HF patients rarely tested for CAD
medwireNews: Tests for ischaemic coronary artery disease (CAD) are badly underutilised in patients with new-onset heart failure (HF), research shows.
The study published in the Journal of the American College of Cardiology found that only 27.4% of 67,161 patients hospitalised with new-onset HF between 2010 and 2013 underwent any test for CAD.
“Despite the fact that CAD is, today, the most common primary etiology of heart failure, a surprising—indeed, an amazing and troubling—number of patients were not subjected to noninvasive or invasive evaluations or revascularization procedures to address the potential underlying problem of culprit CAD”, write the authors of an accompanying editorial.
James Young (Cleveland Clinic, Cleveland, Ohio, USA) and Josef Stehlik (University of Utah School of Medicine, Salt Lake City, Utah, USA) stress that testing and intervention “would not be appropriate” in all patients, but say that “surely many more than those reported” in the current study should have been assessed.
The patients were identified from insurance databases and were aged an average of 73.7 years at admission. Just 17.5% underwent testing for CAD during their initial hospitalisation, with 11.1% undergoing invasive and 7.9% noninvasive testing.
Assessment for CAD was only slightly more likely in the 35,051 patients with a history of CAD than in the 31,110 without, at 16.5%. There was also little difference in rates of testing within 90 days after hospitalisation, at 27.8% versus 26.9%. By this point, 16.5% of all patients had undergone invasive and 14.6% noninvasive testing.
A standard echocardiogram was the most frequent noninvasive test used, with nuclear stress test “a distant second”, report Ajay Kirtane (Columbia University Medical Center/New York-Presbyterian Hospital, USA) and study co-authors. Diagnostic coronary angiography was the most common invasive procedure.
On multivariate analysis, multiple factors were associated with an increased or decreased likelihood of undergoing CAD testing. Factors associated with a decreased likelihood of both invasive and noninvasive testing included age older than 70 years, dementia, previous stroke, peripheral arterial disease, renal disease and chronic obstructive pulmonary disease.
In their editorial, Young and Stehlik ask why such widespread undertesting occurs, and speculate that moves to reduce healthcare costs could partly underlie the trend. But they warn that this may be a false economy, given the improvements in morbidity and quality of life achievable with the diagnosis and management of CAD in HF patients.
“Perhaps this is where the real ‘cost savings’ will occur and counterbalance the expense of diagnostic procedures and interventions”, they conclude.
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