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Coronary Artery Disease Testing Variability in Heart Failure
Quick Takes
- This longitudinal study of CAD testing patterns in patients with incident HF reports that fewer than 40% of patients with incident HF were tested for CAD.
- Despite recommendations from current guidelines, the underutilization of CAD testing has continued across care settings and over time, highlighting an unmet need.
- Given the significant variability, additional studies are indicated to better understand the drivers of and to evaluate strategies to improve adherence to guideline-recommended testing for CAD in patients with new-onset HF.
Study Questions:
What are the contemporary trends in coronary artery disease (CAD) testing for patients with new-onset heart failure (HF), and the geographic and clinician-level variability in testing patterns?
Methods:
The investigators determined the proportion of patients with incident HF who received CAD testing from 2004–2019 using an administrative claims database covering commercial insurance and Medicare. They identified demographic and clinical predictors of CAD testing during the 90 days before and after initial diagnosis. Patients were grouped by their county of residence to assess national variation. Patients were then linked to their primary care physician and/or cardiologist to evaluate variation across clinicians. A multivariable logistic regression model was constructed to compute the covariate-adjusted proportion of patients with incident HF who were tested for CAD.
Results:
Among 558,322 patients with new-onset HF, 34.8% underwent CAD testing and 9.3% underwent revascularization. After multivariable adjustment, patients who underwent CAD testing were more likely to be younger, male, diagnosed in an acute care setting, and have systolic dysfunction or recent cardiogenic shock. Incidence of CAD testing remained flat without significant change post-STICHES (Surgical Treatment for Ischemic Heart Failure Extension Study). Covariate-adjusted testing rates varied from 20%–45% across counties. The likelihood of testing was higher among patients co-managed by a cardiologist (adjusted odds ratio, 5.12; 95% confidence interval, 4.98-5.27) but varied substantially across cardiologists (interquartile range, 50.9%-62.4%).
Conclusions:
The authors concluded that most patients with new-onset HF across inpatient and outpatient settings did not receive timely testing for CAD.
Perspective:
This longitudinal study of CAD testing patterns in patients with incident HF reports that fewer than 40% of patients with incident HF were tested for CAD. Of note, rates of CAD testing have remained flat over the 16-year study period, even after the STICHES trial in 2016 demonstrated long-term mortality benefit with revascularization among patients with ischemic cardiomyopathy. Despite recommendations from current guidelines, the underutilization of CAD testing has continued across care settings and over time, highlighting an unmet need in this high-risk patient population. Given the significant variability across regions, care settings, and practitioners, additional studies are indicated to better understand the drivers of and to evaluate strategies to improve adherence to guideline-recommended testing for CAD in patients with new-onset HF.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease
Keywords: Cardiac Surgical Procedures, Cardiomyopathies, Coronary Artery Disease, Exercise Test, Heart Failure, Inpatients, Myocardial Ischemia, Myocardial Revascularization, Outpatients, Physicians, Primary Care, Secondary Prevention, Shock, Cardiogenic
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