Underutilization of Coronary Artery Disease Testing Among Patients Hospitalized With New-Onset Heart Failure

Abstract

Background: Although ischemic coronary artery disease (CAD) is the most common etiology of heart failure (HF), the extent to which patients with new-onset HF actually undergo an ischemic work-up and/or revascularization is not well defined.

Objectives: This study sought to analyze the patterns of testing for ischemic CAD and revascularization in patients with new-onset HF.

Methods: This was a retrospective cohort study using Truven Health MarketScan Commercial and Medicare databases from 2010 to 2013. The occurrence of noninvasive and invasive ischemic CAD testing and revascularization procedures were examined among patients with new inpatient HF diagnoses during the index hospitalization and within 90 days of admission.

Results: Among 67,161 patients identified with new-onset HF during an inpatient hospitalization, only 17.5% underwent testing for ischemic CAD during the index hospitalization, increasing to 27.4% at 90 days. Among patients with new-onset HF, only 2.1% underwent revascularization during the index hospitalization for HF; by 90 days, the revascularization rate had increased to 4.3%. Of the tests performed for ischemic CAD, stress testing (nuclear stress testing or stress echocardiography) was performed in 7.9% of new-onset HF patients during the index hospitalization (14.6% within 90 days), whereas coronary angiography was performed in 11.1% of patients during the index hospitalization (16.5% within 90 days). In adjusted analyses, HF patients carrying a baseline diagnosis of CAD had greater odds of noninvasive ischemic testing (odds ratio: 1.25; 95% confidence interval: 1.17 to 1.33; p < 0.0001), as well as invasive ischemic testing (odds ratio: 1.93; 95% confidence interval: 1.83 to 2.05; p < 0.0001), at the index hospitalization than those without baseline CAD.

Conclusions: The majority of patients hospitalized for new-onset HF did not receive testing for ischemic CAD either during hospitalization or within 90 days, which suggests significant underutilization of ischemic CAD assessment in new-onset HF patients.

Keywords: angiography; invasive; ischemic CAD; noninvasive; revascularization; stress testing.

FIGURE 1. Patient Flow

From databases containing >81 million patient records, a total of 67,161 heart failure patients were included in this analysis. CAD = coronary artery disease; IP = inpatient.

CENTRAL ILLUSTRATION. Ischemic Work-Up in HF

In this retrospective cohort study, ischemic coronary artery disease (CAD) testing and revascularization procedures were examined among 67,161 patients with new inpatient heart failure (HF) diagnoses during the index hospitalization and within 90 days of admission. Overall, only a minority of patients received any testing for ischemic CAD and those without a history of CAD at baseline received even less. Of the noninvasive (A) and invasive (B) imaging modalities used during index hospitalization and through 90-day follow-up, a standard 2-dimensional echocardiogram was the most commonly performed test.