RESUMEN
OBJECTIVES: We sought to evaluate the relation between warfarin anticoagulation and survival and morbidity from cardiac disease in patients with left ventricular (LV) dysfunction. BACKGROUND: Warfarin anticoagulation plays a major role in the management of patients who have had a large myocardial infarction and in those with atrial fibrillation. However, its use in patients with LV systolic dysfunction has been controversial. METHODS: We reviewed data on warfarin use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between warfarin use and all-cause mortality, as well as the combined end point of death or hospital admission for heart failure. We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between warfarin use and selected patient variables in relation to outcome. RESULTS: On multivariate analysis, use of warfarin was associated with a significant reduction in all-cause mortality (adjusted hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.65 to 0.89, p = 0.0006) and in the risk of death or hospital admission for heart failure (HR 0.82, 95% CI 0.72 to 0.93, p = 0.0002). Risk reduction was observed when each trial or randomization arm was analyzed separately, as well as in both genders. It was not significantly influenced by the presence of atrial fibrillation, age, ejection fraction, New York Heart Association functional class or etiology. CONCLUSIONS: In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.
Asunto(s)
Anticoagulantes/uso terapéutico , Disfunción Ventricular Izquierda/mortalidad , Warfarina/uso terapéutico , Angina Inestable/complicaciones , Gasto Cardíaco Bajo/complicaciones , Enfermedades Cardiovasculares/mortalidad , Causas de Muerte , Estudios de Cohortes , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/complicaciones , Modelos de Riesgos Proporcionales , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Disfunción Ventricular Izquierda/complicacionesRESUMEN
OBJECTIVES: This study sought to evaluate the relation between antiplatelet agent (APA) use and survival and morbidity from cardiac disease in patients with left ventricular (LV) systolic dysfunction. BACKGROUND: APAs play an important role in the prevention and treatment of coronary disease. Their effects in patients with LV systolic dysfunction are unknown. METHODS: We reviewed data on APA use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between their use and all-cause mortality as well as the combined end point of death or hospital admission for heart failure (HF). We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between APA use and selected patient variables in relation to outcome. RESULTS: APA use (46.3% of patients) was associated with significantly reduced mortality from all causes (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73 to 0.92, p = 0.0005) and reduced risk of death or hospital admission for HF (adjusted HR 0.81, 95% CI 0.74 to 0.89, p < 0.0001) but was not influenced by trial assignment, gender, LV ejection fraction, New York Heart Association class or etiology. A strong interaction was observed among APA use, randomization group and all-cause mortality. The association between APA use and survival was not observed in the enalapril group, nor was an enalapril benefit on survival detectable in patients receiving APAs at baseline. However, randomization to enalapril therapy significantly reduced the combined end point of death or hospital admission for HF in APA users. CONCLUSIONS: In patients with LV systolic dysfunction, use of APAs is associated with improved survival and reduced morbidity. This association is retained after adjustment for baseline characteristics. APA use is associated with retained but reduced benefit from enalapril.
Asunto(s)
Enfermedad Coronaria/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Disfunción Ventricular Izquierda/fisiopatología , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antihipertensivos/uso terapéutico , Gasto Cardíaco Bajo/etiología , Gasto Cardíaco Bajo/fisiopatología , Causas de Muerte , Estudios de Cohortes , Intervalos de Confianza , Enfermedad Coronaria/mortalidad , Muerte Súbita Cardíaca/etiología , Método Doble Ciego , Enalapril/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Admisión del Paciente , Placebos , Análisis de Regresión , Factores de Riesgo , Factores Sexuales , Volumen Sistólico/fisiología , Análisis de Supervivencia , Resultado del Tratamiento , Disfunción Ventricular Izquierda/tratamiento farmacológico , Disfunción Ventricular Izquierda/mortalidad , Función Ventricular Izquierda/fisiologíaRESUMEN
Results of the SOLVD prevention trial and of the SAVE trial indicate that long-term treatment with ACE inhibitors in asymptomatic patients with LV systolic dysfunction prevents the progression to overt CHF and reduces hospitalizations for CHF. ACE inhibitors have been shown to reduce mortality in at least some subsets of asymptomatic patients with LV systolic dysfunction, notably those with recent myocardial infarction.