The Efficiency of Attentional Networks in Takostubo Syndrome: A Study With the Attentional Network Task for Interaction

Abstract

Introduction:

The role of cardiovascular risk factors in the occurrence and progression of cognitive impairment is relevant in aging studies. In this condition, attention is one of the processes less studied, but preliminary evidence suggests an association between cardiometabolic alterations and attentional decline. Attention is not a unitary process but a set of independent systems (Alerting, Orienting, Executive), which can interact in certain conditions to ensure maximum behavioral efficiency.

Methods:

We investigated attentive networks and their interactions in patients with Takostubo syndrome (TTS). In all, 20 participants with TTS and 20 individuals without cardiovascular pathologies performed an Attention-Network Task for Interaction, which assesses attentional networks and their interactions.

Results:

Patients with TTS showed an atypical orienting effect when compared to the control group. Moreover, only the control group exhibited an interaction between orienting and alerting.

Conclusion:

These findings establish the relevance of brain–heart interaction in identifying attentional impairment as a prodrome of progressively severe cognitive impairment in TTS.

Keywords

Takostubo syndrome attentional networks attention network task alerting orienting executive control

Introduction

Cognitive impairment is a serious and common disability found in elderly individuals with a history of cardiovascular diseases (CVD). Deficits in multiple cognitive domains have been reported in patients with CVD at different levels of severity, including hypertension, atherosclerosis, and myocardial infarction (Almeida et al., 2007; Forte & Casagrande, 2020; Forte et al., 2020; Pressler et al., 2010; Stanek et al., 2009; Waldstein and Elias, 2001). One of the most common abnormalities reported in CVD is heart failure (HF), which affects about 6.5 million adults worldwide and has a high annual incidence rate (Benjamin et al., 2018). About 80% of patients with HF present some form of cognitive impairment (Bennett and Sauvé, 2003; Pressler et al., 2010; Vogels et al., 2007), and there is evidence that cognitive deficits in HF exceed those observed in other forms of CVD (Trojano et al., 2003). These impairments may lead to lower adherence to treatment regimens and are associated with negative prognoses, poor quality of life, and elevated mortality rates in patients with HF (Bennett and Sauvé, 2003). Cognitive impairment in HF is influenced by numerous pathophysiological factors, such as structural brain pathology, reduced cerebral blood flow, and dysfunctions of the autonomic nervous system (ANS) (Keary et al., 2007). A systematic review by Vogels et al. (2007) found that alterations in left ventricular functions, which are a common consequence of acute myocardial infarction (Cleland et al., 2005), lead to cognitive impairment. This includes deficits in memory, information processing speed, attention, and executive functions. A large-scale neuropsychological assessment conducted by Pressler et al. (2010) found that outpatients with chronic HF who reported dysfunctions in executive functioning, specifically working memory, experienced a significant increase in mortality after 12 months. This evidence has been corroborated by more recent studies (Gathright et al., 2019; Kim et al., 2018).

