Not enough patients with new-onset heart failure get screened for ischemic coronary artery disease (CAD) during their hospital stay, a study found.
Only 17.5% of patients identified with new-onset heart failure underwent testing for ischemic CAD during the index hospitalization. Another 2.1% actually got revascularization during the same stay, reported Ajay J. Kirtane, MD, SM, of Columbia University Medical Center/New York-Presbyterian Hospital, and colleagues online in the Journal of the American College of Cardiology.
By 90 days, 27.4% of the patients received testing and 4.3% underwent revascularization.
The data suggest “significant underutilization of ischemic CAD assessment in new-onset heart failure patients,” the authors concluded, noting that the 2013 American College of Cardiology/American Heart Association guidelines for the management of heart failure currently designate a Class IIa indication to both noninvasive and invasive assessment of ischemic CAD.
“In an increasingly cost-conscious era where there is concern for excessive testing in lower-risk patients, there certainly appears to be concomitant underutilization of appropriate testing in higher-risk patients as well, consistent with a treatment-risk paradox,” Kirtane and colleagues suggested.
Calling the findings “amazing and troubling,” James B. Young, MD, of Cleveland Clinic, and Josef Stehlik, MD, MPH, of the University of Utah School of Medicine, agreed that economics may have had something to do with the results: “There is the possibility that care paths focused on reducing cost per case in the setting of population management might push us away from aggressive testing and therapy in some patients,” they wrote in an accompanying editorial. Perhaps, though there is no evidence to support that, this is what might be occurring in this particular group.”
Moreover, the search for the link between heart failure and CAD continues in a “Where’s Waldo”-like fashion, they commented: “CAD is all too often disguised as Waldo … Looking for Waldo dressed up as ischemic heart disease amongst the myriad difficulties often present in patients with heart failure seems essential.
“Paying better — or, let’s say, more compulsive — attention to current heart failure diagnosis and treatment guidelines seems essential. We might quibble about specific recommendations, but generally, there is agreement about how to approach ischemic heart disease and adhering to the guidelines to do so. Arguably, with increased adherence to guidelines, outcomes would be better.
“Let’s think hard about ‘Getting With the Guidelines’ the next time we see a new heart failure patient, and let’s push for an ischemia work-up and intervention more often than it seems we are doing today,” Young and Stehlik urged.
For the study, Kirtane and colleagues performed a retrospective analysis of claims data from 67,161 patients enrolled in the Truven Health MarketScan Commercial and Medicare databases. Patients were diagnosed with new-onset heart failure during inpatient hospitalization from 2010 to 2013.
CAD screening at the index hospital visit comprised non-invasive stress testing (7.9% of cases) and invasive coronary angiography (11.1%). Within 90 days, 14.6% of patients received stress testing and 16.5% had coronary angiography.
Compared with those who lacked a history of CAD, patients who had previously been diagnosed were more likely to get testing through invasive (odds ratio [OR] 1.93, 95% CI 1.83-2.05) and non-invasive modalities (OR 1.25, 95% CI 1.17-1.33) at index hospitalization.
Baseline CAD was also a predictor of revascularization (OR 9.27, 95% CI 7.74-11.10).
“The potential underuse of ischemic CAD testing in patients with new-onset HF has several potential implications beyond the empiric desire to establish a definitive etiology for heart failure,” the investigators wrote. “The omission of ischemic CAD testing may prevent patients from being treated with aggressive guideline-directed medical therapies for CAD, which can both alleviate symptoms and reduce hard cardiovascular events.”
“Additionally, upfront ischemic testing can lead to lower resource utilization in terms of emergency department visits and rehospitalization for complications of CAD and heart failure.
“Lastly, a significant proportion of patients with heart failure and left ventricular dysfunction have the potential for clinically important improvements in left ventricular function after the appropriate use of coronary revascularization,” they suggested.
The team acknowledged that the study may have been affected by errors in coding and that the outcomes dataset was incomplete.
The study was supported by a grant from Abiomed.
Kirtane reported receiving institutional research grants from Boston Scientific, Medtronic, Abbott Vascular, Abiomed, St. Jude Medical, Vascular Dynamics, and Eli Lilly.
Young and Stehlik declared no relevant competing interests.
Journal of the American College of Cardiology
Doshi D, et al “Underutilization of coronary artery disease testing among patients hospitalized with new-onset heart failure” J Am Coll Cardiol 2016; DOI: 10.1016/j.jacc.2016.05.060.
Journal of the American College of Cardiology
Young JB, et al “Ischemic heart disease in new-onset heart failure, or finding Waldo: where’s Waldo?” J Am Coll Cardiol 2016; DOI: 10.1016/j.jacc.2016.05.061.