title: 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).
abstract: 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.
  
  
  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.
authors.affiliation: Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand. HarveyW@adhb.govt.nz
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Philip E G
authors.initials: PE
authors.lastname: Aylward
authors.forename: Zhen
authors.initials: Z
authors.lastname: Huang
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Dalby
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Weaver
authors.forename: Ståle
authors.initials: S
authors.lastname: Barvik
authors.forename: José Antonio
authors.initials: JA
authors.lastname: Marin-Neto
authors.forename: Jan
authors.initials: J
authors.lastname: Murin
authors.forename: Rolf O
authors.initials: RO
authors.lastname: Nordlander
authors.forename: Wiek H
authors.initials: WH
authors.lastname: van Gilst
authors.forename: Faiez
authors.initials: F
authors.lastname: Zannad
authors.forename: John J V
authors.initials: JJ
authors.lastname: McMurray
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Marc A
authors.initials: MA
authors.lastname: Pfeffer
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage*; D002216:Captopril / Q000008:administration & dosage* / Q000009:adverse effects; D002318:Cardiovascular Diseases / Q000188:drug therapy* / Q000401:mortality; D002423:Cause of Death; D006333:Heart Failure / Q000188:drug therapy / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D009017:Morbidity; D009026:Mortality; D009203:Myocardial Infarction / Q000150:complications* / Q000188:drug therapy; D013599:Systole; D013777:Tetrazoles / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D014633:Valine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000068756:Valsartan; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D013777:Tetrazoles; D000068756:Valsartan; D002216:Captopril; D014633:Valine