CAD and HFrEF: Mind the Gap

Adam DeVore, MD, MHS from Duke University talks about evaluating patients with heart failure with reduced ejection fraction (HFrEF) for coronary artery disease (CAD). He gave this presentation virtually at the 2022 Technology and Heart Failure Therapeutics (THT) Conference.

Dr. DeVore begins by presenting the case of a 61-year-old male with a long history of HFrEF, dilated cardiomyopathy, moderate mitral regurgitation (MR), and well-controlled HIV. The patient presented with acute HF and underwent heart transplant. “I’m just always humbled and kind of fascinated,” states Dr. DeVore, “by the number of times the explanted heart comes back with significant coronary disease.” Dr. DeVore explains that this patient had been through several healthcare systems over 15 years and after transplant his heart was found to have significant coronary disease throughout. Dr. DeVore wonders how often this happens in patients diagnosed with a non-ischemic cardiomyopathy.

Dr. DeVore is examining this data because he is seeing more patients at the time of transplant with more coronary disease than expected. “I’m a believer in revascularization,” he states. “I spend a lot of time thinking about medical therapy for heart failure with reduced ejection fraction, but I think revascularization is often a missed opportunity.”

Dr. DeVore explores the question, “How often do we test for CAD in patients with heart failure?” and presents data indicating that fewer than 40% of older patients with new-onset heart failure received invasive or noninvasive testing for CAD. In addition, in approximately 100,000 insured patients in the United States with new onset heart failure, only one third received testing for CAD. “I don’t think every patient with a diagnosis of heart failure needs to be worked up for coronary disease,” he states, “but, you know, it probably needs to be higher than 1 in 3.”

Dr. DeVore believes this situation occurs because heart failure is a chronic condition that involves care across multiple settings and many different clinicians, and that coordinating care for these patients becomes very complex. “I think this problem needs a quarterback,” he explains, “somebody to really lead this effort in our different heart teams.”

“I do think we do a pretty good job of trying to recover hearts for patients with heart failure,” he states. “If you look in observational data, about a third of people that we follow, just in simple registries, have a significant improvement in their ejection fraction over time. But I think there are opportunities here to do even better.”

Dr. DeVore concludes by emphasizing that 3 things that can be done now to improve care in these patients are to (1) spotlight the issue, (2) develop standardized approaches for work-up, and (3) share best practices.