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Ann Thorac Surg 2002;74:694
© 2002 The Society of Thoracic Surgeons
a Cognitive Neurology, Johns Hopkins Hospital, Meyer 100, 600 N. Wolfe St, Baltimore, MD 21287, USA
e-mail: oselnes{at}jhmi.edu
The problem of cognitive changes after coronary artery bypass grafting (CABG) continues to be a significant concern to patients and physicians alike. Despite ongoing improvements in the surgical and anesthesiological techniques, as many as two-thirds of patients may experience cognitive decline at the time of discharge from the hospital. It has generally been assumed that most of the short-term changes, in particular those relating to memory, are transient and reversible over time. However, some recent studies have demonstrated persistent or late cognitive changes after CABG, raising the possibility of more serious long-term nonreversible problems. None of the long-term follow-up studies have included control groups, however, and the relationship of these late changes to perioperative factors remains unclear.
Unlike the more severe adverse neurological complications of CABG, such as stroke and encephalopathy, the recognition of clinically relevant cognitive decline has been difficult. The most common approach to measuring cognitive change after CABG has been the use of standardized psychometric tests. Although such tests have been shown to be very sensitive, they are time consuming and require specially trained personnel to administer.
The study by Bergh and colleagues relies on a different approach to evaluating cognitive change after CABG: self-report of perceived changes in cognitive abilities, including memory and concentration. Additionally, they also obtained reports from the spouses of patients regarding their perception of cognitive change. They studied two groups of patients: one group with conventional CABG, the other with percutaneous transluminal coronary angioplasty (PTCA). They report two surprising findings. First, the frequency of perceived cognitive change 1 to 2 years after the procedure was quite high. Approximately 60% of the CABG patients perceived their memory to be worse than before surgery. Second, there was no significant difference in the rate of self-reported cognitive symptoms between the CABG and the PTCA groups.
What do these findings tell us about long-term cognitive outcomes after CABG? Perhaps the most obvious interpretation is that although more than half the patients perceive their memory to be worse 2 years after the surgery, the lack of any difference in the frequency of complaints between the CABG and PTCA groups would suggest that these changes are not related to the cardiopulmonary bypass itself. Why do more than half of their patients perceive their memory to be worse 2 years after their procedure? The report by Bergh and colleagues does not provide any information on the prevalence of hypertension, diabetes, hypercholesterolemia, or other risk factors for cerebrovascular disease in their study populations. We know from other studies, however, that such risk factors are very common among patients who undergo CABG or PTCA. Furthermore, there is evidence from other prospective studies of community-dwelling individuals that the presence of one or more of these risk factors increases the probability of cognitive decline in late age. Therefore, the explanation for the high prevalence of perceived cognitive change in this study may be related to pre-existing cerebrovascular disease rather than the cardiac procedures themselves.
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