February 15, 2021Journal of the American Heart AssociationOpen Access

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

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Why the study?

Significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause.

Does ischemic evaluation reduce all-cause mortality in patients admitted with new-onset systolic heart failure?

Structured PICO

Does ischemic evaluation reduce all-cause mortality in patients admitted with new-onset systolic heart failure?

Population

9,625 patients admitted with a new diagnosis of systolic heart failure and a reduction in left ventricular ejection fraction (≤40%) who survived 90 days without a readmission in the VA Healthcare System from January 2006 to August 2017.

Intervention

Ischemic evaluation

Comparator

No ischemic evaluation

Outcome

All-cause mortalityhard clinical

Ischemic evaluation in patients with new-onset systolic heart failure is associated with higher rates of guideline-directed medical therapy, increased revascularization, and significantly lower all-cause mortality.

Implication

Ischemic evaluation was associated with lower mortality in new-onset systolic HF; leaves open causal benefit pending randomized trials.

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.