Decreased attention is one of the most frequently impaired cognitive domains in HF (Bauer & Pozehl, 2011; Pressler et al., 2010). An attentional decline is found in 15%–27% of patients with HF (Jung et al., 2017), suggesting a significant association between Attention impairment and HF(Almeida & Tamai, 2001; Alves et al., 2005; Bornstein et al., 1995; Gorkin et al., 1993; Gunstad et al., 2005; Hoth et al., 2008; Incalzi et al., 2003; Putzke et al., 2000; Tanne et al., 2005; Trojano et al., 2003; Vogels et al., 2007; Wolfe et al., 2006). However, these studies were limited by the lack of a guiding theoretical framework of attention and employed measures that failed to account for multiple dimensions of a theoretical attention framework. The authors failed to take into account the various dimensions of the attentional domain, such as evaluating it using the Trial Making Test (Almeida & Tamai, 2001; Bornstein et al., 1995; Gorkin et al., 1993; Gunstad et al., 2005; Putzke et al., 2000; Serber et al., 2008; Tanne et al., 2005). To the best of our knowledge, no studies have investigated attention deficits in Takotsubo syndrome (TTS). TTS is a form of reversible heart failure, typically triggered by a stressful event (Casagrande et al., 2021). It is identified by left-ventricular dysfunction that resembles that of acute myocardial infarction (IMA), but without any culprit coronary artery abnormalities (Cacciotti et al., 2012). Few studies examined the cognitive factors affecting this cardiac disease. For example, Jurisic et al. (2019) found that patients with TTS had lower scores than the age-matched general population in visuoconstructive, word-finding, and memory tests. From a cognitive perspective, TTS has been related to hypervigilance (Templin et al., 2015), and it is conceivable that it may also be associated with attentional biases, thereby facilitating the detection and exacerbating negative emotions during stressful events. However, there is still a lack of clear investigation into the functioning of attention in TTS. Attention involves various dimensions, including different networks, such as orienting, alerting, and executive control (e.g., Petersen & Posner, 2012). Selective or focused attention involves directly focusing on specific stimuli in space or objects through the orienting system, located in the parietal cortex. Executive control, situated in the prefrontal and anterior cingulate cortex, resolves and controls conflicts between expectations, stimuli, and responses. The alerting system, governed by the right hemisphere, allows for enhanced activation and increased responsiveness to stimuli. It is linked to arousal system and sustained attention that favor faster responses to stimuli (Petersen & Posner, 2012; Posner, 1990). Analyzing the complexity and functionality of the attentional network is crucial understanding how HF affects cognitive functioning. Impaired attentional systems in patients with TTS can be hypothesized as a result of neuroimaging studies showing that they presented alterations in the brain attentional networks (Arcari et al., 2021). Specifically, patients with TTS have exhibited altered neural networks in several attention brain regions, including the amygdala, insula, anterior cingulate cortex, and prefrontal cortex, have been observed in patients with TTS in both the chronic and acute phases of the disease and even before the onset of TTS (Dichtl et al., 2020; Hiestand et al., 2018; Pereira et al., 2016; Radfar et al., 2021; Sabisz et al., 2016; Suzuki et al., 2014; Tawakol et al., 2017). Accordingly, this study aims to examine the efficiency of the attentional networks and their interactions in patients with TTS as compared to healthy controls. To assess simultaneously the three different attentional systems suggested by Posner and Petersen’s attention model, several authors employed the Attention Network Test (ANT) (Fan et al., 2002). The ANT combines the spatial cueing task (Posner, 1980) with the flanker task (Eriksen & Eriksen, 1974). Many studies have shown the connection between attentional functioning and interactions among attentional networks with specific brain areas involved in the control of attentional functions (e.g., Posner & Rothbart, 2007). The use of the ANT has been remarkably successful in simultaneously studying the efficiencies and interactions of the three attentional systems. Many researchers have proposed some variants of the original ANT. One well-known variant is the Attentional Network Test for Interaction (ANTI), proposed by Callejas et al. (2004), which introduced some changes in the evaluation of orienting and alerting, which enable direct assessment of the interaction between these systems. Both the ANT and the ANTI employ arrow stimuli. Another version of the ANTI, called ANTI-Fruit (ANTI-F), has been proposed based on the hypothesis that directional stimuli may overburden the executive system. Another version of the ANTI, called ANTI-Fruit (ANTI-F), has been proposed based on the hypothesis that directional stimuli may overburden the executive system. Thus, the ANTI-F employs non-directional stimuli (i.e., fruits) (Spagna et al., 2014, 2016). The ANT, or some of its variants, has been applied to diverse populations, including adults, adolescents, children, elderly people, and clinical groups (Casagrande et al., 2012, 2017, 2021; Federico et al., 2013, 2017, 2021; Giovannoli et al., 2021; Marotta et al., 2015; Martella et al., 2011). Accordingly, we used the ANTI-F to analyze the single features of attention and their interactions. We expected a general alteration in the single components of the attentional networks due to frontal and parietal modifications in individuals with TTS and the interactions between these systems.

