Patients admitted with new-onset heart failure after acute coronary syndrome. Do they require further invasive ischemic evaluation?
M Ferreira, M I Mendonca, F Escorcio Silva, F Sousa, G Abreu, E Henriques, S Freitas, M Rodrigues, S Borges, A Drumond, A C Sousa, R Palma Dos ReisAbstract
Introduction
Coronary artery disease is a major cause of heart failure(HF), accounting for >50% of all cases. The substantial morbidity and mortality associated with systolic HF following acute coronary syndrome (ACS) highlight the need to identify patients with residual ischemia, although the best strategy is still debated.
Objective
Evaluate the proportion of patients who underwent invasive ischemic evaluation after hospitalisation for new-onset systolic HF following ACS, and to assess its association with all-cause and cardiovascular mortality.
Methods
We analysed 1,720 patients who underwent an ACS (all with prior coronary angiography and at least one vessel obstruction) and were subsequently admitted for new-onset systolic HF (left ventricular ejection fraction ≤40%). They were stratified into two groups according to whether they received a new ischemic evaluation (IE). Median follow-up was 7.6±6.7 years. Cox proportional regression, adjusted for sex, age, diabetes, dyslipidemia, hypertension, obesity, physical inactivity, clearance <60mL/min, smoking, and IE, was used to identify factors associated with cardiovascular and/or all-cause mortality. Kaplan–Meier analysis assessed mortality.
Results
The proportion of patients undergoing IE increased over time, with a marked rise between 2016 and 2023. Among the variables included in the Cox model, only the absence of IE and diabetes were independently associated with both all-cause and cardiovascular mortality. Specifically, patients without IE had higher all-cause mortality (HR=1.67; 95% CI 1.21–2.29; p=0.002) and cardiovascular mortality (HR=1.55; 95% CI 1.11–2.17; p=0.009). Similarly, individuals with diabetes had an increased risk (HR) of 1.49 (95%CI: 1.11-2.01; p=0.008) for all-cause mortality and of 1.50 (95%CI: 1.11–2.06; p=0.012) for cardiovascular mortality. Kaplan-Meier showed that the group without IE had a higher all-cause mortality compared with patients with IE (71.1% vs 47.9%, respectively) and cardiovascular mortality (65.1% vs 45.4%, respectively) at, approximately, 12 years of follow-up.
Conclusion
Patients admitted with new-onset systolic HF after ACS remain at high risk of long-term mortality and may be under-evaluated. When clinically indicated, invasive ischemic assessment should be reconsidered, as increased opportunities for revascularisation and optimised medical therapy may improve outcomes and reduce mortality.For image description, please refer to the figure legend and surrounding text.