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Early Invasive Angiography in Acute Heart Failure
Quick Takes
- Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, and HF readmissions at 2 years.
- There were higher rates of coronary revascularization at 90 days and 2 years when early angiography was performed, suggesting that early intervention could contribute to improved outcomes.
- Given limitations of the current study design and potential selection biases for early angiography, randomized trial evidence is required to validate these results.
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 at least one factor suggesting underlying ischemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. The authors oversampled patients undergoing angiography. They used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7,239 patients with acute HF, 2,994 met inclusion criteria (median age 75 [interquartile range 65-83] years; 40.9% women). The co-primary outcomes were all-cause and cardiovascular mortality. Weighted Cox proportional hazard regression models were used to estimate hazard ratios (HRs) for each outcome at each time point of interest.
Results:
Early angiography was performed in 1,567 patients (52.3%) and was associated with lower all-cause mortality (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 of hospitalized acute ischemic HF patients reports that early coronary angiography was associated with lower all-cause mortality, cardiovascular death, and HF readmissions at 2 years. There were higher rates of coronary revascularization at 90 days and 2 years when early angiography was performed, suggesting that early intervention could contribute to improved outcomes. Overall, this study suggests that early coronary angiography may benefit patients with acute HF with potential underlying ischemia, but given limitations of the current study design and potential selection biases for early angiography, randomized trial evidence is required to validate these results.
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, Secondary Prevention, Troponin
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