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Chang AJ, Liang Y, Hamilton SA, Ambrosy AP. Medical Decision-Making and Revascularization in Ischemic Cardiomyopathy. Med Clin North Am 2024; 108:553-566. [PMID: 38548463 DOI: 10.1016/j.mcna.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Ischemic cardiomyopathy (ICM) is the most common underlying etiology of heart failure in the United States and is a significant contributor to deaths due to cardiovascular disease worldwide. The diagnosis and management of ICM has advanced significantly over the past few decades, and the evidence for medical therapy in ICM is both compelling and robust. This contrasts with evidence for coronary revascularization, which is more controversial and favors surgical approaches. This review will examine landmark clinical trial results in detail as well as provide a comprehensive overview of the current epidemiology, diagnostic approaches, and management strategies of ICM.
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Affiliation(s)
- Alex J Chang
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, 2425 Geary Boulevard, San Francisco, CA 94115, USA
| | - Yilin Liang
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, 2425 Geary Boulevard, San Francisco, CA 94115, USA
| | - Steven A Hamilton
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, 2425 Geary Boulevard, San Francisco, CA 94115, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, 2425 Geary Boulevard, San Francisco, CA 94115, USA; Clinical Trials Program, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
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2
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Huang CW, Kohan S, Liu ILA, Lee JS, Baghdasaryan NC, Park JS, Vallejo JD, Subject CC, Nguyen H, Lee MS. Association Between Coronary Artery Disease Testing in Patients with New-Onset Heart Failure and Heart Failure Readmission and Mortality. J Gen Intern Med 2024; 39:747-755. [PMID: 38236317 PMCID: PMC11043252 DOI: 10.1007/s11606-023-08599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND In patients with new-onset heart failure (HF), coronary artery disease (CAD) testing remains underutilized. Whether widespread CAD testing in patients with new-onset HF leads to improved outcomes remains to be determined. OBJECTIVE We sought to examine whether CAD testing, and its timing, among patients hospitalized with new-onset HF with reduced ejection fraction (HFrEF), is associated with improved outcomes. DESIGN Retrospective cohort study. PARTICIPANTS Adult (≥ 18 years) non-pregnant patients with new-onset HFrEF hospitalized within one of 15 Kaiser Permanente Southern California medical centers between 2016 and 2021. Key exclusion criteria included history of heart transplant, hospice, and a do-not-resuscitate order. MAIN MEASURES Primary outcome was a composite of HF readmission or all-cause mortality through end of follow-up on 12/31/2022. KEY RESULTS Among 2729 patients hospitalized with new-onset HFrEF, 1487 (54.5%) received CAD testing. The median age was 66 (56-76) years old, 1722 (63.1%) were male, and 1074 (39.4%) were White. After a median of 1.8 (0.6-3.4) years, the testing group had a reduced risk of HF readmission or all-cause mortality (aHR [95%CI], 0.71 [0.63-0.79]). These results were consistent across subgroups by history of atrial fibrillation, diabetes, renal disease, myocardial infarction, and elevated troponin during hospitalization. In a secondary analysis where CAD testing was further divided to early (received testing before discharge) and late testing (up to 90 days after discharge), there was no difference in late vs early testing (0.97 [0.81-1.16]). CONCLUSIONS In a contemporary and diverse cohort of patients hospitalized with new-onset HFrEF, CAD testing within 90 days of hospitalization was associated with a lower risk of HF readmission or all-cause mortality. Testing within 90 days after discharge was not associated with worse outcomes.
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Affiliation(s)
- Cheng-Wei Huang
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA.
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Siamak Kohan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Janet S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Nicole C Baghdasaryan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Joon S Park
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Jessica D Vallejo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Christopher C Subject
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Huong Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Ming-Sum Lee
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Zheng J, Heidenreich PA, Kohsaka S, Fearon WF, Sandhu AT. Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure. Circ Heart Fail 2023; 16:e010426. [PMID: 37212148 PMCID: PMC10523905 DOI: 10.1161/circheartfailure.122.010426] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/07/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF. METHODS We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment. RESULTS Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that ≈70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant. CONCLUSIONS Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Chunawala ZS, Qamar A, Arora S, Pandey A, Fudim M, Vaduganathan M, Mentz RJ, Bhatt DL, Caughey MC. Prognostic significance of obstructive coronary artery disease in patients admitted with acute decompensated heart failure: the ARIC study community surveillance. Eur J Heart Fail 2022; 24:2140-2149. [PMID: 35851711 DOI: 10.1002/ejhf.2617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS We aimed to investigate the impact of obstructive coronary artery disease (CAD) in patients with acute decompensated heart failure (ADHF), and examine potential differences in prognostic utility for heart failure with reduced (HFrEF) versus preserved ejection fraction (HFpEF). METHODS AND RESULTS The Atherosclerosis Risk in Communities study conducted hospital surveillance of ADHF from 2005 to 2014. Obstructive CAD was defined as ≥50% or ≥75% stenosis, respectively, for the left main and other major epicardial arteries. Adjusted associations between obstructive CAD and 30-, 60-, and 90-day mortality were analysed. A total of 934 (4146 weighted) patients admitted with ADHF (mean age 72 years, 46% women, 30% Black, 30% HFpEF) had available angiography (61% performed in hospital). Obstructive CAD was more prevalent with HFrEF than HFpEF, whether at the left main (15% vs. 11%), left anterior descending (LAD) (48% vs. 30%), left circumflex (37% vs. 32%), right coronary (42% vs. 32%), or multiple coronary arteries (45% vs. 33%). In-hospital revascularization was performed in 25% and 22% of patients with HFrEF and HFpEF, respectively. Obstructive CAD was associated with higher adjusted mortality, particularly with left main or LAD involvement, and had a more pronounced association with 90-day mortality in HFrEF (odds ratio [OR] 2.77; 95% confidence interval [CI] 1.53-5.02) than HFpEF (OR 0.94; 95% CI 0.36-2.41) (p-interaction = 0.05). CONCLUSION Patients hospitalized with ADHF and coexisting obstructive CAD have higher short-term mortality, warranting the need for effective interventions and secondary prevention.
