International researchers propose standardised outcome to fix inconsistent cognitive-outcome reporting after stroke and cardiac care

A position paper in Circulation reviews the state of cognitive-outcome measurement in cardiovascular and stroke research and finds it wanting on several fronts: wide variation in which cognitive tasks are used, limited population-specific validation, floor and ceiling effects, sociocultural and linguistic bias, a lack of multilingual formats, and heavy reliance on face-to-face testing [Synthesis]. Most consequentially, the authors identify substantial non-random missingness in cognitive outcome data — concentrated among older and more cognitively impaired patients, the group most important to capture — which generates survivor and attrition bias in trial results.

To address this, the authors propose a new composite outcome, “major adverse cognitive events” (MACE-Cog), which does not rely solely on cognitive test performance. It also incorporates inability to complete testing, reported symptoms of cognitive decline, impairment in activities of daily living attributable to cognitive change, new dementia diagnoses, and care-home admission.

This is a proposed framework, not adopted guidance, and the paper itself is not a validation study — MACE-Cog has not yet been tested prospectively against existing measurement approaches. Its practical significance is as a call for cardiovascular and stroke trials and services to move beyond cognitive test scores in isolation, toward an outcome measure capable of capturing patients whom current tools miss entirely, including those who cannot be tested or who decline without meeting a formal diagnostic threshold.