Ischemic CAD Testing Underutilized in New Heart Failure Patients

September 1, 2016

Written by Christopher Chalk, DC, MPH

Ischemic coronary artery disease (CAD) testing appears to be significantly underused in patients newly diagnosed with heart failure (HF) at both initial hospitalization and within a 90 day follow-up period, according to a new retrospective cohort study of 67,161 patients.

Dr. Doshi from Columbia University Medical Center and colleagues reported their findings in the August 2016 edition of the Journal of The American College of Cardiology. “The principle finding of this analysis was that almost three-quarters of patients with new-onset HF did not receive any ischemic CAD testing within 90 days of index admission,” the authors commented. The percentage of patients with known CAD in this study population (53.7%) combined with the poor outcomes of concomitant CAD and HF underscore the importance of the problem, according to the researchers.

Results

Patients with a diagnosis of new-onset HF as the primary diagnosis with at least a 90-day continuous follow-up were taken from the Truven MarketScan and Medicare Supplemental databases (n = 67,161) from 2010 to 2014.

Patient Characteristics

The average age of the patients was 73.68 years with slightly more males (52.4%) than females (47.6%). Common comorbidities included hypertension (83.3%), non-major arrhythmia (59.7%), and CAD (53.7%).

Noninvasive Testing

A standard 2-dimensional echocardiogram was performed in 63.6% of patients during the index hospitalization and 72.9% within 90 days.

Noninvasive Testing for Ischemia in HF Patients

Noninvasive testing included exercise or pharmacological testing with or without echocardiography or myocardial perfusion imaging. The rate during index hospitalization was 7.9% and rose to 14.6% within 90 days. After adjusting for variables patients with a diagnosis of CAD had greater odds of having noninvasive ischemic testing (OR: 1.25, P < .0001) compared to those without CAD at index hospitalization.

Invasive Testing for Ischemia in HF Patients

Coronary angiography was performed in 11.1% of patients during the index hospitalization and 16.5% within 90 days. Right heart catheterization was performed in 7.1% of patients during index hospitalization and 10.8% within 90 days. After adjusting for variables patients with a diagnosis of CAD had greater odds of having invasive ischemic testing (OR: 1.93, P < .0001) compared to those without CAD at index hospitalization.

Revascularization for HF Patients

Percutaneous coronary intervention (PCI) was performed in 1.5% of HF patients during the index hospitalization and 3% of patients within 90 days, while Coronary Artery Bypass Grafting (CABG) was performed in .5% of patients during index hospitalization and 1.3% of patients within 90 days.

American College of Cardiology/American Heart Association Guidelines

According to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for noninvasive ischemic testing in HF, nuclear stress testing or stress echocardiography is reasonable and useful to detect ischemia unless the patient is not eligible for revascularization. However, even with this class IIa indication only 14.4% of patients given a diagnosis of CAD had noninvasive testing within 90 days.

ACC/AHA guidelines for a workup of new-onset HF include recommendations for a 2-dimensional echocardiogram (class I). However, “more than one-quarter of patients with newly diagnosed HF did not even undergo a 2-dimensional transthoracic echocardiogram,” the authors emphasized.

Estimations

The percentage of patients with new onset HF who had a diagnosis of CAD and did not undergo any ischemic testing within 90 days was 72.2%. According to the authors “most patients with new onset HF-even those with a known diagnosis of CAD-did not receive a workup for ischemic CAD.”

The authors estimated the impact of these results. “Even assuming incomplete reporting of testing within the current database, when combining the present findings with the prevalence of CAD in patients with HF and the reported annual incidence of 915,000 patients with new-onset HF, it can be estimated that every year more than 325,000 patients with new-onset HF and CAD might not be adequately assessed for ischemic CAD.”

Implications

The underutilization of ischemic testing in patients with new-onset HF “may prevent patients from being treated with aggressive guideline-directed medical therapies for CAD, which can both alleviate symptoms and reduce hard cardiovascular events,” the authors noted.

In the OPTIMIZE-HF study, the use of coronary angiography in acute heart failure syndromes in patients with CAD was associated with an increased use of heart medication and revascularization. Subsequently, at 60 to 90 days after discharge, significantly lower rates of mortality and re-hospitalizations were reported in this group.

An appropriate increase in the use of ischemic testing should lead to improved heart function, quality of life measures and a lowering in the use of hospital resources, the authors noted.

Questions

This study by Doshi et al. and a similar study by Farmer et al. show a significant underutilization of CAD testing, whereas the OPTIMIZE-HF study as well as others, provide evidence of improved outcomes with increased testing and revascularization. Given that CAD is the most common primary cause of HF, and if the increased use of guideline-recommended testing improves outcomes, then it raises the question ‘why aren’t the majority of HF patients being tested?’

The Farmer et al. study, which included data on cardiovascular testing in incident HF hospitalization for up to 6 months post discharge between 2005 and 2008 (before the Affordable Care Act of 2010), showed somewhat higher utilization rates compared with the Doshi et al. study in which data was from 2010 to 2014. The higher utilization rates in the Farmer et al. study may be related to the longer follow-up period. However, as healthcare moves forward, further changes are being made away from a fee-for-service approach and toward a value-based payment model. In an editorial accompanying the Doshi et al. study, Dr. Young and Dr. Stehlik question whether physicians are being pushed away from more aggressive testing by these healthcare changes and creating the underutilization seen in the Doshi et al. study.

Conclusions

There is a growing consensus that the ACC/AHA guidelines are not being optimally followed. Dr. Young and Dr. Stehlik encourage physicians to increase the implementation of ischemic testing procedures in new-onset HF and consider a stricter adherence to the guidelines.

Doshi D, Ben-Yehuda O, Bonafede M, et al. Underutilization of Coronary Artery Disease Testing Among Patients Hospitalized With New-Onset Heart Failure. J Am Coll Cardiol. 2016;68(5):451-458.

Disclosures: This study was supported by an unrestricted educational grant from Abiomed Inc. Dr. Doshi has received an educational grant from Abiomed. Dr. BenYehuda has received institutional research grants from Abiomed and Thoratec. Dr. Bonafede is an employee of Truven Health, which was awarded a contract to conduct this study in collaboration with Abiomed. Dr. Josephy is an employee of Abiomed. Dr. Karmpaliotis is on the speakers bureaus of Abbott Vascular, Boston Scientific, Medtronic, and Asahi. Dr. Parikh is on the speakers bureaus of Abbott Vascular, Medtronic, CSI, St. Jude Medical, and Boston Scientific; and is on the advisory boards of Abbott Vascular, Medtronic, and Philips. Dr. Moses is a consultant for Boston Scientific and Abiomed. Dr. Kirtane has received institutional research grants to Columbia University from Boston Scientific, Medtronic, Abbott Vascular, Abiomed, St. Jude Medical, Vascular Dynamics, and Eli Lilly. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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