Study finds low rates of CAD testing in patients with new-onset heart failure
Of 558,322 new heart failure patients, 34.8% received coronary artery disease (CAD) testing and 9.3% received revascularization within 90 days, which fell below expectations set by current guidelines, according to authors of a study of U.S. administrative claims data.
In recent years, only about one-third of patients with new-onset heart failure (HF) received testing for coronary artery disease (CAD), a study found.
Researchers used an administrative claims database covering commercial insurance and Medicare to determine the proportion of patients with incident HF who received CAD testing from 2004 to 2019. The primary outcome was the occurrence of CAD testing, defined as the performance of any of the following during the 90 days before or after the initial diagnosis: exercise stress test without imaging, stress echocardiogram, nuclear stress imaging, cardiac MRI, coronary CT angiography, and coronary angiography. The researchers also evaluated rates of revascularization with percutaneous coronary intervention and coronary artery bypass grafting and assessed variation in CAD testing rates by geographic location and clinician type. Results were published online by JACC on March 1.
Overall, of 558,322 patients with new-onset HF, 34.8% received CAD testing and 9.3% received revascularization. Eighty-seven percent of patients were linked to a physician, a primary care physician in 94% and a cardiologist in 52%. Patients linked with a physician had a slightly higher CAD testing rate, at 37.6%. In adjusted analyses, patients undergoing CAD testing were more likely to be younger, male, and diagnosed in an acute care setting and to have systolic dysfunction or recent cardiogenic shock. Compared to those diagnosed in an outpatient setting, care in the ED/inpatient setting was associated with a higher adjusted percentage of patients tested for CAD in the first month (27.5% [95% CI, 27.3% to 27.7%] vs. 35.2% [95% CI, 35.0% to 35.4%]; adjusted odds ratio, 1.43 [95% CI, 1.42 to 1.45]).
In a sensitivity analysis of patients with first-time acute decompensated HF with an inpatient hospitalization, the adjusted rate of CAD testing was 47.6% (95% CI, 47.2% to 48.0%) versus 34.5% in the full cohort (95% CI, 33.4% to 35.6%). Adjusted testing rates ranged from 20% to 45% across counties. Among patients with a primary care physician, the likelihood of testing was higher among those comanaged by a cardiologist (adjusted odds ratio, 5.12; 95% CI, 4.98 to 5.27), but the median testing rate varied considerably across cardiologists (interquartile range, 50.9% to 62.4%).
Rates of CAD testing in the study consistently fell below expectations as set by current guidelines, the authors noted. Among other limitations, the study relied on administrative claims data, which are limited in clinical granularity and may reflect variation in coding standards across practices, they added.
The results suggest that cardiovascular comanagement may help close the gap in CAD evaluation and management in patients with new-onset HF, an accompanying editorial noted. Identification and treatment of ischemic CAD, as well as treatment with guideline-directed medical therapy (GDMT), are grossly lagging in these patients, the editorial said.
“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 editorialists wrote. “The question exists however: who will make this call, and how many will answer?”