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Testing for CAD in Older Patients With New-Onset Heart Failure
Study Questions:
What proportion of patients with new-onset heart failure (HF) are tested for coronary artery disease (CAD)?
Methods:
This is an analysis of the Get With the Guidelines–Heart Failure (GWTG-HF) registry and linked Medicare claims in patients aged ≥65 years who were hospitalized for new-onset HF. In addition to clinical characteristics and left ventricular ejection fraction (LVEF), in-hospital CAD testing was recorded in the registry. Outpatient CAD testing was identified from Medicare claims data in the period ± 90 days from index hospitalization. Logistic regression was used to identify factors associated with use of CAD testing.
Results:
Of 22,747 patients with new-onset HF who could be linked to Medicare claims between 2009 and 2015, 17,185 (76%) were analyzed. Most of the excluded patients were excluded because of in-hospital death, hospice referral, or death within 90 days after discharge. Overall, only 39% of patients had testing for CAD with younger age, male sex, smoking, and hyperlipidemia associated with increased testing (all p < 0.05). Patients with HF with reduced EF (HFrEF, ≤40%) were more likely to undergo testing (odds ratio, 2.42). Furthermore, testing increased over time in patients with HFrEF, rising from 50% in 2009 to 61% in 2015.
Noninvasive testing and invasive angiography were used approximately equally (24% vs. 23%). Only 4.7% of patients underwent percutaneous revascularization and only 2.9% were surgically revascularized. The most common noninvasive testing modalities were stress ECG and nuclear stress testing (20.9% and 20.4%, respectively).
Conclusions:
Utilization of invasive and noninvasive CAD testing in patients with new-onset HF was low and could be a target for care improvement.
Perspective:
The extended follow-up of the STICH trial demonstrated improved survival among patients with surgical revascularization of patients with ischemic cardiomyopathy and LVEF ≤35% and was published in April 2016. One might hope that investigation for CAD in patients with HFrEF meeting STICH entry criteria would increase after that. However, given the high rate of in-hospital and 90-day mortality among this cohort (nearly 1 in 4), it is possible that aversion to higher rates of testing was due to concern over long-term survival due to comorbidities. Nonetheless, if these findings of low use of CAD testing continue to be true among patients meeting criteria for the STICH trial, inclusion of CAD testing as a potential target for improved outcomes in new-onset HF may be fruitful.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: ACC Annual Scientific Session, acc20, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Dyslipidemias, Heart Failure, Hospital Mortality, Hyperlipidemias, Myocardial Revascularization, Outpatients, Patient Discharge, Stroke Volume, Ventricular Function, Left
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