Methods

Participants

Forty participants (27 females and 13 males) were divided into two groups based on their cardiovascular condition, which was assessed by an expert cardiologist. The study included 20 participants diagnosed with TTS (17 females and 3 males; mean age = 69.80 ± 10.81), and 20 healthy participants without cardiovascular pathologies in the control group (HI; 10 females; 10 males; mean age = 66.15 ± 8.93). Exclusion criteria included any previous or current neurological or psychiatric disorders. Additionally, exclusion criteria for the HF group consisted of hypertensive condition, pharmacological treatments, and metabolic syndromes.

The overall procedure of the study, including participants selection, clinical and cognitive assessment, was approved by the Local Ethical Committee of the Department of Dynamic and Clinical Psychology, and Health Studies at “Sapienza” University of Rome (protocol number: 0000663), in accordance with the Helsinki Declaration and Ethical Standard.

Global Cognitive Status

The Mini-Mental State Examination (MMSE) (Folstein et al., 1983) was used to assess global cognitive status. Participants with scores less than or equal to 24 on the MMSE, corrected by age and educational level, were not included in the current study because it represents a cut-off for dementia or significant cognitive decline affecting cognitive performances.

Attentional Networks: ANTI-Fruit

Apparatus

Stimuli were programmed and displayed by E-Prime software on a 17″ monitor with a screen resolution of 1024 pixels × 768 pixels. Responses were collected through the mouse, and headphones were used to administer the auditory alerting tones. A chinrest was fixed at 56 cm from the monitor to guarantee the appropriate head position of the participants.

Stimuli

Each trial began with a central cross of 1◦ (degrees of visual angle). The stimuli consisted of red strawberries and yellow pears, presented on a gray background. The fruits were positioned with the flankers that overlapped the border of an imaginary semicircle where the target was at the center. The flanker could be the same as the target (congruent condition) or different (incongruent condition). The cue was an asterisk of 1◦, and it could be presented in the same position as an upcoming target (valid cue condition) and the opposite location (invalid cue condition), or it could be absent (no-cue condition). The auditory warning stimulus was a 2,000 Hz tone and lasted 50 ms.

Procedure

Subjects were tested individually in a silent and dimly lit room. Before each trial, the fixation cross was presented for a variable duration (400–1,600 ms). The fixation period was followed in 50% of trials by a warning stimulus lasting 50 ms (in randomized order) that allowed for assessing Alerting component of attention. After a fixed interstimulus interval (ISI) of 350 ms, a cue of 50 ms was presented to evaluate the Orienting network, considering three possible conditions: Valid, Invalid, and No-Cue. In the Valid condition (33% of the trials), an asterisk appeared in the same position as the upcoming target; in the Invalid condition (33%), the target appeared in the opposite position than the one signaled by the cue; in the No-Cue condition (33%), no orienting stimulus was presented. The association flankers-target stimulus was aimed at assessing the Executive Control network. Flankers were congruent with the target (i.e., same fruits as the target stimulus) in 50% of the trials, while the trials were incongruent (i.e., different fruits compared to stimulus) in the other trials. The participants had a limit of 1,700 ms to respond to each trial.

The ANTI-F consisted of one training block and three experimental blocks of 128 trials each. The participants completed 48 valid and 48 invalid trials for each flanker and warning condition. Trials were randomly presented within each block. The entire experiment comprised 384 trials for a total duration of around 20 minutes. The participants were instructed to fixate on the central cross and discriminate the fruit on the semicircle center. Figure 1 shows an example of the ANTI-Fruit procedure.

Figure 1.

Schematic of trial in the ANTI-F.

