Early coronary angiography in acute ischemic heart failure is associated with improved survival and lower rates of heart failure hospitalization

Abstract

Abstract Background While coronary ischemia plays a major role in the pathogenesis and prognosis of heart failure (HF), the indications for coronary angiography in acute HF have not been established. Purpose To identify the clinical predictors of performing early coronary angiography in acute ischemic HF and determine the association of angiography with all-cause mortality, cardiovascular death, and HF readmissions. Methods We identified all acute HF patients who presented to any of 70 emergency departments in Ontario, Canada and determined whether they underwent early coronary angiography (defined as angiography performed within 14 days of hospital presentation) using procedural data contained in the Canadian Institute for Health Information (CIHI) database (April 2010 to March 2013). We selected patients for detailed chart review using stratified random sampling, including only those with acute ischemic HF, which we defined inclusively as those who had at least ONE of the following: previous myocardial infarction (MI), troponin elevation, or active angina on presentation. We excluded patients for whom angiography on the index admission might reasonably have been withheld, including those with recent pre-admission angiography or revascularization procedures, palliative patients, and those with contraindications to invasive angiography such as anaphylaxis to contrast, severe renal impairment, and high-risk bleeding. Predictors of 14-day coronary angiography were determined using multivariable logistic regression. We compared mortality and readmissions up to two-year follow-up. Inverse probability of treatment weighting (IPTW) using the propensity score was used to adjust for differences in baseline characteristics between the two cohorts. Results Of 6,172 initially screened patients, 4,118 met criteria for acute ischemic HF. After exclusions, 2,994 were included in the study. Of these, 1,567 (52.3%) underwent early angiography and 1,427 (47.7%) did not (median age 75 [IQR 65–83] years and 40.9% women). Clinical factors associated with greater odds of early angiography included previous MI, anginal symptoms at presentation, New York Heart Association (NYHA) III-IV symptoms, and family history of coronary artery disease. After IPTW, early angiography was associated with lower all-cause mortality (HR 0.74, 95% CI; 0.61–0.90, p=0.002) and cardiovascular death (HR 0.72, 95% CI; 0.56–0.93, p=0.012) at two years. HF readmissions were also lower with early angiography (HR 0.84, 95% CI; 0.71–0.99, p=0.042). Conclusion Early coronary angiography in acute ischemic heart failure was associated with lower all-cause mortality, cardiovascular death, and HF readmissions. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institute of Health Research Grant