Coronary Assessment in Heart Failure within a Safety-Net Setting: Disparities and Outcomes.
Coronary Assessment in Heart Failure within a Safety-Net Setting: Disparities and Outcomes.
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安全网环境下心力衰竭的冠状动脉评估：差异和结果。
DOI：
10.1101/2023.07.06.23292331
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发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Hsue,PriscillaY
中科院分区：
文献类型：
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作者：
Durstenfeld,MatthewS;Thakkar,Anjali;Ma,Yifei;Zier,LucasS;Davis,JonathanD;Hsue,PriscillaY
虽然缺血性心肌病是心力衰竭（HF）的主要原因，但大多数患者在心力衰竭诊断后不进行冠状动脉评估。在安全网人群中，转诊模式尚未研究，冠状动脉评估是否与改善心衰结果相关尚不清楚。方法使用2001-2019年旧金山健康网络中所有HF患者的电子健康记录队列，我们确定了与完成冠状动脉评估（侵入性冠状动脉造影、核应激或冠状动脉计算机断层扫描血管造影）相关的因素。然后，我们模拟了一项随机临床试验，评估选择性冠状动脉的全因死亡率和死亡率和急诊血管造影的综合结果。我们使用倾向分数来解释各组之间的差异。我们使用国家死亡记录来改善死亡率的确定。结果在14829例HF患者中（中位年龄62岁，5855例[40%]女性），3987例（26.9%）完成了冠状动脉评估，13301例患者中有2467例（18.5%）在HF诊断时CAD状态未知。由于种族/民族、病史、药物使用、住房和超声心动图结果的差异，女性和老年人完成冠状动脉评估的可能性较小。在符合纳入“目标试验”条件的5972人中，627人接受了早期选择性冠状动脉评估，5345人没有。冠状动脉评估与较低的死亡率（HR 0.84; 95% CI 0.72-0.97; p=0.025）、较低的复合结局风险、较高的血运重建率和较高的药物治疗使用率相关。结论：在安全网人群中，心衰诊断后冠状动脉评估的差异不能完全用CAD危险因素来解释。我们的目标试验模拟表明，冠状动脉评估与心衰结果的改善有关，可能与更高的血运重建率和GDMT的使用有关，但这一发现不确定是由于未测量的混杂因素造成的。
BackgroundThough ischemic cardiomyopathy is the leading cause of heart failure (HF), most patients do not undergo coronary assessment after heart failure diagnosis. In a safety-net population, referral patterns have not been studied, and it is unknown whether coronary assessment is associated with improved HF outcomes.MethodsUsing an electronic health record cohort of all individuals with HF within San Francisco Health Network from 2001-2019, we identified factors associated with completion of coronary assessment (invasive coronary angiography, nuclear stress, or coronary computed tomographic angiography). Then we emulated a randomized clinical trial of elective coronary assessment with outcomes of all-cause mortality and a composite outcome of mortality and emergent angiography. We used propensity scores to account for differences between groups. We used national death records to improve ascertainment of mortality.ResultsAmong 14,829 individuals with HF (median 62 years old, 5,855 [40%] women), 3,987 (26.9%) ever completed coronary assessment, with 2,467 (18.5%) assessed out of 13,301 with unknown CAD status at HF diagnosis. Women and older individuals were less likely to complete coronary assessment, with differences by race/ethnicity, medical history, substance use, housing, and echocardiographic findings. Among 5,972 eligible for inclusion in the “target trial,” 627 underwent early elective coronary assessment and 5,345 did not. Coronary assessment was associated with lower mortality (HR 0.84; 95% CI 0.72-0.97; p=0.025), reduced risk of the composite outcome, higher rates of revascularization, and higher use of medical therapy.ConclusionsIn a safety-net population, disparities in coronary assessment after HF diagnosis are not fully explained by CAD risk factors. Our target trial emulation suggests coronary assessment is associated with improved HF outcomes possibly related to higher rates of revascularization and GDMT use, but with low certainty that this is finding is not attributable to unmeasured confounding.