Underutilization of CAD Testing in New-Onset Heart Failure

Study Questions:

What are the patterns of testing for ischemic coronary artery disease (CAD) and revascularization in patients with new-onset heart failure (HF)?

Methods:

The investigators conducted a retrospective cohort study using Truven Health MarketScan Commercial and Medicare databases from 2010 to 2013. They examined patients with new inpatient HF diagnoses during the index hospitalization and within 90 days of admission for occurrence of noninvasive and invasive ischemic CAD testing and revascularization procedures. The authors used standard statistical tests for descriptive comparisons, including the Fisher exact test for dichotomous outcomes and Student t test for continuous outcomes. Logistic regression was used to identify demographic and clinical predictors of receiving noninvasive testing in patients with new-onset HF.

Results:

The mean age of the study population was 73.7 years with a slight male predominance (52.4%). The study authors found that among 67,161 patients identified with new-onset HF during an inpatient hospitalization, only 17.5% underwent testing for ischemic CAD during the index hospitalization, increasing to 27.4% at 90 days. Among patients with new-onset HF, only 2.1% underwent revascularization during the index hospitalization for HF; by 90 days, the revascularization rate had increased to 4.3%. Of the tests performed for ischemic CAD, stress testing (nuclear stress testing or stress echocardiography) was performed in 1 in 10 (7.9%) of new-onset HF patients during the index hospitalization (14.6% within 90 days), whereas coronary angiography was performed in 11.1% of patients during the index hospitalization (16.5% within 90 days). In adjusted analyses, HF patients carrying a baseline diagnosis of CAD had greater odds of noninvasive ischemic testing (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.33; p < 0.0001), as well as invasive ischemic testing (OR, 1.93; 95% CI, 1.83-2.05; p < 0.0001) at the index hospitalization than those without baseline CAD. Patients with no history of CAD at baseline were less likely to undergo testing for ischemic CAD (rate of testing during index hospitalization: 16.5% in those without CAD vs. 18.3% with known CAD; p < 0.001; rate of testing within 90 days: 26.9% in those without CAD vs. 27.8% with known CAD; p = 0.009). In contrast, patients with baseline CAD were more likely to undergo an invasive CAD assessment (defined as coronary angiography) compared with those without baseline CAD during the index hospitalization (9.7% in those without CAD vs. 12.3% with known CAD; p < 0.001) and within 90 days (15.4% vs. 17.5%; p < 0.001).

Conclusions:

The authors concluded that ischemic CAD is significantly underutilized in patients with new-onset HF.

Perspective:

This is an important paper because it suggests that a better job can be done identifying ischemic etiology in new-onset HF, particularly because CAD is usually eminently treatable.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Coronary Artery Disease, Coronary Angiography, Diagnostic Imaging, Echocardiography, Stress, Exercise Test, Geriatrics, Heart Failure, Inpatients, Ischemia, Myocardial Revascularization


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