Mortality and morbidity remain high despite captopril and/or valsartan therapy in elderly patients with left ventricular systolic dysfunction, heart failure, or both after acute myocardial infarction : Results from the Valsartan in Acute Myocardial Infarction Trial (VALIANT)

• Published in: Circulation (New York, N.Y.) Vol. 112; no. 22; pp. 3391 - 3399
• Main Authors: WHITE, Harvey D, AYLWARD, Philip E. G, ZANNAD, Faiez, MCMURRAY, John J. V, CALIFF, Robert M, PFEFFER, Marc A, ZHEN HUANG, DALBY, Anthony J, WEAVER, W. Douglas, BARVIK, Stale, MARIN-NETO, Jose Antonio, MURIN, Jan, NORDLANDER, Rolf O, VAN GILST, Wiek H
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 29.11.2005
• Subjects: Age Factors; Aged; Aged, 80 and over; Angiotensin II Type 1 Receptor Blockers - administration & dosage; Biological and medical sciences; Blood and lymphatic vessels; Blood. Blood coagulation. Reticuloendothelial system; Captopril - administration & dosage; Captopril - adverse effects; Cardiology. Vascular system; Cardiovascular Diseases - drug therapy; Cardiovascular Diseases - mortality; Cause of Death; Coronary heart disease; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Heart; Heart Failure - drug therapy; Heart Failure - mortality; Humans; Medical sciences; Medicin och hälsovetenskap; Middle Aged; Morbidity; Mortality; Myocardial Infarction - complications; Myocardial Infarction - drug therapy; Pharmacology. Drug treatments; Systole; Tetrazoles - administration & dosage; Tetrazoles - adverse effects; Treatment Outcome; Valine - administration & dosage; Valine - adverse effects; Valine - analogs & derivatives; Valsartan; Ventricular Dysfunction, Left - drug therapy; Heart; Myocardial infarction; Tetrazole derivatives; Senescence; Valsartan; Peptide hormone; Cardiovascular disease; Heart ventricle; Left ventricular failure; Myocardial disease; Octapeptide; Peptidyl-dipeptidase A; Heart disease; Angiotensin II; Left ventricle performance; Human; angiotensin-converting enzyme inhibitors; Enzyme; Captopril; Mortality; Enzyme inhibitor; AT1 angiotensin receptor; Morbidity; Peptidases; Renin angiotensin system; Treatment; Biphenyl derivatives; Aminoacid; Hydrolases; Peptidyl-dipeptidases; Antihypertensive agent; Angiotensin antagonist; Circulatory system; aging; myocardial infarction, valsartan; Elderly; ACE inhibitor
• ISSN: 0009-7322; 1524-4539; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.105.551143

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. 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. 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.