The intersection between acute coronary syndrome and heart failure

There is a tremendous spectrum of disease severity within the diagnosis of myocardial infarction. The risk of major cardiovascular outcomes is highly related to age and concomitant medical conditions, as well as factors that characterize the extent of the myocardial infarction. Patients that develop pulmonary congestion with transient signs of heart failure and/or left ventricular dysfunction as measured by a reduced ejection fraction are generally at the high end of risk stratification. Prior studies have demonstrated that these patients derive particular benefit with the use of angiotensin-converting enzyme (ACE) inhibitors. The development of angiotensin-receptor blockers (ARBs) raises the question of whether this mode of inhibiting the renin-angiotensin system will be as good as or potentially even better than the ACE inhibitors. Unfortunately, the first major test of this concept in the Optimal Therapy in Myocardial Infarction with the Angiotensin II Antagonist Losartan (OPTIMAAL) study did not show a favourable trend for the ARB. The Valsartan in Acute Myocardial Infarction Trial (VALIANT) study is in its final phases of completion and is testing whether the use of the ARB valsartan either alone or in combination with captopril can improve survival over and above what is already achievable with the ARB. Since this patient population is at particularly high risk, even small relative improvements in clinical outcomes will have major public health implications.