Internal Medicine Journal 38 (2008) 845851

O R I G IN A L A RT I C L E

Do patients with heart failure appropriately undergo invasive

procedures post-myocardial infarction? Results from a
prospective multicentre study
D. Tobing,1 J. French,1 J. Varigos,2 A. Meehan,2 B. Billah,2 and H. Krum,2 for the post-MI audit group*
1
Liverpool Hospital and South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales and 2National Health and
Medical Research Council Centre of Clinical Research Excellence in Therapeutics, Department of Epidemiology and Preventive Medicine
Monash University, Melbourne, Australia

Key words Abstract

congestive heart failure, myocardial infarction,
invasive procedure, angiography, angioplasty.
Correspondence
John French, Department of Cardiology,
Liverpool Hospital, Liverpool, NSW 2170,
Australia.
Email: j.french@unsw.edu.au
Received 17 July 2007; accepted 31 October
2007.
doi:10.1111/j.1445-5994.2007.01594.x
Background: The degree of adherence to guideline recommendations that
patients following myocardial infarction (MI) with congestive heart failure
(CHF) undergo early angiography, and angioplasty if indicated, is unknown.
Methods: We prospectively evaluated the use of invasive procedures in
patients with segment-elevation myocardial infarction (STEMI), non-STEMI
and CHF, admitted in 1 month to 16 Australian hospitals.
Results: Of 475 post-MI patients (248 (52.2%) with STEMI), 112 (23.6%) had
CHF, (57 (23.0%) with STEMI). Patients with CHF, compared with those
without CHF, were older (67.8 vs 63.2 years; P = 0.002) and were more often
women (34 vs 24%, P = 0.03), but had similar rates of other risk factors.
Compared with post-MI patients without CHF, patients with CHF had fewer
invasive procedures: angiography 72.3% versus 85.1% (P = 0.002) and angio-
plasty 33.9% versus 52.9% (P < 0.001) (12 (2.5%) patients underwent coro-
nary surgery in-hospital); and among STEMI patients (angiography 72.3% CHF
vs 89.5% no CHF [P < 0.001]; angioplasty 50.9% CHF vs 69.1% no CHF
[P = 0.011]); these differences remained significant after adjustment for clinical
covariates. Of the 121 (25.5%) post-MI patients aged 75 years, compared with
those <75 years, the frequencies of angiography and angioplasty procedures
were 66.1% versus 87.6% (P < 0.001) and 33.9% versus 53.4% (P < 0.001),
respectively; 66% of the elderly with, and without, CHF had angiography.
Conclusion: The presence of CHF post-MI resulted in lower rates of use of
angiography and angioplasty, which was not explained by lower procedure rates
in the elderly. As these guideline-recommended procedures may improve survival
in patients with CHF post-MI, future strategies should aim to enhance their use.

Funding: This study was supported by an unrestricted educational
grant from Pfizer Pharmaceuticals, Australia.
Potential conflicts of interest: Henry Krum has served on advisory
boards for AstraZeneca, Pfizer, Roche, Bristol-Myers Squibb and
Sanofi-Aventis.
*Participating investigators: Roger Ku (Alfred Hospital); Mark Hor-
rigan and Louise Brown (Austin and Repatriation Medical Centre);
Gishel New and Louise Roberts (Box Hill Hospital); John Counsell
and Marianne Martin (Dandenong Hospital); Randall Hendricks and
Gill Tullock (Fremantle Hospital); James Rogers and Bets Conway
(Gosford Hospital); John French and Elizabeth Newland (Liverpool
Hospital); Richard Harper and Lisa Jenkins (Monash Medical
Centre); Steven Coverdale and Sue Murray (Nambour Hospital);
Warren Walsh and Anne Russell (Prince of Wales Hospital); Paul
Garrahy and Tom Christensen (Princess Alexandra Hospital);
Andrew Adjani and Michele Sallaberger (Royal Melbourne Hospi-
tal); Greg Nelson and Annie Loxton (Royal North Shore Hospital);
Peter Thompson and Patricia Taaffe (Sir Charles Gairdner Hospital);
David Rees and Glenn Paull (St George Hospital); Robert Whitbourn
and Britt Christensen (St Vincents Hospital, Melbourne).

