Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure

Identifying Demographic and Clinical Determinants of Ischemic Workup in Patients with Heart Failure

Background/Objectives: Coronary artery disease (CAD) is a common and treatable cause of heart failure (HF), but ischemic evaluation is often overlooked when evaluating patients with new-onset HF. Here, we sought to discern demographic and clinical predictors of ischemic workup in patients with newly diagnosed HF. Methods: A retrospective study of 200 consecutive patients with new-onset HF admitted to our safety-net hospital between 2011 and 2015 was performed. We developed a multivariate logistic regression model to analyze determinants of undergoing ischemic evaluation. Results: A total of 99 patients (49.5%) underwent ischemic workup, while 101 patients (50.5%) did not. The mean age of the cohort was 73.9 ± 16, with 50% as male and 51% as White. In total, 41.5% of patients had HF with reduced ejection fraction, and 37% of patients had HF with preserved ejection fraction. Among the patients who underwent ischemic evaluation, 63.6% received nuclear stress testing, 24.2% received cardiac catheterization, 9.1% received stress echocardiography, and 3% received computed tomography angiography. Demographic and clinical factors such as sex, age, race, presence of hypertension, hyperlipidemia, chronic kidney disease, diabetes, or obesity had no significant association with receiving ischemic workup (p > 0.05). Patients with known CAD (OR 2.816, p = 0.015) and a higher social deprivation index (SDI) (OR 1.022, p = 0.003) were significantly more likely to receive an ischemic evaluation. Atrial fibrillation was significantly negatively associated with receiving ischemic workup (OR: 0.24; p = 0.001). Conclusions: In our single-center safety-net hospital analysis, known CAD and higher SDI were significant predictors of ischemic evaluation in patients with newly diagnosed HF. Multiple demographic features, including age, sex, race, and clinical features, including HF type, hypertension, hyperlipidemia, and diabetes, had no significant correlation with ischemic workup.

The Prevalence of Coronary Artery Disease and Its Prognostic Impact on the Management of Patients With Acute Decompensated Heart Failure: A Prospective Cohort Study With a Short-Term Follow-Up

Introduction Heart failure (HF) poses a major global health challenge, with acute decompensated heart failure (ADHF) representing a critical phase that requires immediate medical intervention. Coronary artery disease (CAD) plays a significant role in many HF cases, contributing to disease progression through myocardial ischemia and impaired ventricular function. While the connection between CAD and HF is well-established, its specific effect on short-term outcomes in patients with ADHF is less understood, especially in regions like the Middle East. This study aims to evaluate the influence of CAD on short-term outcomes in patients presenting with ADHF and identify key differences in demographics, clinical parameters, and outcomes, including intensive care unit (ICU) admissions and medications, between patients with and without CAD, addressing gaps in current understanding and offering insights to improve clinical management. Methods This prospective cohort study was conducted at King Saud University Medical City (KSUMC) in Riyadh, Kingdom of Saudi Arabia (KSA), from April 2023 to April 2024. We included a total of 144 known heart failure patients presenting with acute heart failure (AHF) to the emergency department (ED). Secondary data was collected from the KSUMC medical records database to track patient outcomes after six months. Significant coronary angiography lesions, defined as 70% stenosis or greater, or a history of myocardial ischemia were necessary as evidence of CAD to meet the inclusion criteria. Statistical analyses were conducted using Chi-squared tests for categorical variables and t-tests for continuous variables. All analyses were performed using RStudio version 4.3.1 (Posit Software, Boston, MA), with a significance threshold set at p < 0.05. Results The study included 144 known heart failure patients presenting with acute decompensation, with 83 (57.6%) patients having CAD. CAD patients were younger (median age: 66 versus 67 years, p = 0.026) and predominantly male (75.9% versus 59%, p = 0.031). Diabetes mellitus was significantly more prevalent among patients with CAD (74.7% versus 49.2%, p = 0.002). Ejection fraction (EF) was notably lower in the CAD group with a greater proportion having an ejection fraction of 40% or less (89.2% versus 62.3%, p < 0.001). Additionally, CAD patients had more frequent ICU admissions (37.3% versus 13.1%, p = 0.001) and were more likely to present with chest pain (38.6% versus 21.3%, p = 0.027), while weight loss and lower extremity edema were more common in non-CAD patients (p < 0.05). Despite these worse clinical signs, CAD patients did not have significantly higher mortality at 180 or 360 days. Conclusion Although there was no statistically significant difference in mortality, CAD patients exhibited more severe disease indicators, such as lower ejection fractions and increased ICU hospitalizations. These findings underscore the importance of early detection and tailored treatment strategies for CAD in ADHF patients. Clinicians should prioritize aggressive management of CAD to prevent disease progression and reduce the need for ICU admissions. Future studies should focus on long-term outcomes and explore the impact of specific interventions, such as early revascularization or optimized heart failure therapies, to better understand how CAD influences ADHF prognosis.