Statistical Analysis

A power analysis (power of > 80%; type 1 error (α < .05) a priori was conducted to define the total sample size, considering a medium effect size. An average sample of 40 (20 for each group) participants was considered adequate for this study. To analyze the reaction times (RTs) and accuracy (ACC), only the trials in which corrected responses were registered in the time range between 200 and 1,700 ms were considered via automatic e-prime filtering. No people reported an accuracy lower than 50%, and no participants were excluded from the analysis. A Groups (TTS; Healthy) × Warning (No-warning and Warning) × Cue (Invalid cue; Valid cue) × Flanker (Congruent and Incongruent) mixed ANOVA was conducted on the RTs of the correct responses and the percentage of accuracy. To estimate the effect of each attentional system, single ANOVAs were conducted on the Orienting effect (RTs invalid-cue−RTs valid-cue), the Executive Control effect (RTs incongruent trials−RTs congruent trials), and the Alerting effect (RTs no-warning−RTs warning). A high score of orienting effect reflects the ability to rapidly orient the attention toward the targets appearing in the cued positions. A lower Executive Control index reflects the ability to inhibit the interfering effect of distractor stimuli. The alerting effect represents the benefit of alerting on the speed of the response to the target. Planned comparisons were used to analyze the effects further.

All statistical analyses were conducted with Statistica 10.0.

Results

Demographic Variable

All results are reported in Table 1.

Table 1.

Main Characteristics of the Sample.

Variables	Healthy controls	TTS	F	p
N (F/M)	20 (10/10)	20 (17/3)
Age	66.15 (8.93)	69.80 (10.81)	1.35	.25
Years of education	12.90 (4.10)	10.50 (4.32)	3.24	.08
MMSE	28.43 (1.83)	27.10 (2.68)	3.10	.08
BMI	26.84 (4.76)	22.44 (4.06)	8.28	.007
SBP	127.30 (15.33)	138.65 (18.72)	4.39	.04
DBP	79.35 (9.92)	76.65 (11.93)	< 1	.44
HR	76.94 (15.95)	68.05 (8.05)	4.91	.03

Attentional Network Task: Reaction Times

The Groups (Healthy; TTS) × Warning (Warning; No Warning) × Flanker (Congruent; Incongruent) × Cue (Valid; Invalid) ANOVA highlighted significant main effects of Warning (F1,38 = 43.73; p < .001; pn2 = 0.53), Flanker (F1,38 = 68.31; p < .001; pn2 = 0.64) and Cue (F1,38 = 130.55; p < .001; pn2 = 0.77). Specifically, participants had faster RTs in the Warning than No-Warning trials, in the Congruent than Incongruent Condition, and in Valid compared to Invalid trials. The main effect of the Group was not significant (F1,38 = 1.58; p = .22).

Importantly, we observed a significant Cue × Group interaction (F1,38 = 6.39; p = .016; pn2 = 0.14), patients with TTS (mean = 77 ms) showed a greater attentional orienting than Controls (mean = 49 ms). Finally, the Cue × Warning x Flanker (F1,38 = 5.49; p = .024; pn2 = 0.13) and the Cue × Warning × Flanker × Group (F1,38 = 7.97; p = .007; pn2 = 0.17) interactions were statistically significant. Partial ANOVAs were conducted to disentangle these interactions. Separate analyses were conducted on each group. Only the Control group showed a significant Warning × Cue interaction (F1,19 = 10.59; p = .004; pn2 = 0.36) in the incongruent condition, indicating a greater orienting effect in the warning condition (82 ms) as compared to no warning condition (9 ms). In the patients with TTS, this interaction was non-significant (F < 1); see Figure 2.

Figure 2.

Mean and Std. Err of RTS in healthy individuals and patients with TTS of Warning and no-Warning trials in congruent and incongruent conditions.

The ANOVA between groups on the attentional effects showed only a significant Orienting effect (see Figure 3).

Figure 3.

Mean and Std. Err of attentional effects.

Table 2 shows reaction times and accuracy data of participants’ groups, and Table 3 shows Alerting, Orienting, and Conflict effects.

Table 2.

Reaction Times and Accuracy in ANTI-F Conditions of Healthy and TTS Groups.