2008 The Authors

Journal compilation 2008 Royal Australasian College of Physicians 845
Tobing et al.
Introduction
The clinical syndromes of congestive heart failure (CHF)
and cardiogenic shock, predominantly because of left
ventricular dysfunction, complicate acute ST-elevation
myocardial infarction (STEMI) and non-STEMI in
approximately 1525% of patients.17 Left ventricular
pump failure accounts for approximately 2/3 of
hospital mortality in post-myocardial infarction (MI)
patients.8,9 Angiography during the initial hospitalization
provides anatomical risk stratification and identifies
patients who may benefit from percutaneous coronary
intervention (PCI) or urgent coronary surgery. Revascu-
larization has been associated with improved survival
in patients with acute MI and CHF or cardiogenic
shock.7,1014
Guidelines have been published for clinicians managing
patients post-STEMI, which provide recommendations
for use of angiography and revascularization proce-
dures.14,15 In patients with non-STEMI regardless of the
presence of CHF, three recent trials have provided con-
sistent evidence of the benefit for an early invasive
and revascularization strategy.1618 Also, several pharma-
cological treatments have been shown to improve
survival including beta-blockers, angiotensin converting
enzyme inhibitors and spironolactone.1921
In this study, we examined guideline-based use of inva-
sive procedures and other therapies in post-MI (with and
without ST elevation), stratified by the clinical diagnosis of
CHF made at admission, or at any time during the initial
hospitalization.
Methods
Patient group
We prospectively determined the use of invasive proce-
dures in all patients with MI admitted to 16 Australian
hospitals over 1 month during the period of December
2004 to February 2005.22 The hospitals, predominantly
with cardiac catheter laboratories (CCL) and PCI capabil-
ities (except 2) were located in all mainland states and
comprised those with the highest MI-documented sep-
arations in each state, as obtained from Australian Institute
of Health and Welfare data. Patients required the diagnosis
of STEMI or non-STEMI; patients with cardiogenic shock
at presentation were excluded.
Definitions
The diagnosis of MI required increases in levels of tropo-
nins T and/or I or creatine kinase myocardial brain (MB),
846
based on each hospitals reference ranges. Patients were
stratified by the clinical diagnosis of CHF made, at admis-
sion or at any time, during the hospitalization. The defi-
nition of CHF was according to European Society of
Cardiology (ESC) guidelines.23 CHF status was determined
before hospitalization, on admission, during hospitaliza-
tion and at discharge. Angiography and PCI during the
initial hospitalization, including following interhospital
transfer, were reported. Cardiogenic shock was defined
as the presence of systemic hypotension with evidence of
end-organ hypoperfusion.
Collection of details and analysis
Details were collected by the study coordinator at each site
upon hospital discharge from the index MI, on an indi-
vidual case report form. Details obtained included MI
location, the type of MI (STEMI and non-STEMI) and
the performance of angiography and/or PCI carried out
during the patients index hospitalization. Administration
of guideline-based medications at both admission and
discharge were also recorded. The details were entered
in the database and verified by double data entry and
manual checking of >95% of fields.
Differences in procedures and prescribing were deter-
mined by chi-squared analysis, with a two-tailed P-value
<0.05 considered to be statistically significant. Age was
compared between those with and without CHF by
Students unpaired t-test. Predictors of CHF were deter-
mined by logistic regression analysis, entering all rele-
vant demographic parameters into a backwards-stepwise
model. Analyses were adjusted according to differences
in baseline characteristics of patients with, and with-
out, CHF.
Results
Of 475 patients with MI (248 (52.2%) with STEMI)
included in this study, CHF occurred in 112 patients
(23.6%), including 57 patients (23.0%) with STEMI.
Patients with MI complicated by CHF were older, more
likely to be women and more likely to have history of prior
CHF, but had similar frequencies of other risk factors,
compared with patients who did not have, or develop,
CHF (Table 1). According to CHF status post-MI, admin-
istration of cardiovascular medications at discharge is
shown in Figure 1. Significantly fewer patients with CHF
received beta-blockers compared with those without
CHF. Fewer patients with CHF, compared with those
without CHF, received aspirin, clopidogrel or statin ther-
apy, whereas more patients received warfarin, spironolac-
tone and other diuretics. Spironolactone use, even in
patients with established CHF, was low at 7.8%.
2008 The Authors
Journal compilation 2008 Royal Australasian College of Physicians
 Invasive procedures in CHF post-MI