Association Between Coronary Assessment in Heart Failure and Clinical Outcomes Within a Safety-Net Setting Using a Target Trial Emulation Observational Design

BACKGROUND

Ischemic cardiomyopathy is the leading cause of heart failure (HF). Most patients do not undergo coronary assessment after HF diagnosis. There are no randomized clinical trials of coronary assessment after HF diagnosis.

METHODS

Using an electronic health record cohort of all individuals with HF within the San Francisco Health Network from 2001 to 2019, we identified factors associated with coronary assessment. Then, we studied the association of coronary assessment within 30 days of HF diagnosis with all-cause mortality and a composite of mortality and emergent angiography using a target trial emulation observational comparative-effectiveness approach. Target trial emulation is an approach to causal inference based on creating a hypothetical randomized clinical trial protocol and using observational data to emulate the protocol. We used propensity scores for covariate adjustment. We used national death records to improve the ascertainment of mortality and included falsification end points for the cause of death.

RESULTS

Among 14 829 individuals with HF (median, 62 years old; 5855 [40%] women), 3987 (26.9%) ever completed coronary assessment, with 2467/13 301 (18.5%) with unknown coronary artery disease status at HF diagnosis assessed. Women, older individuals, and people without stable housing were less likely to complete coronary assessment. Among 5972 eligible persons of whom 627 underwent early elective coronary assessment, coronary assessment was associated with lower mortality (hazard ratio, 0.84 [95% CI, 0.72-0.97]; P=0.025), reduced risk of the composite outcome (hazard ratio, 0.86 [95% CI, 0.73-1.00]), higher rates of revascularization (odds ratio, 7.6 [95% CI, 5.4-10.6]), and higher use of medical therapy (odds ratio, 2.5 [95% CI, 1.7-3.6]), but not the falsification end points.

CONCLUSIONS

In a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by coronary artery disease risk factors. Early coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and guideline-directed medical therapy but with low certainty that this finding is not attributable to unmeasured confounding.

Association Between Coronary Artery Disease Testing in Patients with New-Onset Heart Failure and Heart Failure Readmission and Mortality

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.

Risk factors and prognosis of perioperative acute heart failure in elderly patients with hip fracture: case-control studies and cohort study

BACKGROUND

Elderly patients with hip fracture who develop perioperative acute heart failure (AHF) have a poor prognosis. The aim of the present study is to investigate the potential risks of AHF in elderly hip-fracture patients in the postoperative period and to evaluate the prognostic significance of AHF.

METHODS

A retrospective analysis was conducted on hip fracture patients at the Third Hospital of Hebei Medical University, who were continuously in hospital from September 2018 to August 2020. To identify independent risk factors for AHF in elderly patients with hip fracture, univariate and multivariate Logistic regression analysis was employed. The Kaplan-Meier survival curve illustrated the relationship between all-cause mortality in the AHF and non-AHF groups. An assessment of the correlation between baseline factors and all-cause mortality was conducted by means of univariable and multivariable Cox proportional hazards analysis.

RESULTS

We eventually recruited 492 patients,318 of whom were in the AHF group. Statistical significance was found between the two groups for age group, concomitant coronary heart disease, COPD, haemoglobin level below 100 g/L on admission, albumin level below 40 g/L on admission, and increased intraoperative blood loss. Age over 75, concomitant coronary artery disease, hemoglobin level below 100 g/L and albumin level below 40 g/L on admission were independent risk factors for AHF in older hip fracture patients. The AHF group exhibited a higher incidence of perioperative complications, such as anemia, cardiovascular issues, and stress hyperglycemia, as well as all-cause mortality. Based on our COX regression analysis, we have identified that the main risk factors for all-cause mortality in AHF patients are concomitant coronary heart disease, absence of pulmonary infection, absence of diabetes, absence of cancer, and absence of urinary tract infection.

CONCLUSION

Enhancing hip fracture prevention for AHF is particularly important. It is crucial to make informed decisions to avoid poor prognoses. Patients whose age over 75 years old, concomitant coronary heart disease, hemoglobin < 100 g/L and album< 40 g/L on admission are more likely to develop perioperative AHF. To avert complications and potential fatalities, patients with AHF must receive appropriate care during the perioperative period.