	Reaction time		Accuracy
	Healthy individuals	TTS	Healthy individuals	TTS
No warning
Congruent
Valid	761.84 (120.36)	813.35 (124.21)	0.98 (0.04)	0.94 (0.15)
Invalid	822.53 (119.40)	874.95 (164.14)	0.98 (0.03)	0.95 (0.12)
No warning
Incongruent
Valid	879.55 (193.27)	885.38 (180.49)	0.97 (0.07)	0.92 (0.15)
Invalid	888.02 (130.94)	984.08 (203.42)	0.96 (0.06)	0.95 (0.11)
Warning
Congruent
Valid	713.96 (110.42)	793.33 (180.86)	0.99 (0.02)	0.96 (0.14)
Invalid	759.18 (124.75)	852.62 (182.05)	0.98 (0.05)	0.94 (0.14)
Warning
Incongruent
Valid	811.74 (156.11)	859.70 (181.29)	0.96 (0.09)	0.94 (0.14)
Invalid	893.75 (179.16)	947.99 (183.72)	0.95 (0.11)	0.93 (0.16)

Table 3.

Attentional Effects in Healthy Individuals and Patients with TTS.

	Healthy individuals	TTS	F	p
Alerting	43.85 (31.91)	43.85 (38.33)	<1	.99
Orienting	49.09 (31.41)	61.75 (37.27)	6.39	.01
Conflict	99.55 (75.80)	86.22 (51.66)	<1	.52
Accuracy	0.97 (0.01)	0.94 (0.13)	1.06	.31

Attentional Network Task: Accuracy

The Groups (Healthy; TTS) × Warning (Warning; No Warning) × Flanker (Congruent; Incongruent) × Cue (Valid; Invalid) ANOVA on accuracy did not report significant main effects (all F < 2.10; p > .16) nor interactive effects (all F < 1.63; p > .21), except for the Warning x Cue (F1,37 = 6.93; p = .02) interaction. In the Warning condition, RTs were faster for valid than invalid trials (F = 2.25; p = .03), while no other significant differences emerged from the planned comparison (all F < 1.53; all p > .13).

Discussion

During heart failure (HF), the brain can suffer from a temporary limitation in blood supply, which can lead to hypoxic brain injury (Woo et al., 2009), resulting in cognitive impairment. Furthermore, HF alters autonomic response (i.e., parasympathetic and sympathetic activity balance), which has been found to affect cognitive functioning (Forte et al., 2019, 2022; La Rovere et al., 2003). Although the cognitive impact of HR may not be directly perceptible, it may affect daily activities and quality of life (Moradi et al., 2020). Impairments resulting from HF may include alteration in memory, attention, and executive control (Woo et al., 2009), which can have an impact on behavior. Attention represents a relevant outcome of cognitive impairment, and even if it was not commonly assessed as learning and memory in preclinical dementia diagnoses such as Alzheimer’s disease, it is more consistently associated with the later development of dementia (Twamley et al., 2006). Although only 10% of the longitudinal case-control studies assessed attentional networks, those that did found that attention performance discriminated between AD cases and controls in 100% of cases (Twamley et al., 2006). Furthermore, also vascular dementia is associated with changes in attentional processes (Akanuma et al., 2016). Therefore, investigating the connection between cardiovascular health and cognitive function appears relevant.

Focusing specifically on analyzing the attentional networks in TTS in comparison to healthy controls could offer valuable insight into early markers of cognitive impairment linked to dementia, especially those related to attention. Therefore, it is essential to evaluate all the components of attention and their interactions. Accordingly, we employed the Attentional Network Task in our study, which has been proven effective in previous research, including studies on the elderly populations (e.g., Casagrande et al., 2021; Federico et al., 2021). By utilizing the ANT for the first time with cardiovascular patients, we were able to successfully identify the functionality of all attentional systems strongly (all effect sizes were very high). Most importantly, the task revealed significant differences in attentional functions between patients with TTS and healthy controls.