Table 1 Characteristics of patients with MI according to CHF status CHF; 132/191 (69.1%) no CHF; P = 0.011). The timing
during hospitalization or at discharge of angioplasty was not recorded, so rates of PCI for re-
No CHF CHF 95% confidence perfusion (primary PCI, rescue PCI and facilitated PCI)
(n = 363) (n = 112) intervals and for revascularization are not separately reported.
(for difference) The frequency of patients receiving neither fibrinolytics
Age (year) 63.2 0.7 67.8 1.2*
nor PCI did not differ according to CHF status (9/57
Sex (male/female) (%) 76/24 66/34* (15.8%) CHF; 38/191 (19.9%) no CHF; P = not signifi-
Smoking (%) 35.1 31.0 20.06 to 0.14 cant). Of these 47 STEMI patients (19%), 35 patients
Hypertension (%) 53.0 56.9 20.14 to 0.06 underwent angiography.
Hyperlipidaemia (%) 53.5 50.0 20.07 to 0.14 In the 121 (25.5%) post-MI patients aged 75 years
Diabetes (%) 21.2 25.9 20.14 to 0.04 compared with those aged <75 years, the rates of angio-
Familial CVD (%) 32.3 25.0 20.02 to 0.17
graphy and PCI were 66.1 versus 87.6% (P < 0.001) and
Prior ACS (%) 26.9 31.0 20.14 to 0.04
Prior CHF (%) 2.7 11.2* 20.14 to 20.03
33.9 versus 53.4% (P < 0.001), respectively. However, the
Prior stroke (%) 9.0 8.6 20.05 to 0.06 rate of angiography in the elderly was 66%, irrespective of
Prior MI (%) 23.6 27.6 20.13 to 0.05 the presence or absence of CHF.
Prior PCI (%) 10.6 9.5 20.05 to 0.07

*P < 0.05 for comparison of rates in patients with, and without, CHF.
ACS, acute coronary syndrome; CHF, congestive heart failure; CVD,
cardiovascular disease; MI, myocardial infarction; PCI, percutaneous
coronary intervention.
Use of invasive procedures in post-MI
patients with CHF
Of 475 patients admitted with MI, angiography during the
initial hospitalization was carried out in 82.1% (87.9%
STEMI; 75.8% non-STEMI; P < 0.001) and PCI was car-
ried out in 48.4% (64.9% STEMI; 30.4% non-STEMI;
P < 0.001); coronary surgery was carried out in 12 patients
(2.5%). Only 75 patients (15.8%) were not assessed by
either angiography or echocardiography during the index
hospitalization. The rates of use of angiography and PCI in
patients with CHF were lower than those in post-MI
patients (non-STEMI and STEMI) without CHF (Fig. 2;
Table 2). Also patients with CHF complicating STEMI were
less likely to undergo PCI compared with patients with
STEMI, without CHF (Table 3).
The rates of use of fibrinolytic therapy among the
patients with ST elevation were 74/248 (29.8%) (28/57
(49.1%) in those with CHF and 46/191 (24.1%) in patients
without CHF (P < 0.01)), and the rate of PCI during
hospitalization was 161/248 (64.9%) (29/57 (50.8%)
Predictors of use of procedures and therapies
after MI according to CHF status
Factors associated with use of procedures and medications
at discharge according to CHF status for all patients post-MI,
including after adjustment for the baseline covariates of age,
sex, prior CHF and diabetes mellitus, are shown in Table 2.
There were differences in rates of use of invasive procedures
even after adjustments for differences in baseline charac-
teristics for angiography (P = 0.03) and PCI (P = 0.005).
Among STEMI patients with CHF, after adjustment for
covariates, the frequency of performance of PCI also
remained significantly different (P = 0.032), (Table 3).
Discussion
In this prospective study of post-MI CHF management in
16 Australian centres predominantly with CCL that were
PCI capable, the rate of development of CHF was 23.6%,
which is similar to rates previously reported.8,15,24 In these
centres, we found that invasive procedures including
angiography and PCI in CHF post-MI patients appear to
be under-used based on guideline recommendations. This
finding was not merely because of low procedure rates in
elderly CHF patients. We also found reduced prescribing of
some evidence-based therapies shown to improve prog-
nosis in post-MI CHF patients.

Figure 1 Cardiovascular medications on

discharge according to CHF status. There 100
were significantly higher rates of prescrib- 90
Frequency (%)

ing of warfarin, spironolactone and other 80

70
diuretics in patients with CHF ( ) post- 60
myocardial infarction, compared with 50
those without CHF ( ) (P < 0.05). ACE-I/ 40
ARB, ACE inhibitors angiotensin receptor 30
20
blockers; ASA, aspirin; BB, beta-blocker; 10
CHF, congestive heart failure; clopid, clo- 0
pidogrel; spiro, spironolactone. ACE/ARB BB Spiro ASA Clopid Statin Warfarin Diuretic

2008 The Authors

Journal compilation 2008 Royal Australasian College of Physicians 847
Tobing et al.

