Heart Failure After Acute Myocardial Infarction

mprovements in the treatment of acute myocardial infarc- tion (AMI), especially use of reperfusion therapy, have led to larger numbers of survivors. In patients who would have survived despite reperfusion therapy, use of this treatment should lead to greater myocardial salvage and a reduced extent of ventricular injury in many. However, others who might not have survived previously may now do so, but with substantial left ventricular damage.1,2 The net consequence of these 2 opposing effects on the early and later risk of developing heart failure after AMI is uncertain. There has been concern, however, that an increasing pool of survivors of AMI might fuel an "epidemic" of heart failure. Article p 2057 Although we have a substantial amount of data on the rates of heart failure overall, rates of heart failure after AMI have been less well studied. Furthermore, the clinical trials, regis- tries and epidemiological studies that have reported the rate of heart failure after AMI have used different case ascertain- ment and diagnostic criteria. Examination of 4 of the major trials of fibrinolysis (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arter- ies (GUSTO I), Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO IIb and GUSTO III), and the Assessment of the Safety and Efficacy of a New Thrombo- lytic trial (ASSENT II)) in AMI revealed that heart failure was present at admission in 12.5% of the 61 041 participants, with 29.4% having evidence of heart failure at any time during admission.3 The rate was similar in the 15 078 patients enrolled in the Intravenous nPA for the Treatment of Infarct- ing Myocardium Early II study (InTIME II), where 23% presented with heart failure.4 However, clinical trials can only be cautiously generalized to the community because of the selection of participants.5 Registries provide further confirmation that this complica- tion of AMI is common. The National Registry of MI, consisting of 606 500 patients with AMI, identified heart failure in 20.4% of individuals at admission with 8.6% developing heart failure subsequently.6 The Valsartan in