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Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a
Matthew S Durstenfeld1, Anjali Thakkar1, Yifei Ma1
1Division of Cardiology at Zuckerberg San Francisco General and Department of Medicine, University of California, San Francisco (UCSF).
Insights
Early coronary assessment after heart failure diagnosis is linked to lower mortality. Disparities exist in who receives this assessment, with women and older individuals less likely to undergo it. Further research is needed to confirm findings.
Area of Science:
- Cardiology
- Public Health
- Health Services Research
Background:
- Ischemic cardiomyopathy is the primary cause of heart failure (HF).
- Coronary assessment is infrequently performed after HF diagnosis, with no existing randomized trials.
- Disparities in coronary assessment exist within safety-net populations.
Purpose of the Study:
- To identify factors associated with coronary assessment post-HF diagnosis.
- To evaluate the association of early coronary assessment with mortality and other outcomes.
- To explore disparities in access to coronary assessment.
Main Methods:
- Utilized an electronic health record cohort (2001-2019) of individuals with HF.
- Employed target trial emulation and propensity scores for causal inference.
- Used national death records to ascertain mortality and included falsification endpoints.
Main Results:
- 26.9% of HF patients completed coronary assessment; women, older individuals, and those unstably housed were less likely to be assessed.
- Early coronary assessment was associated with lower all-cause mortality (HR 0.84) and a composite outcome (HR 0.86).
- Early assessment correlated with increased revascularization (OR 7.6) and medical therapy use (OR 2.5).
Conclusions:
- Disparities in coronary assessment after HF diagnosis persist and are not fully explained by traditional risk factors.
- Early coronary assessment may improve HF outcomes, potentially through increased revascularization and guideline-directed medical therapy.
- The certainty of these findings is limited by potential unmeasured confounding.
Background:
Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis.
Methods:
Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death.
Results:
Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points.
Conclusions:
In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.