100 Figure 2 Rates of use of invasive proce-

dures in post-MI patients according to CHF
90
status. Angio and PCI in patients post-MI
80
(n = 475). Also, in patients (with CHF ( )
70 and with no CHF ( )) with STEMI, angio-
Patients (%)

60 graphy and PCI rates are shown among

50 the 112 patients who had CHF. All compar-
isons were significantly different (P < 0.05)
40
except for angiography rates in the elderly
30 in CHF compared with no CHF (angio
20 >75 years). Angio, angiography; CHF, con-
10 gestive heart failure; MI, myocardial in-
farction; PCI, percutaneous coronary
0
Angiography PCI Angio STEMI PCI STEMI Angio >75 years intervention; STEMI, ST elevation MI.

Use of invasive procedures invasive procedures in post-MI CHF patients. These

In this study, there was approximately half the rate of PCI
carried out, in post-MI CHF patients (with and without ST
elevation), compared with other post-MI patients, and
there remained a significant association even after adjust-
ment for covariates. The 2004 American College of
Cardiology/American Heart Association guidelines state
patients who receive fibrinolytic therapy for STEMI with
ejection fraction < 40% or ejection fraction > 40% with
high-risk features should undergo catheterization and
revascularization as indicated.14,25 The 2007 focused
update of these guidelines emphasise a strategy of coro-
nary angiography with the intention to perform PCI (or
cardiac surgery if indicated on post MI patients treated
with fibrinolytic therapy who: (a) had/have cardiogenic
shock (aged < 75) and are suitable for revascularisation;
or (b) have severe CHF or pulmonary oedema; or (c) have
haemodynamically compromising arthythmias. Also, the
ESC PCI guidelines (2005) indicate that patients with CHF
post-MI should have angiography, and PCI where indi-
cated, carried out during the index hospitalization
because of the prognostic benefit of revascularization.15
There are several potential reasons for under-use of
may have included unrecorded comorbidities or physi-
cian preferences/biases.26 Although most of 16 different
hospitals had CCL, decisions regarding an invasive
approach may have been influenced by scheduling fac-
tors. Also, as a higher frequency of patients with CHF
received fibrinolysis, and as combined fibrinolysis /PCI
rates did not differ according to CHF status, clinicians may
have chosen to non-invasively risk stratify more CHF
patients. In addition, revascularization may have been
undertaken after the initial hospitalization as, except for
interhospital transfer, we were not able to determine
whether percutaneous or surgical revascularization was car-
ried out on an (early) subsequent hospitalization.
We found that elderly patients were less likely to
undergo angiography or PCI than those aged <75 years,
although rates of angiography in elderly patients, with
and without heart failure, were similar. As elderly
patients with acute coronary syndrome (ACS) often have
benefits from revascularization in terms of reduced mor-
bidity,26 whether these rates were appropriate in the
context of comorbidities could not be determined. How-
ever, given the high mortality rate of elderly patients with

Table 2 Use of procedures and medicationsy after myocardial infarction according to congestive heart failure status

OR (unadj.) P-value 95% CI OR (adj.) P-value 95% CI

Angiography 0.46 0.002 0.441.05 0.55 0.03 0.481.23

Angioplasty 0.46 0.001 0.290.71 0.51 0.005 0.320.82
ACE/ARB 0.72 0.213 0.431.21 0.75 0.295 0.441.28
Beta-blockers 0.59 0.045 0.360.99 0.70 0.182 0.411.18
Spironolactone 3.44 0.011 1.338.88 2.45 0.091 0.876.98
Aspirin 0.52 0.056 0.271.02 0.58 0.097 0.281.11
Clopidogrel 0.54 0.005 0.350.83 0.57 0.016 0.360.90
Statin 0.37 0.001 0.210.65 0.38 0.002 0.210.70
Warfarin 3.61 0.001 1.747.49 3.06 0.004 1.446.52
Diuretic 3.42 0.000 2.045.74 2.87 0.000 1.664.96
y
Medications at discharge. ACE, ACE inhibitor; adj, adjusted for differences in baseline characteristics according to CHF status; ARB, angiotensin receptor
blocker; CHF, congestive heart failure; CI, confidence interval; OR, odds ratio, of patients with CHF compared with those without, CHF; unadj, unadjusted.