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Affiliation(s)
- Zainali S Chunawala
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Arman Qamar
- Section of Interventional Cardiology and Vascular Medicine, Northshore University Healthsystem, Chicago, IL, USA
| | - Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Marat Fudim
- Divsion of Cardiology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert J Mentz
- Divsion of Cardiology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Melissa C Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, NC, USA
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DeVore AD, Bosworth HB, Granger BB. Improving implementation of evidence-based therapies for heart failure. Clin Cardiol 2022; 45 Suppl 1:S52-S59. [PMID: 35789019 PMCID: PMC9254671 DOI: 10.1002/clc.23845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
Treatment options for patients with heart failure have improved rapidly over the last few decades. Data from large scale clinical trials demonstrate that medical and device therapies can improve quality of life, reduce hospitalizations for acute heart failure, and reduce mortality. However, the use of many of these therapies in routine practice is remarkably low. There are many reasons for suboptimal implementation of evidence-based therapies for heart failure, and we believe addressing the large gap between what can be accomplished in clinical trials versus routine practice is a critical and urgent public health issue. In this review, we outline reasons for this implementation gap and review recent studies attempting to address this issue. We also provide recommendations for future interventions and areas of clinical investigation to improve implementation for patients with heart failure.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Department of MedicineDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation Durham Veterans Affairs Medical CenterDurhamNorth CarolinaUSA
- Department of Population Health SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDivision of General Internal Medicine, Duke University Medical CenterDurhamNorth CarolinaUSA
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Bradi B. Granger
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNorth CarolinaUSA
- Duke University School of Nursing, Duke University School of MedicineDurhamNorth CarolinaUSA
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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; 79:849-860. [PMID: 35241218 PMCID: PMC9031351 DOI: 10.1016/j.jacc.2021.11.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) is the most common cause of new-onset heart failure (HF). Although guidelines recommend ischemic evaluation in this population, testing has historically been underutilized. OBJECTIVES This study aimed to identify contemporary trends in CAD testing for patients with new-onset HF, particularly after publication of the STICHES (Surgical Treatment for Ischemic Heart Failure Extension Study), and to characterize geographic and clinician-level variability in testing patterns. METHODS We determined the proportion of patients with incident HF who received CAD testing from 2004 to 2019 using an administrative claims database covering commercial insurance and Medicare. We identified demographic and clinical predictors of CAD testing during the 90 days before and after initial diagnosis. Patients were grouped by their county of residence to assess national variation. Patients were then linked to their primary care physician and/or cardiologist to evaluate variation across clinicians. RESULTS Among 558,322 patients with new-onset HF, 34.8% underwent CAD testing and 9.3% underwent revascularization. After multivariable adjustment, patients who underwent CAD testing were more likely to be younger, male, diagnosed in an acute care setting, and have systolic dysfunction or recent cardiogenic shock. Incidence of CAD testing remained flat without significant change post-STICHES. Covariate-adjusted testing rates varied from 20% to 45% across counties. The likelihood of testing was higher among patients co-managed by a cardiologist (adjusted OR: 5.12; 95% CI: 4.98-5.27) but varied substantially across cardiologists (IQR: 50.9%-62.4%). CONCLUSIONS Most patients with new-onset HF across inpatient and outpatient settings did not receive timely testing for CAD. Substantial variability in testing persists across regions and clinicians.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, California, USA.
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Department of Medicine, Palo Alto VA Veteran's Affairs Hospitals, Palo Alto, California, USA. https://twitter.com/paheidenreich
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Department of Medicine, Palo Alto VA Veteran's Affairs Hospitals, Palo Alto, California, USA. https://twitter.com/wfearonmd
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA. https://twitter.com/ATSandhu
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McGuinn E, Warsavage T, Plomondon ME, Valle JA, Ho PM, Waldo SW. Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure. J Am Heart Assoc 2021; 10:e019452. [PMID: 33586468 PMCID: PMC8174286 DOI: 10.1161/jaha.120.019452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new‐onset systolic heart failure. Methods and Results Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high‐performing (90th percentile) and low‐performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90–4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin‐converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all‐cause mortality (hazard ratio, 0.54; 95% CI, 0.47–0.61) compared with those without an evaluation. Conclusions Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline‐concordant care could lead to an improvement in clinical outcomes.
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Affiliation(s)
- Erin McGuinn
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | | | - Mary E Plomondon
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
| | - Javier A Valle
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
| | - P Michael Ho
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO
| | - Stephen W Waldo
- Rocky Mountain Regional VA Medical Center Aurora CO.,University of Colorado School of Medicine Aurora CO.,CART Program VHA Office of Quality and Patient Safety Washington DC
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Piña IL. How Long Will We Play the Ostrich Game? Circ Heart Fail 2020; 13:e007043. [DOI: 10.1161/circheartfailure.120.007043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ileana L. Piña
- Department of Medicine, Wayne State University, Detroit, MI
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