HFSA 2021: Does All New-Onset Heart Failure Need CAD Assessment?

Adam DeVore, MD, MHS, explores the question “Do all patients with new-onset heart failure need assessment for coronary artery disease?” and emphasizes that “considering assessments for coronary disease as a quality measure should be an important part of high-quality heart failure care.” He gave this presentation virtually at the 2021 Heart Failure Society of America (HFSA) scientific meeting. Dr. DeVore is Associate Professor of Medicine at Duke University.

Dr. DeVore is particularly interested in the unrecognized prevalence of CAD in patients with heart failure with reduced ejection fraction (HFrEF). “This is a gap in care that I think can be addressed, but we have to be thinking a little bit about how we’re approaching this as clinicians and then also how our heart failure programs are approaching this.”

Dr. DeVore presents the case of a 61-year-old patient with HFrEF who received a heart transplant and the pathology report on the explanted heart revealed extensive coronary artery disease. “This story, to me, just is all too common for us,” states Dr. DeVore. “That we find out about more coronary disease than we previously appreciated.”

A strong proponent of revascularization with medical therapy for heart failure, Dr. DeVore emphasizes, “The evidence that we have suggests that revascularization is an important pathway to think about for quite a few of our patients with a low ejection fraction.” However, data show that CAD testing is significantly underutilized among hospitalized patients with new-onset heart failure. Presenting data from Doshi et al., Dr. DeVore explains that testing for CAD was done in only 18% of hospitalized new-onset HF patients during the hospitalization and in less than a third of these patients out to 90 days. “I thought those numbers were really striking,” Dr. DeVore comments. He also presents data from O’Connor et al. demonstrating that testing for CAD occurred in only 39% of older patients with new-onset heart failure

From Kosyakovsky et al. published in 2021, Dr. DeVore highlights that in patients with acute heart failure and an “ischemic phenotype,” those undergoing invasive angiography within 2 weeks of admission had better outcomes over time including fewer heart failure readmissions over the next 2 years as well as improved cardiovascular mortality and all-cause mortality over the next 2 years. “It certainly makes you think that if we could test a way to make a commitment to this as a pathway of care we might see improved outcomes,” states Dr. DeVore.

Returning to his initial question, Dr. DeVore states that he does not believe that all new-onset HF patients require CAD assessment. Yet, given the data revealing that less than 40% of these patients are being tested, he concludes, “I don’t know what the exact right number is, but I know it should be higher than that because our expected prevalence of coronary disease would be much higher than 40% in this population of patients.” He suggests that more standardized approaches may be what needs to be investigated. “Can we study that and see, does that give us an opportunity to improve these numbers and maybe even improve downstream outcomes for our patients?”