2008 The Authors

848 Journal compilation 2008 Royal Australasian College of Physicians
 Invasive procedures in CHF post-MI

Table 3 Use of procedures and medicationsy among ST-elevation myocardial infarction patients according to congestive heart failure status

Unadjusted OR P-value 95% CI Adjusted OR P-value 95% CI

Angiography 0.55 0.155 0.421.42 0.60 0.257 0.471.70

Angioplasty 0.46 0.012 0.250.85 0.50 0.032 0.270.94
ACE/ARB 0.72 0.213 0.431.21 0.46 0.054 0.211.01
Beta-blockers 0.59 0.045 0.360.99 0.32 0.004 0.150.69
Spironolactone 1.70 0.546 0.309.52 0.67 0.71 0.085.7
Aspirin 0.70 0.516 0.232.07 0.69 0.507 0.222.09
Clopidogrel 0.43 0.013 0.220.84 0.45 0.024 0.220.90
Statin 0.30 0.004 0.130.69 0.29 0.006 0.120.70
Warfarin 3.73 0.012 1.3310.46 3.60 0.018 1.2510.40
Diuretic 2.84 0.009 1.296.23 2.37 0.043 1.035.45
y
Medications at discharge. ACE, ACE inhibitor; ARB, angiotensin receptor blocker; CHF, congestive heart failure; CI, confidence interval; OR, odds ratio,
patients with CHF compared with those without CHF (adjusted adjusted for baseline characteristics).

CHF and ACS, this group may have been expected to
derive a significant absolute benefit from an invasive
strategy.
Use of evidence-based pharmacological
therapies for CHF
The relative under-use of invasive procedures in post-MI
patients with CHF may have influenced the use of some
pharmacological therapies,22 as we found that clopido-
grel was less frequently given in post-MI CHF patients, in
concordance with the decreased use of PCI. This study
was undertaken just before the publication of evi-
dence for the benefit of clopidogrel therapy in STEMI
patients.27,28 Results supporting its use in patients with
Non-ST Elevation Acute Coronary Syndrome had been
reported some years previously.29 In contrast, compared
with those without CHF, there was significantly greater
prescribing of warfarin in patients with CHF post-MI.
Several trials3032 in various post-MI clinical settings have
shown that aspirin plus warfarin with international nor-
malized ratio ranges of 23.5 achieve better clinical out-
comes than aspirin alone, especially in higher risk
patients. Also, the 2004 STEMI ACC/AHA guidelines
state as a class II/A recommendation to prescribe warfarin
to post-STEMI patients with left ventricular dysfunction
and extensive regional wall-motion abnormalities.14,25
In STEMI patients, there was less prescribing of beta-
blockers and ACE-I/angiotensin receptor blocker, which
are recommended in the 2004 ACC/AHA guidelines as
discharge therapy for all patients post-MI without contra-
indication. Perhaps (unrecorded) physician concerns
about haemodynamic and clinical instability in the acute
phase of STEMI may have limited prescribing of these
agents,33 although guidelines state that therapy should
start soon after the event if there was no contraindication
and should be continued indefinitely.14,15 Also, there was
less prescribing of statins in CHF post-MI patients in
comparison to those without CHF.
Although patients with CHF derive benefit from multiple
agents, particularly in the elderly, this has to be weighed
against adverse events, risks and possibility of drug inter-
actions.34 Recent analyses have confirmed that elderly
patients and those with comorbid risk factors do indeed
derive substantial benefit with proven CHF therapies35,36
and their use should therefore be encouraged in this setting.
Limitations
This study prospectively examined patterns of post-MI care
in Australian, predominantly tertiary care, hospitals over
a 1-month period. These results may not be applicable to
other health-care settings. The apparent under-use of inva-
sive procedures, particularly PCI, and some pharmacothera-
pies in post-MI CHF patients, may have been appropriate
for unrecorded reasons (such as important comorbidities).
Also, the rates of PCI for reperfusion (primary PCI, rescue
PCI and facilitated PCI) and for revascularization were not
separately reported. Finally, although rates of non-invasive
risk stratification other than echocardiography, such as by
exercise stress testing, were not formally recorded, very few
patients with STEMI (<5%) did not undergo PCI or angi-
ography (or fibrinolysis).
Conclusion
In conclusion, the presence of CHF in post-MI patients was
associated with the under-use of invasive procedures, as
recommended by recent guidelines, even after adjustment
for covariates. There was also under-use of evidence-based
drug therapies that enhance survival in patients with CHF
post-MI. These findings suggest the need for ongoing eval-
uation of use of evidence-based therapies in the routine
clinical care setting, especially high-risk post-MI patients
such as those with congestive heart failure.

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Journal compilation 2008 Royal Australasian College of Physicians 849
Tobing et al.
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