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Myocardial Infarction in Heart Failure With Preserved Ejection Fraction: Pooled Analysis of 3 Clinical Trials
Jonathan W Cunningham1, Muthiah Vaduganathan1, Brian L Claggett1
1Brigham and Women's Hospital, Boston, Massachusetts.
Insights
A history of myocardial infarction (MI) increases cardiovascular death risk in heart failure with preserved ejection fraction (HFpEF) patients. Experiencing an MI post-diagnosis significantly elevates subsequent risks for cardiovascular death and heart failure hospitalization.
Area of Science:
- Cardiology
- Heart Failure Research
- Clinical Trials
Background:
- Myocardial infarction (MI) and heart failure with preserved ejection fraction (HFpEF) share common risk factors.
- The prognostic impact of MI in HFpEF patients remains unclear.
Purpose of the Study:
- To investigate the association between prior or incident myocardial infarction (MI) and cardiovascular (CV) events in patients with heart failure with preserved ejection fraction (HFpEF).
Main Methods:
- Pooled data from 8,916 patients across three major trials: CHARM Preserved, I-Preserve, and the Americas region of TOPCAT.
- Examined whether MI before or after enrollment independently predicted CV death and heart failure (HF) hospitalization.
Main Results:
- At baseline, 30% of patients had a history of MI, which was independently associated with a 42% increased risk of CV death (HR: 1.42) and a 55% increased risk of sudden death.
- No significant difference in HF hospitalization or HF death was observed based on prior MI.
- Following enrollment, incident MI (3.8% of patients) led to a 31-fold increase in CV death risk within 30 days and a 2.4-fold increase in HF hospitalization risk.
Conclusions:
- Prior MI in HFpEF is linked to higher CV and sudden death risks, but not necessarily HF outcomes.
- Patients with HFpEF who experience MI face substantially elevated risks of subsequent CV death and HF hospitalization.
- Emphasizes the critical need for primary and secondary MI prevention strategies in the HFpEF population.
Objectives:
The authors investigated the relationship between past or incident myocardial infarction (MI) and cardiovascular (CV) events in heart failure with preserved ejection fraction (HFpEF).
Background:
MI and HFpEF share some common risk factors. The prognostic significance of MI in patients with HFpEF is uncertain.
Methods:
The authors pooled data from 3 trials-CHARM Preserved (Candesartan Cilexietil in Heart Failure Assessment of Reduction in Mortality and Morbidity), I-Preserve (Irbesartan in Heart Failure With Preserved Systolic Function), and the Americas region of TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) (N = 8,916)-and examined whether MI before or following enrollment independently predicted CV death and heart failure (HF) hospitalization.
Results:
At baseline, 2,668 patients (30%) had history of MI. Prior MI was independently associated with greater risk of CV death (4.7 vs. 3.5 events/100 patient-years [py], adjusted hazard ratio [HR]: 1.42 [95% confidence interval (CI): 1.23 to 1.64]; p < 0.001). Excess sudden death drove this difference (1.9 vs. 1.2 events/100 py, adjusted HR: 1.55 [95% CI: 1.23 to 1.97]; p < 0.001). There was no difference in HF hospitalization (5.9 vs. 5.5 events/100 py, adjusted HR: 1.05, 95% CI: 0.92 to 1.19) or HF death by prior MI. During follow-up, MI occurred in 336 patients (3.8%). Risk of CV death increased 31-fold in the first 30 days after first post-enrollment MI, and remained 58% higher beyond 1 year after MI. Risk of first or recurrent HF hospitalization increased 2.4-fold after MI.
Conclusions:
Prior MI in HFpEF is associated with greater CV and sudden death but similar risk of HF outcomes. Patients with HFpEF who experience MI are at high risk of subsequent CV death and HF hospitalization. These data highlight the importance of primary and secondary prevention of MI in patients with HFpEF. (Candesartan Cilexietil in Heart Failure Assessment of Reduction in Mortality and Morbidity [CHARM Preserved]; NCT00634712; Irbesartan in Heart Failure With Preserved Systolic Function [I-Preserve]; NCT00095238; and Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist [TOPCAT]; NCT00094302).
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