Using coronary angiography as the first diagnostic test in HFrEF patients reduced heart failure hospitalizations to 1.0% versus 5.2% with non-invasive strategies, with no mortality difference.
Does an invasive diagnostic strategy (coronary angiography) reduce mortality or improve clinical outcomes compared to non-invasive strategies in patients with HFrEF?
Using coronary angiography as the initial diagnostic strategy in patients with newly diagnosed HFrEF is associated with fewer subsequent heart failure hospitalizations compared to non-invasive testing, though it does not impact mortality.
Abstract Introduction Patients with heart failure with reduced ejection fraction (HFrEF) must be studied to clarify the underlying aetiology. However, different diagnosis schemes are being followed in clinical practice. Methods All patients with HFrEF referred to a specialized Heart Failure Unit between 2011 and 2022 were included. Exclusion criteria were: prior coronary artery disease or acute myocardial infarction (AMI) as debut of HFrEF. We analysed two different diagnostic approaches: -Non-invasive study (cardiac magnetic resonance imaging (CMR) / stress echocardiography / coronary CT / SPECT myocardial perfusion imaging as first test) vs invasive study (coronary -angiography (CA) as first test). -CMR guided study (CMR as first test) vs non-invasive coronary ischemia guided study (stress echocardiography /coronary CT/ SPECT myocardial perfusion imaging as first test) vs coronary angiography guided study (coronary angiography as first test). Primary endpoint was mortality. Secondary endpoints were heart failure (HF) hospitalizations, new coronary revascularization, AMI and improvement of ejection fraction. Results 581 patients were included. Baseline characteristics are shown in Table 1. -Non-invasive study vs invasive study: 381 patients were included in the non-invasive group and 200 in the invasive group. Patients in invasive group were older (66.8 vs 62.5 years old; p0.001) and more diabetic (45% vs 31%; p0.001). No other differences in sex neither renal function were found. No differences in mortality among groups were found. Patients with invasive study had less HF hospitalizations (1.0% vs 5.2%; p=0,013) (Figure 1) and a trend to greater improvement in EF (17.1% vs 14.5%; p=0.084). No differences in AMI or follow-up cardiac revascularization were found. -CMR guided study vs non-invasive coronary ischemia guided study vs coronary angiography guided study: 319 patients were included in CMR guided study, 62 in non-invasive ischemia guided study and 200 with coronary angiography. Patients in CMR group were younger (61.7 vs 66.4 vs 66.8 years old; p0,001). Non-invasive ischemia group patients had better EF (33.5% vs 30.0% and 29.6%; p=0.004). No other differences in sex, renal function or risk factors were found. Non differences in mortality among groups were found. Patients with CMR guided study and CA guided study had greater improvement in EF than patients with coronary ischemia guided study (14,7% and 14,5% vs 7,35%; p0,001). Patients with CA had less HF hospitalizations (1.0% vs 5.2% and 5%; p=0,045). No differences in AMI or cardiac revascularization were found. Conclusion The use of coronary angiography as a first strategy for the diagnosis of the aetiology in patients with HFrEF patients is associated with fewer HF hospitalizations. No differences in mortality were found between the different strategies. Based on this data, an invasive study should be considered by protocol in patients with a recent diagnosis of heart failure.Figure 1 Table 1
Florez et al. (2025) studied this question. Using coronary angiography as the first diagnostic test in HFrEF patients reduced heart failure hospitalizations to 1.0% versus 5.2% with non-invasive strategies, with no mortality difference.