Coronary artery disease
Usefulness of Right Ventricular Fractional Area Change to Predict Death, Heart Failure, and Stroke Following Myocardial Infarction (from the VALIANT ECHO Study)

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Severe right ventricular dysfunction independent of left ventricular ejection fraction increased the risk of heart failure (HF) and death after myocardial infarction (MI). The association between right ventricular function and other clinical outcomes after MI was less clear. Two-dimensional echocardiograms were obtained in 605 patients with left ventricular dysfunction and/or clinical/radiologic evidence of HF from the VALIANT echocardiographic substudy (mean 5.0 ± 2.5 days after MI). Clinical outcomes included all-cause mortality, cardiovascular (CV) death, sudden death, HF, and stroke. Baseline right ventricular function was measured in 522 patients using right ventricular fractional area change (RVFAC) and was related to clinical outcomes. Mean RVFAC was 41.9 ± 4.3% (range 19.2% to 53.1%). The incidence of clinical events increased with decreasing RVFAC. After adjusting for 11 covariates, including age, ejection fraction, and Killip’s classification, decreased RVFAC was independently associated with increased risk of all-cause mortality (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.31 to 1.98), CV death (HR 1.62, 95% CI 1.30 to 2.01), sudden death (HR 1.79, 95% CI 1.26 to 2.54), HF (HR 1.48, 95% CI 1.17 to 1.86), and stroke (HR 2.95, 95% CI 1.76 to 4.95), but not recurrent MI. Each 5% decrease in baseline RVFAC was associated with a 1.53 (95% CI 1.24 to 1.88) increased risk of fatal and nonfatal CV outcomes. In conclusion, decreased right ventricular systolic function is a major risk factor for death, sudden death, HF, and stroke after MI.

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Methods

VALIANT was a multinational, double-blind, randomized, active-controlled study of 14,703 patients with 3 parallel treatment groups comparing the efficacy and safety of long-term treatment with valsartan, captopril, and their combination within 12 hours to 10 days after acute MI in patients with acute HF, left ventricular systolic dysfunction, or both.1 Inclusion and exclusion criteria and details of patient characteristics were previously described. Clinical sites participating in the main

Results

Baseline RVFAC for 522 patients was approximately symmetrically distributed (mean RVFAC 41.9 ± 4.3%; Figure 1). Across RVFAC categories (Table 1), there were no differences with respect to age, gender, pulmonary disease, smoking, hemodynamic variables, Killip’s classification, medications, or infarct location. Individuals in the lowest RVFAC category had a higher incidence of hypertension, previous MI, previous congestive HF, a higher proportion of non–Q-wave MIs, larger left ventricular

Discussion

In this analysis, baseline right ventricular function assessed using RVFAC was found to be a significant independent predictor for a broad spectrum of CV outcomes in patients with left ventricular dysfunction and/or HF complicating MI. These results confirmed the importance of right ventricular function after infarction and argue for routine assessment of right ventricular function in high-risk patients.

The concept that impaired right ventricular function after MI was associated with poor

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