CORRESPONDENCE: LETTER TO THE EDITOR
Declining In-Hospital Mortality and Increasing Heart Failure Incidence in Elderly Patients With First Myocardial Infarction
Azam Torabi, MD*,
Alan S. Rigby, PhD and
John G.F. Cleland, MD
* Department of Cardiovascular and Respiratory Studies, MRTDS Building, Castle Hill Hospital, Castle Road, Kingston Upon Hull HU16 5JQ, England (Email: azam.torabi{at}hey.nhs.uk).
Ezekowitz et al. (1) report a decreasing overall mortality rate but an increasing incidence of heart failure (HF), especially late-onset HF, in a large cohort of patients with a first myocardial infarction in Alberta between 1994 and 2000. They found that in most patients (76%) who had suffered a myocardial infarction, HF developed. We have published similar data from the United Kingdom in patients from a single, large hospital service who had a first or recurrent myocardial infarction in 1998 (2), and reported that in 63% HF developed over the subsequent 6 years. Interestingly, we reported that 84% of those who died during follow-up first developed HF. Recalculation of data provided by Ezekowitz et al. (1) yields a similar figure (92%) in a somewhat older population (Fig. 1). However, some disparity does exist. Whereas Ezekowitz et al. (1) suggest a relatively modest increase in 5-year mortality in those in whom HF developed, our data suggest a striking difference (Table 1). This most likely reflects differences in diagnostic criteria. We defined HF as intervention with diuretic agents for symptoms or signs of HF; Ezekowitz et al. (1) used hospital codes and billing information, and <25% of patients coded as HF received diuretic agents.
The high proportion of patients in whom HF develops after a myocardial infarction might seem surprising because ischemic heart disease is common and the prevalence of HF is only about 1% (3). This reflects the poor prognosis of HF and suggests that the burden of HF may be better described by its incidence rather than prevalence (4). HF is also often under-represented in health care statistics because events such as death or hospitalization are ascribed to the cause of HF rather than to its presence. Death is usually a complex process, and attributing death to only one reason often is inappropriate. For instance, a patient could die of a lethal arrhythmia in the setting of worsening HF induced by a recurrent ischemic event. This patient died as a consequence of a constellation of events. What is important is to identify which interventions might produce worthwhile benefits for patients.
Clearly, reducing the incidence of HF is an important goal of treating myocardial infarction because it may improve well-being as well as extend life. In most patients in whom HF develops after a myocardial infarction, it occurs shortly after an initial or recurrent coronary event, suggesting these as possible therapeutic targets. However, treatment with aspirin (5), statins (6), or revascularization (7) have so far all proved disappointing in randomized trials of patients with chronic HF, although these data should not be extrapolated to acute care of myocardial infarction. More attention needs to be paid to HF as an end point in trials of treatment for myocardial infarction. Because HF is often a difficult and subjective diagnosis, trials need to develop standard objective criteria, possibly including measurement of natriuretic peptides and the requirement for therapy with loop diuretic agents.
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1. Ezekowitz JA, Kaul P, Bakal JA, et al. Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction J Am Coll Cardiol 2009;53:13-20.[Abstract/Free Full Text]2. Torabi A, Cleland JGF, Khan NK, et al. The timing of development and subsequent clinical course of heart failure after a myocardial infarction Eur Heart J 2008;29:859-870.[Abstract/Free Full Text] 3. Cleland JGF, Torabi AKN. Epidemiology and management of heart failure and left ventricular systolic dysfunction in the aftermath of a myocardial infarction Heart 2005;91(Suppl):7-13.[Abstract/Free Full Text] 4. Lloyd-Jones DM, Larson MG, Leip MS, et al. Lifetime risk for developing congestive heart failure—the Framingham Heart Study Circulation 2002;106:3068-3072.[Abstract/Free Full Text] 5. Cleland JGF, Findlay I, Jafri S, et al. The Warfarin/Aspirin Study in Heart Failure (WASH): a randomized trial comparing antithrombotic strategies for patients with heart failure Am Heart J 2004;148:157-164.[CrossRef][Web of Science][Medline] 6. Kjekshus J, Apetrei E, Barrios V, et al. CORONA Group Rosuvastatin in older patients with systolic heart failure N Engl J Med 2007;357:2248-2261.[Abstract/Free Full Text] 7. Coletta AP, Cleland JGF, Cullington D, et al. Clinical trials update from Heart Rhythm 2008 and Heart Failure 2008: ATHENA, URGENT, INH study, HEART and CK-1827452 Eur J Heart Fail 2008;10:917-920.[Abstract/Free Full Text]
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