Early invasive coronary angiography and acute ischaemic heart failure outcomes

Abstract

Aims While myocardial ischaemia plays a major role in the pathogenesis of heart failure (HF), the indications for coronary angiography during acute HF are not established. We determined the association of early coronary angiography during acute HF hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization. Methods and results In a two-stage sampling process, we identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010 to March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, we defined a cohort with acute ischaemic HF as patients with at least one factor suggesting underlying ischaemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. We oversampled patients undergoing angiography. We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7239 patients with acute HF, 2994 met inclusion criteria [median age 75 (interquartile range 65–83) years; 40.9% women]. Early angiography was performed in 1567 patients (52.3%) and was associated with lower all-cause mortality [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.61–0.90, P = 0.002], cardiovascular death (HR 0.72, 95% CI 0.56–0.93, P = 0.012), and HF readmissions (HR 0.84, 95% CI 0.71–0.99, P = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR 2.58, 95% CI 1.73–3.86, P < 0.001) and coronary artery bypass grafting (HR 2.94, 95% CI 1.75–4.93, P < 0.001) within 2 years. Conclusions Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischaemia.

Coronary Assessment in Heart Failure within a Safety-Net Setting: Disparities and Outcomes

“…15 Observational data from Ontario suggest that early invasive coronary angiography within 2 weeks of HF diagnosis is associated with four times higher rates of revascularization within 90 days, 26% lower morality and 16% lower heart failure readmissions at two years. 9 However, that study included those with known CAD and those presenting with acute coronary syndromes who are much more likely to benefit from immediate invasive angiography. Not surprisingly, we also found that early coronary assessment was associated with higher GDMT prescriptions (even prior to coronary assessment) and higher likelihood of revascularization.…”

“…Observational studies suggest that coronary assessment during HF hospitalization or within 2 weeks of diagnosis is associated with higher use of medical therapy and revascularization, and with reduced mortality and rehospitalization. 8,9 Despite the evidence, most commercially-insured patients with HF do not undergo coronary assessment within 90 days, with disparities by county, patient demographics, and co-management by a cardiologist. 10 Women and persons of Black race are less likely to be referred for coronary assessment in other settings.…”

Early Postoperative Complications in Patients with Acute Myocardial Infarction During Emergency Coronary Bypassing

“…The long-term prognosis for primary PCI and external CABG is similar, but the average length of hospital stay for PCI is shorter. In addition, a large number of modern clinics do not always have the opportunity to accept a patient urgently for surgery [9]. Therefore, it is necessary to develop simple clear criteria for selecting patients with acute myocardial infarction for emergency surgical revascularization.…”

Estimation of the Absolute Risk of Cardiovascular Disease and Other Events: Issues With the Use of Multiple Fine-Gray Subdistribution Hazard Models

“…For example, heart failure is a challenge because of the multiplicity of potentially important outcomes including heart failure hospitalization, ischemia-related hospitalization, emergency department visits, sudden death, cardiovascular death, and worsening heart failure. 10 , 11 These outcomes may have different degrees of importance to subspecialist physicians (eg, heart failure specialists, cardiac electrophysiologists, interventional cardiologists, cardiac surgeons), generalists, and hospitalists. Based on our prior work engaging patients, 12 , 13 the outcomes that are important to patients extend beyond all-cause mortality.…”