Cognitive Impairment in Atrial Fibrillation (DIAL-F)

September 5, 2019 updated by: Texas Cardiac Arrhythmia Research Foundation

Mild Cognitive Impairment (MCI) in Patients With Atrial Fibrillation (AF), Trajectories of the Progression of MCI and Factors Associated With the Progression

This study aims to compare the incidence of new-onset cognitive impairments and change in existing impairment status between AF patients undergoing either catheter ablation or remaining on anti-arrhythmic drugs (AAD) as assessed by Montreal Cognitive Assessment (MoCA).

Study Overview

Status

Unknown

Conditions

Detailed Description

Background: AF is mostly a disease of elderly. Up to 10% of people aged 80 years or older suffer from this arrhythmia and the rate is projected to triple in the next 20 years (1). Evidence is emerging that AF may increase the risk of all forms of dementia (2). Cerebral hypoperfusion and the risk of cerebrovascular micro- and macro-embolism are plausible explanations for the predisposition for cognitive decline in AF (1). Such insults may act alone or in concert with other neuropathological changes common in the brain of older individuals such as neuritic plaques or neurofibrillary tangles, in lowering cognitive reserves and accelerating the onset of dementia (3).

Prior studies on AF and dementia have yielded conflicting results.

An earlier study provided evidence supporting an association between AF and increased incidence of dementia in patients with stroke (4). In a prospective study conducted on participants of ONTARGET and TRANSCEND trials, it was revealed that cognitive and functional decline are important consequences of atrial fibrillation, even in the absence of overt stroke (5). Another independent study, observed similar results for risk of dementia in AF in participants with and without clinically recognized stroke during follow-up (3). Evidences from a previous research demonstrated not only a significant association of AF with all forms of dementia including Alzheimer's disease, but also higher mortality rate in patients with coexistent dementia and AF (2). On the contrary, some studies did not find any significant risk-association between AF and dementia (6-8).

These contradictory results compel the necessity for a prospective study on a large population to obtain a clear understanding of the association between AF and cognitive impairment. The potential association between the two conditions can have a very important clinical implication; if there were a causal relationship between AF and dementia then the different therapeutic strategies of AF may have differing influence on dementia risk (3). Thus, this knowledge would facilitate in personalizing treatment approaches for individuals with AF.

Anti-arrhythmic drugs are considered as the first line of therapy in AF and catheter ablation is widely-recognized as the best option in drug-refractory cases. Recent published data suggested that effective rhythm-control by catheter ablation reverses the risk of dementia in AF (9). However, it was an epidemiologic study from a health-care database where ICD codes were used to identify clinical dementia. Therefore, mischaracterization of the dementia subtypes was a major possibility in their study.

None of the other currently ongoing studies or registries on AF ablation in US includes dementia as one of the outcomes to be assessed. Therefore, our study will be the first to examine the benefit of successful catheter ablation on cognitive function in AF patients by directly assessing cognition using standardized instruments.

There are several standardized screening tools available to assess cognitive status, namely Mini-Mental State Examination (MMSE), Cognitive Abilities Screening Instrument (CASI) and Montreal cognitive assessment (MoCA). All have their strengths and limitations, but MoCA is considered the most efficient because of its cross-cultural applicability and its higher sensitivity for detecting mild cognitive impairments. In our study, MoCA would be used to evaluate cognitive status in AF patients.

