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Inadequate Testing for CAD Infuses Heart Failure Space


This new analysis of commercial and Medicare Advantage claims from all 50 states investigated utilization of and testing trends for coronary artery disease (CAD) among adults aged 18 and older presenting with new-onset heart failure.

Despite coronary artery disease (CAD) being the most common cause of new-onset heart failure (HF) and that both the American College of Cardiology and the American Heart Association recommend clinicians consider testing for it via noninvasive imaging or coronary angiography among patients with HF, timely testing does not occur in most settings according to new study data.

These results were seen even after considering inpatient and outpatient settings, and the findings were published recently in Journal of the American College of Cardiology.

“Because CAD is a common and treatable cause of HF, early identification is an important part of disease management,” the study authors wrote. “In this study, we aimed to identify the demographic and clinical factors associated with CAD testing among patients with incident HF across care settings, as well as temporal, geographic, and clinician-level testing variability.”

The STICH and STICHES trials, the results of which were published in 2011 and 2016, respectively, underscored the benefits of cardiovascular mortality following coronary artery bypass graft surgery and of evaluating ischemic etiology, but more data are needed, they added.

Among the 558,322 individuals who presented with incident heart failure (ie, first admission for the condition) between 2005 and 2019, less than half underwent CAD testing or revascularization, at 34.8% and 9.3%, respectively. And these testing rates remained low, ranging from just 20% to 45% across county of residence, even after adjusting for covariates.

Further, 21.7% underwent exercise stress testing, nuclear stress imaging, cardiac MRI, and coronary CT angiography to test for CAD.

Patients’ counties of residence (using zip codes) were considered to account for national variation, but the rates did not change significantly in the aftermath of the STICHES trial (from an adjusted odds ratio [aOR] of 0.99 to 1.01). Heart failure was diagnosed based on International Classification of Diseases, Ninth and 10th Edition codes, and the primary study outcome was occurrence of CAD testing.

Following the identification of demographic and clinical predictors of CAD testing for the 3 months both before and after an incident HF diagnosis, the authors determined that younger age, male sex, receiving a diagnosis in an acute care setting (eg, emergency department [ED] or inpatient stay), history of systolic dysfunction or recent cardiogenic shock, and the presence of cardiovascular risk factors (eg, hyperlipidemia, obesity, smoking history) indicated a greater likelihood of CAD testing.

In addition, after adjusting for specialty care, patients comanaged by a cardiologist had a testing rate for CAD that was more than 4 times that of patients not under such care (aOR, 5.12; 95% CI, 4.98-5.27). Among the cardiologists themselves, the percentage who referred patients for testing ranged from 50.9% to 62.4%.

The authors’ analysis also showed that Black patients were 10% less likely to undergo CAD testing vs White patients (aOR, 0.90; 95% CI, 0.88-0.92) but that Asian patients were 6% more likely than White patients to undergo CAD testing (aOR, 1.06; 95% CI, 1.01-1.10). This rate jumped to 43% if patients had to visit the ED on their index date or required hospitalization in the month after their HF diagnosis (aOR, 1.43; 95% CI, 1.42-1.45).

Negative predictors for testing included chronic kidney disease, chronic obstructive pulmonary disease, depression, and alcohol use disorder, with the lowest rates of 22% and 16.3% observed in persons with a history of a psychotic disorder or dementia, respectively.

Per county, the highest CAD testing rate was seen in Clay County, Florida (45.2%), and the lowest testing rate was seen in San Luis Obispo County, California (45.2%). Rates of myocardial infarction ranged from 3.6 per 1000 Medicare beneficiaries in Blaine County, Idaho, to 21.9 in Clay County, for the 2005 through 2018.

The authors noted that even with guidelines recommending CAD testing and despite the data from the STICHES trial showing there is benefit to CAD, their data show this is not the case and the picture remains bleak; in particular, because their numbers show rates remained flat over the 16 years of their analysis. Their analysis also highlights missed opportunities for testing, especially among patients with CAD risk factors, Black patients, and women.

“Our findings raise concern that patients with new-onset HF are not only undertested but also undertreated for CAD. Omission of timely testing precludes management of the most common and potentially reversible etiology of HF,” they concluded. “The continued underuse of CAD testing in patients with new-onset HF leaves much room for improvement.”


Zheng J, Heidenreich PA, Kohsaka S, Fearon WF, Sandhu AT. Variability in coronary artery disease testing for patients with new-onset heart failure. J Am Coll Cardiol. 2022;79(9):849-860. doi:10.1016/j.jacc.2021.11.061

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