Heart Failure Patients Still Undertested for CAD

People with new-onset heart failure (HF) continued to lack adequate testing for coronary artery disease (CAD), a common and treatable cause of HF, and nationwide variations in testing rates suggested room for quality improvement across physicians and geographic regions.

From a large pool of patients with incident HF in 2004-2019, just 34.8% underwent CAD testing during the 90 days before and after the initial diagnosis -- 21.7% getting noninvasive testing and 20.7% coronary angiography, according to Alexander Sandhu, MD, MS, of Stanford University School of Medicine in California, and colleagues.

Cardiologists were roughly five times more likely than primary care providers (PCPs) to have their HF patients get tested for CAD, though there was wide variation among cardiologists, too, they reported in the Journal of the American College of Cardiology.

"The wide discrepancy in testing rates between PCPs and cardiologists is particularly striking, because nearly 50% of our cohort were linked to a PCP without cardiology comanagement," Sandhu's group wrote.

With this report, the authors extend prior observations of underutilization of testing for CAD to HF outpatients in the contemporary era. Since 2013, guidelines have recommended consideration of noninvasive imaging or coronary angiography among patients with incident HF eligible for revascularization.

"Barring a sea change in how noncardiovascular clinicians manage HF, it is not unreasonable to argue that absent major contraindications, every patient diagnosed with new-onset HF should be referred to a cardiovascular clinician, with establishment of GDMT [guideline-directed medical therapy] goals and CAD testing," commented James Januzzi Jr, MD, of Massachusetts General Hospital in Boston, and E. Magnus Ohman, MB BCh, of Duke Clinical Research Institute in Durham, North Carolina.

Given the overall testing rate of 57% by cardiologists, however, "even this might leave us short of the goal of routine CAD testing for our affected patients," they wrote in an accompanying editorial.

Sandhu and colleagues found that CAD testing stayed flat even after the 2016 STICHES report showing a long-term mortality benefit to revascularization among patients with ischemic cardiomyopathy. Ultimately, 9.3% of people with new-onset HF underwent revascularization in the study.

"Our findings raise concern that patients with new-onset HF are not only undertested but also undertreated for CAD," the authors wrote. "Omission of timely testing precludes management of the most common and potentially reversible etiology of HF."

"A call to action to address the massive gaps in quality of HF care is sorely needed, with a concerted effort to close the shortfalls in GDMT and CAD treatment in persons with HF. The question exists however: who will make this call, and how many will answer?" Januzzi and Ohman wrote.

The observational study relied on Clinformatics DataMart, an administrative claims database from Optum.

Included were 558,322 adults with a new diagnosis of HF, excluding people with a prior CAD diagnosis and those who had recently received dialysis. Participants averaged age 71.7, and 55.5% were women.

Patient characteristics associated with greater likelihood of CAD testing included ages 40-64 versus older people, men over women, Asian and white patients over Black ones, and greater acuity at presentation.

"Importantly, prominent CAD risk factors such as hypertension, diabetes, obesity, and sleep apnea were not strongly associated with testing, revealing missed opportunities for high-yield CAD workup. In contrast, negative predictors included alcohol use disorder and chronic obstructive pulmonary disease, both of which increase mortality in patients with ischemic heart disease," Sandhu's group found.

Disproportionately low rates of CAD testing were also shown in patients with a history of psychotic disorder and dementia.

Additionally, testing rates varied geographically -- from a low of 20% in San Luis Obispo County, California, to a high of 45% in Clay County, Florida.

"The root causes of observed geographic differences are unclear, but prior research has identified disparities in resource availability, health care access, socioeconomic conditions, and healthy public policies. Regional gaps in testing highlight the importance of continued surveillance to uncover underlying drivers," according to Sandhu and colleagues.

They cautioned that the study was subject to local differences in coding practices, unmeasured confounding, and limitations in the granularity of the available clinical data.

"Regardless of these limitations, there is little chance the results would meaningfully change had other data sources been used," Januzzi and Ohman said.

"Given that CAD has such an established role as a major cause of a leading diagnosis associated with hospitalization and death, widespread availability of tools for its diagnosis, and a dramatic benefit from its treatment in those with HF, one might think that clinicians would pursue the presence of ischemic heart disease with dogged determination. Disappointingly this has not been the case," they stated.

Comment