Alberto Volpi

Determinants of 6-month mortality in survivors of myocardial infarction after thrombolysis. Results of the GISSI-2 data base. The Ad hoc Working Group of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI)-2 Data Base.

BackgroundCurrent knowledge of risk assessment in survivors of myocardial infarction is largely based on data gathered before the advent of thrombolysis. It must be determined whether and to what extent available information and proposed criteria of prognostication are applicable in the thrombolytic era. Methods and ResultsWe reassessed risk prediction in the 10 219 survivors of myocardial infarction with follow-up data available (ie, 98% of the total) who had been enrolled in the GISSI-2 trial, relying on a set of prespecified variables. The 3.5% 6-month all-cause mortality rate of these patients compared with the higher value of 4.6% found in the corresponding GISSI-1 cohort, originally allocated to streptokinase therapy, indicates a 24% reduction in postdischarge 6-month mortality. On multivariate analysis (Cox model), the following variables were predictors of 6-month all-cause mortality: ineligibility for exercise test for both cardiac (relative risk [RR], 3.30; 95% confidence interval [CI], 2.36-4.62) and noncardiac reasons (RR, 3.28; 95% CI, 2.23-4.72), early left ventricular failure (RR, 2.41; 95% CI, 1.87-3.09), echocardiographic evidence of recovery phase left ventricular dysfunction (RR, 2.30; 95% CI, 1.78-2.98), advanced (more than 70 years) age (RR, 1.81; 95% CI, 1.43 -2.30), electrical instability (ie, frequent and/or complex ventricular arrhythmias) (RR, 1.70; 95% CI, 1.32-2.19), late left ventricular failure (RR, 1.54; 95% CI, 1.17-2.03), previous myocardial infarction (RR, 1.47; 95% CI, 1.14-1.89), and a history of treated hypertension (RR, 1.32; 95% CI, 1.05-1.65). Early post-myocardial infarction angina, a positive exercise test, female sex, history of angina, history of insulin-dependent diabetes, and anterior site of myocardial infarction were not risk predictors. On further multivariate analysis, performed on 8315 patients with the echocardiographic indicator of left ventricular dysfunction available, only previous myocardial infarction was not retained as an independent risk predictor. ConclusionA decline in 6-month mortality of myocardial infarction survivors, seen within 6 hours of symptom onset, has been observed in recent years. Ineligibility for exercise test, early left ventricular failure, and recovery-phase left ventricular dysfunction are the most powerful (RR, >2) predictors of 6-month mortality among patients recovering from myocardial infarction after thrombolysis. Qualitative variables reflecting residual myocardial ischemia do not appear to be risk predictors. The lack of an independent adverse influence of early post-myocardial infarction angina on 6-month survival represents a major difference between this study and those of the prethrombolytic era.

Valsartan Benefits Left Ventricular Structure and Function in Heart Failure: Val-HeFT Echocardiographic Study

OBJECTIVES The objective of the study was to evaluate the effect of an angiotensin receptor blocker on left ventricular (LV) structure and function when added to prescribed heart failure therapy. BACKGROUND The clinical benefit derived from heart failure therapy is attributed to the regression of LV remodeling. METHODS At 302 multinational sites, 5,010 patients in New York Heart Association (NYHA) classification II to IV heart failure taking angiotensin-converting enzyme inhibitor (ACEI) and/or beta-blocker (BB) were randomized into valsartan and placebo groups and followed for a mean of 22.4 months. Serial echocardiographic measurements of left ventricular internal diastolic diameter (LVIDd) and ejection fraction (EF) were recorded. Total study reproducibility calculated to 90% power at 5% significance defined detectable differences of 0.09 cm for LVIDd and 0.86% for EF. RESULTS Baseline LVIDd and EF for valsartan and placebo groups were similar: 3.6 +/- 0.5 versus 3.7 +/- 0.5 (cm/m(2)) and 26.6 +/- 7.3 versus 26.9 +/- 7.0 (%). Mean group changes from baseline over time were compared. Significant decrease in LVIDd and increase in EF began by four months, reached plateau by one year, and persisted to two years in valsartan compared with placebo patients, irrespective of age, gender, race, etiology, NYHA classification, and co-treatment therapy. Changes at 18 months were -0.12 +/- 0.4 versus -0.05 +/- 0.4 (cm/m(2)), p < 0.00001 for LVIDd, and +4.5 +/- 8.9 versus +3.2 +/- 8.6 (%), p < 0.00001 for EF. The exception occurred in patients taking both ACEI and BB as co-treatment, in whom the decrease in LVIDd and increase in EF were no different between valsartan and placebo groups. CONCLUSIONS The Val-HeFT echocardiographic substudy of 5,010 patients with moderate heart failure demonstrated that valsartan therapy taken with either ACEI or BB reversed LV remodeling.

Distribution of propafenone and its active metabolite, 5-hydroxypropafenone, in human tissues

Tissue distribution of antiarrhythmic drugs, and particularly their myocardium uptake, can be relevant in the interpretation of their effects.’ h on one occasion the eosinophilic count exceeded 1.5 X lo9 cells/L. In

High- and low-risk groups: early and late prognostic stratification.

Prognostic data obtained from studies carried out since the advent of thrombolysis confirm the notion that short-term survival after acute myocardial infarction is primarily influenced by age and clinical indicators of infarct size or global left ventricular dysfunction. In survivors of the in-hospital phase of infarction, markers of left ventricular failure or dysfunction are still the most powerful risk predictors, whereas qualitative variables related to residual ischaemia do not predict outcome. The relatively low overall risk profile of survivors of the in-hospital phase of infarction in the GISSI-2 study appears to reflect favourable changes in the sizes of risk strata that result from a general improvement in management strategies.

The relationship between B-type natriuretic peptide, heart structure, and function in 4,300 patients with heart failure enrolled to Val-HeFT

by initial treatment strategy (MED, PCI, CABG) using SF-36 physical function, health utility and Seattle angina questionnaire. Linear modeling to predict 1 year physical function (SF-36 PF) included pt characteristics and treatment strategy. Results: PCI was the initial treatment strategy in 41%, CABG 22% and MED 37% I” elderly CAD pts. Survival at 1 yr was highest among pts undergolng CABG (60% CABG, 72% PCI, 50% MED). Pts undergoing CABG also had less angina, higher health utility rating, and better physical functioning at 1 yr than those treated with either PCI or MED (Table). CABG remained a significant predlctor (p=O.OOl) of higher 1 yr physical function (PF) even after adjusting for baseline PF. age, gender, education, prior MI, DM, PVD, EF, CAD severity and other predictors. In contrast, pts undergoing PCI had a non-significant trend toward better physical functioning at 1 year. Conclusions: After adjusting for potential confounders, CABG still affords elderly pts significantly better angma relief and funchonal outcomes at 1 year than either MED or IO:45 a.m.