Fatal myocardial rupture after acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT).
BACKGROUND
Myocardial rupture is a relatively rare and usually fatal complication of myocardial infarction (MI). Early recognition of patients at greatest risk of myocardial rupture provides an opportunity for early intervention.


METHODS
VALIANT was a double-blind, randomized, controlled trial comparing valsartan, captopril, and their combination in high-risk patients post-MI. Myocardial rupture was identified by autopsy (available in 138/589 patients dying within 30 days of index MI), echocardiography, direct surgical visualization, or presence of hemopericardium. An independent clinical end points committee reviewed medical records for all deaths or suspected nonfatal cardiovascular events.


RESULTS
Rupture was identified in 45 (0.31%) patients enrolled in VALIANT, occurring 9.8 +/- 6.0 days after the qualifying MI. Rupture accounted for 7.6% (45/589) of all deaths occurring in the first 30 days of follow-up and 24% (33/138) of deaths in which autopsies were obtained. Compared with survivors, rupture was associated with increased age, hypertension, increased Killip class, lower estimated glomerular filtration rate, and Q wave MI, and inversely related to beta-blocker and diuretic use. Compared with patients who died of other causes within 30 days, patients with myocardial rupture were more likely to have had an inferior MI, Q wave MI, or hypertension; to have used oral anticoagulants; or to have received thrombolytic therapy.


CONCLUSIONS
Although rare, myocardial rupture accounted for nearly one fourth of all deaths within the first 30 days after high-risk MI, suggesting an estimated incidence of approximately 1% within the first 30 days. A number of clinical characteristics may identify post-MI patients at higher risk of myocardial rupture.
Shamshad
Faisal
F
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Kenchaiah
Satish
S
Finn
Peter V
PV
Soler-Soler
Jordi
J
McMurray
John J V
JJ
Velazquez
Eric J
EJ
Maggioni
Aldo P
AP
Califf
Robert M
RM
Swedberg
Karl
K
Kober
Lars
L
Belenkov
Yuri
Y
Varshavsky
Sergei
S
Pfeffer
Marc A
MA
Solomon
Scott D
SD
D000368:Aged; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use*; D002423:Cause of Death / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000209:etiology* / Q000503:physiopathology; D006342:Heart Rupture, Post-Infarction / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D011379:Prognosis; D012189:Retrospective Studies; D013777:Tetrazoles / Q000627:therapeutic use*; D013997:Time Factors; D014633:Valine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000068756:Valsartan; D018487:Ventricular Dysfunction, Left / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology
D047228:Angiotensin II Type 1 Receptor Blockers; D013777:Tetrazoles; D000068756:Valsartan; D014633:Valine