The older adult population is the fastest-growing segment of the U.S. population. Cardiovascular disease is common among older patients, which leads to excess morbidity, mortality, and health care utilization. Cognitive impairment is also common in older adults with cardiovascular disease and is expected to increase in parallel with cardiovascular disease because both conditions share the same underlying risk factors. Cardiovascular disease also exacerbates cognitive impairment through hypertension, cerebral hypoperfusion, inflammation, arrhythmia, emboli, and medication adverse events. Moreover, cognitive impairment can undermine the treatment of patients with cardiovascular disease because of changes in health literacy, adherence, and even the likelihood that guideline-directed medical and/or interventional management are under-prescribed. Patients with cognitive impairment are also more likely to endure delays in care and reduced participation in formative cardiovascular trials. In this State-of-the-Art review, we aim to: 1) examine the distinct types of cognitive impairment prevalent among cardiac patients; 2) explore the fundamental pathophysiology and mechanisms of cognitive impairment in adults with cardiovascular disease; 3) delineate the bidirectional impact of cognitive impairment and cardiovascular disease; and 4) discuss evidence-based management strategies to mitigate cognitive impairment in patients with cardiovascular diseases.