Key result
Each 10-year age increase in patients with heart failure or LV dysfunction post-MI was associated with a higher risk of mortality (HR 1.49; 95% CI 1.426-1.557; P<0.0001).
Why the study?
Does captopril, valsartan, or both reduce mortality and morbidity in elderly patients with heart failure and/or left ventricular ejection fraction <40% after acute myocardial infarction?
RCT (n=14,703)
randomized
Does captopril, valsartan, or both reduce mortality and morbidity in elderly patients with heart failure and/or left ventricular ejection fraction <40% after acute myocardial infarction?
Despite treatment with captopril and/or valsartan, elderly patients with heart failure or LV dysfunction post-MI experience high mortality and morbidity, underscoring the need for improved adherence to other evidence-based therapies like beta-blockers and statins.
Answers are grounded in this paper and cite their sources.
Mortality risk rises sharply with age despite ACEI/ARB in post-MI HF/LV dysfunction; confirms need for age-stratified trials of adjunctive therapies.
BACKGROUND: The elderly constitute an increasing proportion of acute myocardial infarction patients and have disproportionately high mortality and morbidity. Those with heart failure or impaired left ventricular left ventricular function after acute myocardial infarction have high complication and mortality rates. Little is known about outcomes with contemporary therapies in these patients. METHODS AND RESULTS: The Valsartan in Acute Myocardial Infarction Trial (VALIANT) randomized 14,703 patients with heart failure and/or left ventricular ejection fraction <40% to receive captopril, valsartan, or both. Mortality and a composite end point, including cardiovascular mortality, readmission for heart failure, reinfarction, stroke, and resuscitated cardiac arrest, were compared for the age groups of <65 (n=6988), 65 to 74 (n=4555), 75 to 84 (n=2777), and > or =85 (n=383) years. With increasing age, 3-year mortality almost quadrupled (13.4%, 26.3%, 36.0%, and 52.1%, respectively), composite end-point events more than doubled (25.2%, 41.0%, 52.3%, and 66.8%), and hospital admissions for heart failure almost tripled (12.0%, 23.1%, 31.3%, and 35.4%). Outcomes did not differ between the 3 study treatments in any age group. Adverse events associated with captopril and valsartan were more common in the elderly and in patients receiving combination therapy. With increasing age, use of aspirin, beta-blockers, and statins declined, and use of digoxin, calcium-channel blockers, and non-potassium-sparing diuretics increased. On 3-year multivariable analysis, each 10-year age increase was associated with a hazard ratio of 1.49 (95% CI, 1.426 to 1.557; P<0.0001) for mortality and an odds ratio of 1.38 (95% CI, 1.31 to 1.46; P<0.0001) for readmission with heart failure. CONCLUSIONS: Outcomes remained poor in elderly patients with heart failure and/or impaired left ventricular systolic function after acute myocardial infarction, although most received beta-blockers and all received an ACE inhibitor and/or an angiotensin receptor blocker. Better therapies and increased use of aspirin, beta-blockers, and statins are needed in this important and increasing patient group.
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White et al. (2005) conducted an RCT in Acute myocardial infarction with heart failure and/or left ventricular systolic dysfunction (n=14,703). Captopril, valsartan, or both vs. Compared against each other was evaluated on Mortality (HR 1.49, 95% CI 1.426 to 1.557, p=<0.0001). Each 10-year age increase in patients with heart failure or LV dysfunction post-MI was associated with a higher risk of mortality (HR 1.49; 95% CI 1.426-1.557; P<0.0001).
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