Heart failure

Inadequate testing for CAD breathes space for heart failure

Although coronary artery disease (CAD) is the most common cause of new-onset heart failure (HF) and the American College of Cardiology and American Heart Association recommend that clinicians consider testing for it with imaging Noninvasive or coronary angiography in patients with HF, timely testing does not occur in most settings according to new study data.

These results were seen even after accounting for inpatient and outpatient settings, and the results were published recently in Journal of the American College of Cardiology.

“Because coronary artery disease is a common and treatable cause of HF, early identification is an important part of disease management,” the study authors wrote. “In this study, we sought to identify demographic and clinical factors associated with CAD testing in patients with incident HF across all care settings, as well as temporal, geographic, and clinician variability in testing. . »

The POINT and POINTS trialswhose results were published in 2011 and 2016, respectively, highlighted the benefits of cardiovascular mortality after coronary artery bypass surgery and assessment of ischemic etiology, but more data are needed, they added.

Of the 558,322 people who experienced incident heart failure (i.e. first admission for the disease) between 2005 and 2019, less than half underwent coronary artery disease testing or revascularization, at 34.8 % and 9.3%, respectively. And those testing rates remained low, ranging from just 20% to 45% in county of residence, even after adjusting for covariates.

In addition, 21.7% underwent stress testing, nuclear stress imaging, cardiac MRI, and coronary angiography to test for coronary artery disease.

Patient counties of residence (using zip codes) were considered to account for national variation, but rates did not change significantly following the STICHES trial (from an adjusted odds ratio [aOR] from 0.99 to 1.01). Heart failure was diagnosed based on International Classification of Diseases, Ninth and 10th edition codes, and the primary outcome of the study was the occurrence of coronary artery disease testing.

Following the identification of demographic and clinical predictors of coronary artery disease testing for the 3 months before and after a diagnosis of incident HF, the authors determined that a young age, male, receiving a diagnosis at a acute care (eg, emergency department [ED] or hospital stay), a history of systolic dysfunction or recent cardiogenic shock, and the presence of cardiovascular risk factors (eg, hyperlipidemia, obesity, history of smoking) indicated a greater likelihood of coronary screening.

In addition, after adjusting for specialist care, patients co-managed by a cardiologist had more than 4 times the detection rate for CAD than unmanaged patients (aOR, 5.12; 95% CI, 4 .98-5.27). Among cardiologists themselves, the percentage who referred patients for testing ranged from 50.9% to 62.4%.

The authors’ analysis also showed that black patients were 10% less likely to undergo a CAD test than white patients (aOR, 0.90; 95% CI, 0.88-0.92), but that Asian patients were 6% more likely than white patients to undergo a CAD test. (aOR, 1.06; 95% CI, 1.01-1.10). This rate increased to 43% if patients had to go to the emergency department on their index date or if they had to be hospitalized within one month of their heart failure diagnosis (aOR, 1.43; 95 CI %, 1.42-1.45).

Negative predictors for the tests included chronic kidney disease, chronic obstructive pulmonary disease, depression and alcohol use disorders, with the lowest rates of 22% and 16.3% seen in people with a history of psychotic disorder or dementia, respectively.

By county, the highest CAD testing rate was seen in Clay County, Florida (45.2%), and the lowest testing rate was seen in San Luis Obispo County, California (45.2%). Myocardial infarction rates ranged from 3.6 per 1,000 Medicare beneficiaries in Blaine County, Idaho, to 21.9 in Clay County, from 2005 to 2018.

The authors noted that even with guidelines recommending CAD testing and despite data from the STICHES trial showing that there is benefit to CAD, their data shows that this is not the case and the picture remains dark ; in particular, because their figures show that the rates have remained stable over the 16 years of their analysis. Their analysis also highlights missed opportunities for screening, particularly among patients with risk factors for coronary artery disease, black patients and women.

“Our results raise concerns that patients with recent-onset HF are not only undertested, but also undertreated for coronary artery disease. burden of the most common and potentially reversible etiology of IC,” they concluded. “The continued underuse of CAD testing in patients with new-onset IC leaves much room for ‘improvement.”


Zheng J, Heidenreich PA, Kohsaka S, Fearon WF, Sandhu AT. Variability in coronary artery disease testing for patients with new-onset heart failure. J Am Coll Cardiol. 2022;79(9):849-860. doi:10.1016/j.jacc.2021.11.061