Our findings demonstrate a significant increase in attentional orienting among patients with TTS compared to controls. This result may suggest that patients with TTS may exhibit a modified attentional orienting, potentially stemming from reduced suppression by top-down inhibitory control mechanisms and/or upregulation in the brainstem arousal systems. Consistent with this view, patients with HF exhibit modified sustained attention and vigilance, as suggested by Jerskey et al. (2009). This is likely due to impairment of cerebral areas, including attentional neural networks, triggered by changes in cardiac pumping. These deficits may result in greater levels of hypervigilance (i.e., symptom-specific anxiety) in TTS (Oliveri et al., 2020), resulting in enhanced orienting network functioning. Furthermore, these findings provide evidence of the heart–brain interaction (for a review, see Forte et al., 2019, 2020), indicating that cardiac tone plays a significant role in modulating attentional functions. In fact, autonomic failure resulting from HF can generate brain functional alterations, including neural attentional networks, thus supporting the result of this study (Frenneaux, 2004). HF is characterized by a dysregulation of the autonomic sympathetic/parasympathetic imbalance accompanied by concomitant abnormalities of cardiorespiratory reflex control (Braunwald & Bristow, 2000; Floras, 2003). The severity of HF, disease progression, and mortality are related to the degree of autonomic imbalance (Shehab et al., 2004). ANS dysfunctions, as well as cerebral hypoperfusion, atrophy, and brain gray matter loss of the brain, could explain mechanisms underlying cognitive impairment, including attention, in individuals with heart failure (Woo et al., 2009). A neuroimaging study conducted on patients with heart failure found that those with autonomic dysfunction had impairment in several brain areas, including the hippocampus, caudate nucleus, prefrontal cortex, and hypothalamus. These regions are essential for several cognitive processes such as attention (Woo et al., 2009).

Another possible explanation for the heightened Orienting effect is an improvement in the functionality of the neural networks involved in this attentional process. This hypothesis is supported by the healthy lifestyles of patients with TTS (see Casagrande et al., 2022), suggested by their lower BMI in this sample with TTS, which could have prevented impairment of the neural networks due to arteriosclerotic processes.

Many studies have confirmed that the three attentional networks (alerting, orienting, and executive control) work independently, each with its own distinct neural substrates (Fan et al., 2002, 2005; Xuan et al., 2016). However, they also interact to influence performance and behavioral responses involving attentional processes (Callejas et al., 2004; Fan et al., 2009; Wen et al., 2014). The studies indicated that alerting increases the attentional orienting effect (Callejas et al., 2004; Fuentes & Campoy, 2008; Spagna et al., 2014). In the present study, we observed an interaction between alerting and orienting in healthy participants, particularly under incongruent conditions. However, attentional orienting in participants with TTS has a lesser advantage from the alerting tone than the controls, resulting in a similar orienting effect with and without the auditory alerting cue. As previously mentioned, overall attentional orienting was higher in individuals with TTS than in the control group. However, the use of an auditory alerting cue appears to reduce the difference between the two groups. From a functional perspective, this interaction results in activation of the frontoparietal network, bilateral inferior and middle frontal gyri, intraparietal sulcus bilaterally, right insula, and subcortical regions of the right putamen and areas of the cerebellum (Xuan et al., 2016). This evidence demonstrates that cortical and subcortical areas play a crucial role in implementing attentional functions and underlie their dynamic interactions (Xuan et al., 2016). Thus, the lack of interaction in attentional networks observed in patients with TTS can express a certain grade of damage of the neural networks due to the cardiovascular event. HF may be associated with brain abnormalities, such as reduced gray matter and hyperintensity of white matter, cerebral atrophy, brain infarcts, alterations in cerebral metabolism, decreased cerebral perfusion, and alteration of the autonomic nervous system (Stanek et al., 2009). These structural alterations may affect the functional response of the attentional networks and their interactions, including specific regions of the brain, such as frontal, temporal, and parietal lobes (Alves et al., 2005).

Finally, persons with heart failure exhibited higher patterns of controlled or uncontrolled blood pressure, which are generally associated with cognitive impairments when compared to healthy controls (Forte & Casagrande, 2020; Forte et al., 2020). These factors may have an impact on our findings, and therefore more research is required in order to clarify this issue.

