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Early Invasive Angiography in Acute Heart Failure
Quick Takes
- In acute HF hospitalized patients, early coronary angiography was associated with lower all-cause mortality, cardiovascular death, and HF readmissions at 2 years.
- These data suggest that early coronary angiography may benefit patients with acute HF and potential underlying ischemia, supporting the need for an evidence-based clinical framework for the diagnosis and assessment of coronary artery disease in the acute HF population.
- The study findings support the ACC/AHA HF guidelines that state: “When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization.”
Study Questions:
What is the association of early coronary angiography during acute heart failure (HF) hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization?
Methods:
The investigators, using a two-stage sampling process, identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010–March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, they defined a cohort with acute ischemic HF as patients with ≥1 factor suggesting underlying ischemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. The authors oversampled patients undergoing angiography and used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Weighted Kaplan–Meier survival curves and the adjusted log-rank test were used to compare all-cause mortality between groups after IPTW.
Results:
Of 7,239 patients with acute HF, 2,994 met inclusion criteria (median age 75 [interquartile range, 65-83] years; 40.9% women). Early angiography was performed in 1,567 patients (52.3%) and was associated with lower all-cause mortality (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.61-0.90; p = 0.002), cardiovascular death (HR, 0.72; 95% CI, 0.56-0.93; p = 0.012), and HF readmissions (HR, 0.84; 95% CI, 0.71-0.99; p = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR, 2.58; 95% CI, 1.73-3.86; p < 0.001) and coronary artery bypass grafting (HR, 2.94; 95% CI, 1.75-4.93; p < 0.001) within 2 years.
Conclusions:
The authors concluded that early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischemia.
Perspective:
This study reports that in acute HF hospitalized patients, early coronary angiography was associated with lower all-cause mortality, cardiovascular death, and HF readmissions at 2 years. These data suggest that early coronary angiography may benefit patients with acute HF and potential underlying ischemia, supporting the need for an evidence-based clinical framework for the diagnosis and assessment of coronary artery disease in the acute HF population. While randomized trial data are required to validate these results, the findings support the American College of Cardiology/American Heart Association (ACC/AHA) HF guidelines that state: “When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization.”
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and SIHD, Acute Heart Failure, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Angina Pectoris, Coronary Angiography, Coronary Artery Bypass, Emergency Service, Hospital, Geriatrics, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Patient Readmission, Percutaneous Coronary Intervention, Primary Prevention, Troponin
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