopathy: The ARIC Study","volume":"11","author":"Johansen","year":"2022","journal-title":"J. Am. Heart Assoc."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"858","DOI":"10.1161\/STROKEAHA.124.047747","article-title":"Markers of Left Atrial Myopathy: Prognostic Usefulness for Ischemic Stroke and Dementia in People in Sinus Rhythm","volume":"56","author":"Masini","year":"2025","journal-title":"Stroke"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"e045054","DOI":"10.1161\/JAHA.125.045054","article-title":"Association of Atrial Electrophysiological Abnormalities with Cognitive Decline and Cerebrovascular Disease","volume":"15","author":"Tan","year":"2026","journal-title":"J. Am. Heart Assoc."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"e936365","DOI":"10.12659\/MSM.936365","article-title":"A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke","volume":"28","author":"Arnautu","year":"2022","journal-title":"Med. Sci. Monit."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Rosca, C.I., Sharma, A., Nisulescu, D.-D., Otiman, G., Duda-Seiman, D.-M., Morariu, S.I., Lighezan, D.F., and Kundnani, N.R. (2023). Prevalence of Cardio-Embolic Brain Complications in Permanent and Paroxysmal Atrial Fibrillation Patients. Healthcare, 11.","DOI":"10.3390\/healthcare11020175"}],"container-title":["Clinics and Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/5\/82\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T17:53:22Z","timestamp":1777053202000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-7283\/16\/5\/82"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,24]]},"references-count":50,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["clinpract16050082"],"URL":"https:\/\/doi.org\/10.3390\/clinpract16050082","relation":{},"ISSN":["2039-7283"],"issn-type":[{"value":"2039-7283","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,24]]}}}