Besides MoCA, the following questionnaires will be used to assess other risk-factors for cognitive impairment and quality of life in AF patients

  1. Hospital anxiety and Depression scale (HAD): to evaluate anxiety and depression
  2. Katz Index of Independence in Activities of Daily Living (ADL) and Lawton's Instrumental Activities Of Daily Living Scale (IADL): to assess independent living skills
  3. Multidimensional Scale of Perceived Social Support by Zimet et al: to appraise perception of social-support in this study
  4. International Physical Activity Questionnaire (IPAQ): to obtain internationally comparable data on health-related physical activity
  5. Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire: to assess the AF-specific changes in QoL before and after ablation

Study Objectives

Primary Objectives:

To evaluate the number of patients showing improvement or no-worsening in cognitive status at 2 years follow-up after catheter ablation or after the beginning of drug-therapy in non-ablation group

Secondary Objectives:

  1. Study the interaction between depression, social support and cognitive status
  2. Evaluate the impact of social supports on the trajectory of dementia
  3. Examine the correlation between physical activity and cognitive impairment
  4. Assess the impact of arrhythmia recurrence on dementia across the control and the study group

Study Design:

This prospective multicenter study will enroll 888 consecutive AF patients at different centers in US, Asia and Europe.

Consenting patients will perform the MoCA evaluation. Patients with a score < 17 will be deemed a screen failure. Qualifying patients will be evaluated and the appropriate treatment strategy for managing arrhythmia will be independently determined by the treating physician. Patients undergoing a clinically indicated catheter ablation for AF will be assigned to the Ablation group and those determined to stay on AAD will form the AAD group. Based on physician decision, left atrial appendage occlusion or exclusion procedures may be performed for reducing the thromboembolic risk. The AAD group will continue on AADs as prescribed in accordance with standard of care at the discretion of the physician.

Study Type

Observational

Enrollment (Anticipated)

888

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • United States
    • Texas
      • Austin, Texas, United States, 78705
        • Recruiting
        • Texas Cardiac Arrhythmia Institute, St. david's Medical Center
        • Contact:

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

50 years to 75 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Sampling Method

Non-Probability Sample

Study Population

Detail study information will be provided to the patients and written informed consent will be obtained from the each patient or family member before enrolling in the study. Consenting patients will be evaluated and the appropriate treatment strategy for managing arrhythmia will be independently determined by the physicians at the participating centers. Patients undergoing catheter ablation for AF will be included in the study group and those determined to stay on AAD will form the control group.

Description

Inclusion Criteria:

  1. Age: ≥ 50 years, male or female subjects
  2. Clinical diagnosis of AF
  3. Ability to provide written, informed consent

Exclusion Criteria:

  1. Patients with established dementia
  2. MoCA score ≤ 17 on Montreal Cognitive Assessment (MoCA)
  3. Use of illicit drugs
  4. Alcohol use: >12 drinks/week on average
  5. Clinical evidence of delirium or altered mental status
  6. Medically unstable patients (acute/unstable or poorly controlled problems that would demand focused, relatively urgent or emergent medical attention)

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Observational Models: Case-Control
  • Time Perspectives: Prospective

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
improvement or no-worsening in MoCA score assessed at baseline and 2 year follow-up
Time Frame: 2 years
The primary efficacy endpoint of this study will be the objective response rate (ORR); objective response being defined as improvement or no-worsening in MoCA score assessed at baseline and 2 year follow-up.
2 years

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Correlation between MoCA score and physical activity, social support, anxiety and depression
Time Frame: 2 years
  1. Correlation of scores between the HAD and the social support scale
  2. Correlation of scores between HAD and MoCA
  3. Association between social support and MoCA score
  4. Correlation between physical activity and MoCA scale
  5. Association between arrhythmia recurrence and MoCA score
  6. Comparison of QoL between baseline and post-ablation period
2 years

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Texas Cardiac Arrhythmia Research Foundation

Investigators

  • Study Director: Mitra Mohanty, MD, TCAI

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

July 1, 2014

Primary Completion (Anticipated)

June 1, 2020

Study Completion (Anticipated)

December 1, 2022

Study Registration Dates

First Submitted

March 20, 2013

First Submitted That Met QC Criteria

March 20, 2013

First Posted (Estimate)

March 22, 2013

Study Record Updates

Last Update Posted (Actual)

September 9, 2019

Last Update Submitted That Met QC Criteria

September 5, 2019

Last Verified

September 1, 2019

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • TCAI_DIAL-F

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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