Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure

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.

Keywords: coronary artery disease; ischemic evaluation; revascularization; systolic heart failure.

Figure 1. Cohort construction.

Figure 2. Temporal trends in admissions for heart failure with reduced ejection fraction, showing the number of patients admitted with and without an ischemic evaluation as well as the proportion (line) stratified by time.

Figure 3. Mortality among propensity‐weighted patients admitted with heart failure and reduced ejection fraction, stratified by an ischemic evaluation.

The hazard ratio (HR) for mortality was reduced 46% (HR, 0.54; 95% CI, 0.47–0.61) among patients with an ischemic evaluation compared with those without an ischemic evaluation, with the comparison beginning 90 days after the index presentation to mitigate the immortal time bias.

Figure 4. Composite of mortality and rehospitalization for heart failure or myocardial infarction among propensity‐weighted patients admitted with heart failure and reduced ejection fraction, stratified by an ischemic evaluation.

The hazard ratio (HR) for the composite was reduced 31% (HR, 0.69; 95% CI, 0.64–0.75) among patients with an ischemic evaluation compared with those without an ischemic evaluation, with the comparison beginning 90 days after the index presentation to mitigate the immortal time bias.