Although TTS is acknowledged as a transitional cardiac condition, the data on its morbidity and mortality rates is heterogeneous. While some authors have reported a higher impact of TTS on health (involving also psychiatric and neurologic disorders; Templin et al., 2015) compared to other cardiovascular syndromes, other authors have reported a similar (Olliges et al., 2020) or less severe impact (Cacciotti et al., 2012). TTS is considered as a stress-induced cardiomyopathy, associated with an inadequate management of life events (Casagrande et al., 2021), which can generate high stress levels representing the starting point of a cascade of physiological events that induce the transitive cardiac event. Our study found that the physiological changes caused by TTS could significantly affect attentional functioning.

Despite the reported evidence, this study has some limitations. The lack of neurophysiological measures, such as EEG or fMRI, prevents direct causal effect determination of cardiovascular events on the neural mechanisms related to the attentional networks. Moreover, the gender imbalance between the two groups of patients might be limiting because of potential gender differences in attentional features (Merchán et al., 2021), making these results preliminary. Further studies should aim to balance groups based on gender and age to enable more robust interpretations. Additionally, controlling for age could reveal fascinating outcomes pertaining to the impacts of cardiac events at various life stages, thus enhancing the recognition of cardiovascular functionality as a marker of cognitive impairment and dementia (Forte et al., 2020). Finally, it is important to take into account that the observed effects and interactions occur in an elderly population that already experiences by impaired attentional systems (e.g., Casagrande et al., 2021).

Conclusions

Cognitive impairment is a common co-morbid condition in patients with HF. The mechanisms underlying the link between cardiac dysfunctions and cognitive functions in HF remain unclear, but are relevant to the markers of different types of dementia. This study supported prior evidence of altered attentional functionality following heart failure and, for the first time, highlighted differences in the functionality of the attentional networks in TTS disease. The potential association between TTS and cognitive impairment has crucial clinical implications. Patients with TTS should be thoroughly evaluated for cognitive performance, specifically attention, to prevent that a simple and still not consolidated difficulty can result in significant alterations of their ability to perform daily life activities and comply with self-care behaviors. Generally, investigating attentional deficits in HF, including their expression in different subdomains, is important because of the potential association with more extensive brain effects of cardiovascular alterations and the consequent cognitive impairment. Additionally, patients with higher attention dysfunctions report lower adherence to HF self-care regimens that can lead to more frequent re-hospitalizations, relapse occurrence, and mortality rates (Cameron et al., 2010; Dickson et al., 2007). For these reasons, further studies are needed in this field. We anticipate that this preliminary evidence will enable a more detailed analysis of the attentive functions in various cardiovascular conditions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Francesca Favieri

Data Availability Statement

Data are available upon reasonable request to the corresponding authors.

Author Biographies

Giuseppe Forte Postdoctoral researcher at the Department of Dynamic and Clinical Psychology and Health Studies (Sapienza University of Rome). Expert in Body-brain interaction, Cognitive functions, Autonomic nervous system integration.

Francesca Favieri Postdoctoral researcher at the Department of Dynamic and Clinical Psychology and Health Studies (Sapienza University of Rome). Expert in Psychological, Cognitive, and Neuropsychological functioning in Clinical conditions and Risk behaviors.

Andrea Marotta Profesor Contratado Doctor Indefinido at the Department of Experimental Psychology, University of Granada. Expert in Attentional networks, Social attention, and Executive functions.

Luca Arcari Cardiologist at MG Vannini Hospital, expert in Cardiology, Cardiovascular health, and Takotsubo syndrome.

Luca Cacciotti Medical Director of the Cardiology Unit at MG Vannini Hospital. Expert in Cardiological, Cardiovascular health, and Takotsubo syndrome.

Maria Casagrande Professor at the Department of Dynamic and Clinical Psychology and Health Studies (Sapienza University of Rome). Expert in Attention, Executive Functions, Aging, Psychophysiology, Neuropsychology, and Health Psychology.

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