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Introduction: Patients with decreased LV ejection fraction (LVEF) presenting with elevated troponin incur high in-patient and follow-up mortality. Despite guidelines, testing for CAD and guideline-directed therapy in such patients has not been consistently utilized. To better understand this issue, we investigated hospital practice patterns in this vulnerable population. Methods: We conducted a tertiary single-center study of consecutive in-patients with abnormal troponin results on testing performed for clinical indications as requested by the treating physician. The study cohort included 432 patients, 67 +/- 14 years old with HTN in 75%, DM in 38%, smoking in 51%, dyslipidemia in 64%, family history of CAD in 28% and personal history of CAD or equivalent in 46%. Among them, 412 patients underwent echocardiographic LVEF assessment. Patients were then stratified according to the LVEF. The use of both ischemic evaluation and evidence-based medical therapy were compared. Hospital and long-term outcomes were analyzed. Results: Hospital mortality was 51/432 (11.8%) and during 28.1+/-13.8 months of follow-up additional 82/432 (18.9%) patients expired. Ischemia evaluation (both cardiac catheterization and non-invasive) was underutilized across all subgroups, including patients with decreased LVEF. Regarding guideline-directed medical therapy, only beta-blocker therapy was consistently utilized. Afterload reduction therapies such as angiotensin convertase enzyme inhibitors, angiotensin II receptor blockers, neprilysin inhibitors, hydralazine and nitrates were significantly underutilized. Statins and mineralocorticoid receptor blockers were also significantly underused (Table). Conclusions: Despite increased mortality, there continues to be room for improvement in the utilization of diagnostic evaluation and application of evidence-based therapy and in patients admitted with elevated cardiac biomarkers.

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