Less Is Not Always More: Screening for Coronary Disease Underused in Patients With Heart Failure
The medical community has focused on potential overuse of various tests and treatments in recent years, but it appears that ischemic CAD assessment and subsequent revascularization are being withheld from the majority of patients with new-onset heart failure, according to an analysis of insurance claims.
Only 17.5% of such patients underwent invasive or noninvasive screening for ischemic CAD during the index hospitalization, with the rate rising to just 27.4% within 90 days, lead author Darshan Doshi, MD (Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, NY), and colleagues report.
Moreover, only 2.1% and 4.3% of patients underwent revascularization during the index hospitalization and within 90 days, respectively.
Senior author Ajay Kirtane, MD (Columbia University Medical Center/NewYork-Presbyterian Hospital), told TCTMD the underuse of CAD screening was not unexpected—because it is concordant with what he and his colleagues had observed anecdotally—but said he was surprised by how low the rate was.
He predicted, however, that the recently reported 10-year results from the STICH trial—which showed that CABG reduces all-cause and cardiovascular mortality compared with medical therapy in patients with heart failure and severe LV dysfunction—will be used to strengthen guideline recommendations and provide greater support for CAD testing in this population.
“Those data are pretty unequivocal,” he said, cautioning that the populations of the current analysis (all patients with new-onset heart failure) and the STICH trial (patients with ischemic cardiomyopathy) differ. “But I think as a general paradigm, if somebody has heart failure—particularly given that ischemic heart disease is the most common cause of it in the Northern hemisphere—we ought to at least diagnose it and then consider appropriate therapy for it,” Kirtane said.
Commenting on the study for TCTMD, Eric Velazquez, MD (Duke University, Durham, NC), one of the principal investigators of STICH, said, “My perspective is that we didn’t have many patients who had heart failure who were being evaluated extensively for coronary disease because—prior to STICH—[physicians] really didn’t have data to suggest that revascularization could lead to an improvement in outcomes.”
But the benefits of surgical revascularization seen in STICH are not the only reason to increase use of CAD screening in patients with heart failure, he noted. “The reality is that without knowing information around whether patients have coronary disease, we can’t even apply appropriate medical therapy.”
Thus, the rate of testing “should be much, much higher,” Velazquez said. “If we were to broaden the evaluation appropriately to the vast majority of patients with heart failure, I think we’d have a better understanding of what’s driving those symptoms, what’s impacting the prognosis, and what treatments not only medically but also revascularization-wise would benefit them.”
The most recent heart failure guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) included a class IIa recommendation—meaning that it is reasonable—for both noninvasive and invasive assessment of ischemic CAD in patients with heart failure, but there is little data on how often that testing is performed.
For the study, published online ahead of the August 2, 2016, issue of the Journal of the American College of Cardiology, the investigators looked at data from the Truven Health MarketScan Commercial and Medicare Supplemental databases on 67,161 patients hospitalized with new-onset heart failure between 2010 and 2013.
Slightly more than half (54%) had known CAD at baseline, and these patients were more likely to undergo noninvasive testing for ischemia (OR 1.25; 95% CI 1.17-1.33), invasive assessment (OR 1.93; 95% CI 1.83-2.05), and revascularization (OR 9.27; 95% CI 7.74-11.10).
The low rates of testing overall in this study and a prior smaller analysis, however, “are sobering” considering the recommendations from ACC/AHA and other groups, the authors say.
“Even assuming incomplete reporting of testing within the current database, when combining the present findings with the prevalence of CAD in patients with HF and the reported annual incidence of 915,000 patients with new-onset HF, it can be estimated that every year more than 325,000 patients with new-onset HF and CAD might not be adequately assessed for ischemic CAD,” they write.
And the underuse of testing might not be limited to CAD assessment in this population, as “more than one-quarter of patients with newly diagnosed HF did not even undergo a 2-dimensional transthoracic echocardiogram, despite the fact that the ACC/AHA guidelines establish echocardiography as a class I recommendation in the work-up for new-onset HF,” they add. “This speaks to a larger issue at hand, namely that patients being hospitalized for new-onset HF may not be receiving an appropriate HF work-up in general.”
‘Less Is Actually Less’
Kirtane pointed out that there has been a lot of discussion over the last decade about overuse of invasive and noninvasive testing for CAD. In certain cases, he said, less testing can be the right way to go, particularly in lower-risk patients.
“On the other hand, I would say that if you’re sick, then less is actually less and people can benefit from the appropriate use of these types of therapies,” he said. “So for me, that’s kind of the take-home message.”
James Young, MD (Cleveland Clinic, Cleveland, OH), and Josef Stehlik, MD, MPH (University of Utah, Salt Lake City), address that issue in an accompanying editorial.
“If data indicate, which they do, that select diagnostic and therapeutic procedures are beneficial in appropriate patients, and if guidelines address this situation in reasonable fashion, which they do, it makes sense that more aggressive testing for ischemic heart disease (and determining any relationship to new-onset heart failure) should occur,” they write.
The editorialists say that a move toward new approaches to healthcare delivery that focus on reducing costs might lessen use of aggressive testing in some types of patients, adding that this could be what’s happening in the heart failure population.
“We might think about that a bit and consider the argument made by seeking value in healthcare,” Young and Stehlik write. “When value translates into meaningful patient outcomes divided by cost, we must include the fact that appropriate diagnosis and management of ischemic syndromes in new-onset heart failure, though costly, could translate into morbidity reduction and improvement in quality of life. Perhaps this is where the real ‘cost savings’ will occur and counterbalance the expense of diagnostic procedures and interventions.”
Note: Several coauthors are faculty members of the Cardiovascular Research Foundation, the publisher of TCTMD.
Doshi D, Ben-Yehuda O, Bonafede M, et al. Underutilization of coronary artery disease testing among patients hospitalized with new-onset heart failure. J Am Coll Cardiol. 2016;68:450-458.
Young JB, Stehlik J. Ischemic heart disease in new-onset heart failure, or finding Waldo: where’s Waldo? J Am Coll Cardiol. 2016;68:459-460.
- The study was supported by an unrestricted educational grant from Abiomed.
- Doshi reports having received an educational grant from Abiomed.
- Kirtane reports having received institutional research grants to Columbia University from Boston Scientific, Medtronic, Abbott Vascular, Abiomed, St. Jude Medical, Vascular Dynamics, and Eli Lilly.
- Young, Stehlik and Velazquez report no relevant conflicts of interest.