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Sickest Minority of Heart Attack Patients Constitute Majority of In-Hospital Deaths

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Duke Health News 919-660-1306

CHICAGO -- An international "snapshot" of almost 5,600 heart
attack patients has shown that while those who also have heart
failure and/or a weak left pumping chamber represent about 42
percent of total heart attack patients, they account for 81.5
percent of the deaths in hospital, according to Duke University
Medical Center cardiologists and their international
colleagues.

These findings are important, the researchers said, because
they clearly identify those heart attack patients who are at
highest risk for death. Just as importantly, the researchers
also found that this group of patients does not adequately
receive proven therapies -- both medical and procedural -- that
could improve their chances for survival.

The results of the Duke analysis were presented today (March
30, 2003) by Duke cardiologist Eric Velazquez, M.D., during the
52nd annual scientific sessions of the American College of
Cardiology.

"This sizeable minority of heart attack patients appears to
be at the highest risk for dying of their heart attack while in
the hospital," Velazquez said. "The message for cardiologists
is to identify these patients and aggressively treat them with
therapies that have proven to be effective.

"We need to do a better job identifying and treating these
patien" Velazquez said. "They are the sickest heart attack
patients and they have the most to gain from aggressive
treatment."

Heart failure is a condition marked by abnormal heart
function that leads to symptoms of lung congestion and an
inability to meet the metabolic demands of the body. Patients
whose left ventricle -- the main pumping chamber of the heart
-- pumps at less than 40 percent of its strength have what is
termed left ventricular systolic dysfunction (LSVD). LVSD can
be, but not always, a cause of heart failure.

Patients with heart failure and/or LVSD are not usually
enrolled in typical clinical trials involving heart attack
because they are believed to be too sick, Velazquez said.

To gain better insights into these patients, Velazquez
organized a separate patient registry in conjunction with an
ongoing clinical trial on the effect of valsartan -- an
angiotensin II receptor blocker (ARB) -- on patients with HF
and/or LVSD after a heart attack. Valsartan is currently
approved for lowering blood pressure.

The overall trial, dubbed VALIANT (VALsartan In Acute
myocardial iNfarcTion) enrolled over 14,500 patients in 24
countries.

To gain a "snapshot" of contemporary heart attack patients
worldwide, Velazquez gathered additional data on 5,592
consecutive MI patients enrolled from 1999-2001. Of those
patients, 2,352 (42 percent) also suffered from heart failure
and/or LVSD and were theoretically eligible for the VALIANT
trial.

"What we ended up with was a real-world registry of patient
data," Velazquez said. "These patients are a significant
minority of patients whose effect on overall in-hospital
morbidity and mortality appears to be profound.

"The overall in-hospital death rate was 6.9 percent,"
Velazquez continued. "However, the patients with heart failure
and/or LVSD had a 13.1 percent death rate, compared to 2.4
percent for the other patients."

Also, the heart attack patients with heart failure and/or
LVSD averaged 12 days in the hospital, compared to 7.6 days for
the other group.

In addition to following how these patients fared during
their hospitalization, Velazquez also gathered data on
different treatments used on these patients.

"Only 34.2 percent of these patients received
angiotensin-converting enzyme (ACE) inhibitors and 58 percent
received beta-blockers within the first 24 hours," Velazquez
continued. "These medicines have been proven in clinical trials
to improve mortality rates. As far as revascularization
procedures, 31.4 percent received angioplasty and 11 percent
underwent coronary artery bypass surgery.

"This registry sets the stage for VALIANT by reinforcing the
critical need to identify the best strategies to treat this
high risk group of MI patients," Velazquez said. "We know that
ACE inhibitors improve mortality for heart attack patients, and
we are still determining the role of ARBs."

The goal of VALIANT is to determine whether or not valsartan
can reduce the mortality of heart attack patients with heart
failure and/or LVSD. It will be tested alone and in conjunction
with captopril, an ACE inhibitor.

VALIANT is supported by Novartis Pharmaceuticals, East
Hanover, N.J. and the principal investigator is Marc Pfeffer,
M.D., Harvard University Medical School and Brigham &
Women?s Hospital, Boston.

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