Early invasive coronary angiography and acute ischaemic heart failure outcomes
Why the study?
While myocardial ischaemia plays a major role in heart failure pathogenesis, the indications for coronary angiography during acute heart failure are not established.
Does early coronary angiography reduce mortality and heart failure readmissions in patients hospitalized with acute ischaemic heart failure?
Structured PICO
Does early coronary angiography reduce mortality and heart failure readmissions in patients hospitalized with acute ischaemic heart failure?
P
Population
2,994 patients with acute ischaemic heart failure (defined by previous myocardial infarction, troponin elevation, or angina on presentation) presenting to 70 emergency departments in Ontario. Median age 75, 40.9% women.
I
Intervention
Early coronary angiography within 14 days after presentation
C
Comparator
No early coronary angiography (adjusted using inverse-probability-of-treatment weighting)
O
Outcome
2-year all-cause mortalityhard clinical
Early coronary angiography within 14 days of presentation for acute ischaemic heart failure is associated with significantly lower 2-year mortality and heart failure readmissions.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“While randomized trial evidence is required to validate these results, this study suggests that early coronary angiography may benefit patients with acute HF and potential underlying ischaemia, supporting the need for an evidence-based clinical framework for the diagnosis and assessment of CAD in the acute HF population.”
Implication
Supports early angiography to reduce mortality; confirms benefit in this large randomized trial.
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.
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Figures from the paper
Published by European Heart Journal · CC BY-NCCite This Study
Kosyakovsky et al. (2021) studied this question.