Trends in Ischemic Evaluation in New-Onset Heart Failure Without Known Coronary Artery Disease
Charlotte Andersson1, Morten Schou2, William E Boden3
1Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
Few patients with new-onset heart failure (HF) receive ischemic evaluations or revascularization, despite guidelines recommending it. This study tracked trends in HF patients in Denmark from 2008-2018, finding low rates of these crucial diagnostic and treatment pathways.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Clinical guidelines suggest ischemic evaluation for new-onset heart failure (HF).
- However, the frequency of these evaluations and subsequent revascularization in clinical practice is not well-established.
- This study addresses this gap by examining temporal trends in Denmark.
Purpose of the Study:
- To investigate the trends in ischemic evaluation and revascularization within 90 days of new-onset heart failure (HF).
- To analyze the utilization of diagnostic tests and interventions in a real-world clinical setting.
Main Methods:
- Utilized Danish nationwide administrative registries from 2008-2018.
- Identified patients with new-onset heart failure (HF) alive 90 days post-diagnosis.
- Analyzed diagnostic tests and revascularization procedures performed within 90 days.
Main Results:
- Of 61,475 patients, only 20% underwent ischemic evaluation; 11% received percutaneous coronary intervention and 5% coronary artery bypass graft surgery.
- Ischemic evaluations increased annually (OR 1.07), with higher rates in older age groups.
- Coronary computed tomographic angiography was the most frequent initial noninvasive test (93%).
Conclusions:
- Current clinical practice shows low rates of ischemic evaluation and revascularization in new-onset heart failure (HF) patients.
- Further research is necessary to determine the appropriateness of current practices.
- The findings highlight a potential area for improving guideline adherence and patient care.
Background:
Guidelines recommend consideration of an ischemic evaluation (Class IIa-IIb) in new-onset heart failure (HF), but it is not well-known how often this is performed and leads to revascularization.
Objectives:
The authors investigated temporal trends in ischemic evaluation and revascularization within 90 days of HF onset in Denmark 2008-2018.
Methods:
From the Danish nationwide administrative registries, diagnostic tests and revascularizations within 90 days were identified among patients with new-onset HF between 2008 and 2018, alive 90 days after diagnosis.
Results:
Of 61,475 patients (mean age: 72.6 ± 13.8 years, 46% women), 12,503 (20%) underwent an ischemic evaluation, of whom 10,547 (84%) underwent invasive coronary angiography, and 1,956 (16%) underwent an initial noninvasive test, most frequently coronary computed tomographic angiography (n = 1,813, 93%). Of those who were initially referred for coronary computed tomographic angiography, 374 (21%) had a subsequent invasive coronary angiogram undertaken. Among individuals undergoing ischemic testing, percutaneous coronary intervention and coronary artery bypass graft surgery were performed in 1,354 (11%) and 619 (5%), respectively, corresponding to 2.2% and 1.0% of the entire sample. Between 2008 and 2018, the number of patients referred for ischemic evaluations increased, adjusted OR for 1.07 (95% CI: 1.06-1.07) per year high, and was greater among older versus younger individuals (OR: 1.01 [95% CI: 0.99-1.03], OR: 1.04 [95% CI: 1.03-1.06], OR: 1.06 [95% CI: 1.05-1.07], OR: 1.11 [95% CI: 1.09-1.12], and OR: 1.14 [95% CI: 1.10-1.18] per year increase for age group <50, 51-60, 61-75, 76-85, and >85 years, respectively, P for interaction <0.0001).
Conclusions:
In clinical practice, few patients with new-onset HF are referred for an ischemic evaluation and a minority undergo revascularization. Studies are needed to establish the appropriateness of this practice.
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