September 20, 2006European Heart Journal
Predictors of stroke in high-risk patients after acute myocardial infarction: insights from the VALIANT trial
Why the study?
Risk models for predicting early and late stroke in high-risk post-myocardial infarction patients needed to be determined.
What are the predictors of early and late stroke in high-risk patients after acute myocardial infarction?
Structured PICO
What are the predictors of early and late stroke in high-risk patients after acute myocardial infarction?
P
Population
14,703 patients with acute myocardial infarction complicated by heart failure, left ventricular (LV) systolic dysfunction, or both
I
Intervention
Valsartan, captopril, or their combination (parent trial intervention)
O
Outcome
Early (<45 days) and late (>45 days) stroke (fatal or non-fatal)hard clinical
In high-risk post-MI patients, DBP >90 mmHg and atrial fibrillation are powerful, modifiable predictors of stroke that merit targeted therapeutic intervention.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This risk score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF”
JMJohn McMurrayProfessor of Medical Cardiology, University of Glasgow
“VALIANT has identified valsartan as an important new therapy for these high risk patients”
RSRonald S. FreudenbergerCardiologist, Lehigh Valley Hospital Heart Institute
“These risk tools may be helpful but certainly must be used with caution and proper training as with any other tool. As tools, they should be used to help inform clinical decision-making, not become the absolute arbiter.”
Implication
May guide closer monitoring for stroke in high-risk post-MI patients; leaves open the role of intensified antithrombotic therapy pending randomized data.[[1]](https://www.ahajournals.org/doi/abs/10.1161/JAHA.122.
Abstract
AIMS: We sought to determine risk models for predicting early and late stroke in a large cohort of high-risk post-myocardial infarction (MI) patients. METHODS AND RESULTS: We prospectively analysed data from 14 703 patients in the VALIANT trial with acute MI complicated by heart failure, left ventricular (LV) systolic dysfunction, or both. Patients were randomized 0.5-10 days after acute MI to valsartan, captopril, or their combination. We evaluated risk factors for early (<45 days) and late (>45 days) stroke by using multivariable Cox proportional hazards regression analyses with stepwise variable selection techniques applied to 92 pre-specified potential predictor variables. After randomization, 463 (3.2%) patients had fatal (n = 124) or non-fatal (n = 339) strokes, with 134 strokes occurring in the first 45 days. The strokes were classified as ischaemic (348), haemorrhagic (40), or of indeterminate cause (75). Estimated glomerular filtration rate and heart rate when in sinus rhythm were the most powerful predictors of early stroke (<45 days after MI), whereas diastolic blood pressure (DBP) >90 mmHg, prior stroke, and atrial fibrillation (AF) were the most powerful predictors of stroke overall. Ejection fraction and sex were not predictive of stroke in this cohort. CONCLUSION: Among high-risk patients presenting with MI but without initial neurological symptoms, the risk of stroke 6 weeks thereafter is 0.94% (95% CI 0.78-1.09). Of the most powerful baseline predictors of stroke, DBP and AF are amenable to therapeutic interventions and thus merit special attention in these patients.
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Cite This Study
Sampson et al. (2006) studied this question.