Author + information
- Justin A. Ezekowitz, MBBCh, MSc⁎ (, )
- Padma Kaul, PhD,
- Jeffrey A. Bakal, PhD,
- Paul W. Armstrong, MD,
- Robert C. Welsh, MD and
- Finlay A. McAlister, MD, MSc
- ↵⁎2C2 Cardiology WMC, 8440 112th Street, Edmonton, Alberta T6G 2B7, Canada
We appreciate the interest of Dr. Torabi and colleagues in our study (1), which demonstrated the significance of heart failure (HF) after myocardial infarction.
They identified the significance of early HF in ∼900 patients in a similar time period (1998), followed up for a similar time (5 years). Heart failure not only develops as an early event, but as importantly shown by our analysis, it also develops in those who left the hospital without HF, with 71% developing late HF within 5 years. The median age of our 7,733-patient Alberta cohort (1) is 5 years older than that of Dr. Torabi and colleagues, which may explain in part the morbidity and mortality event rates.
Late development of HF is well established by landmark trials of angiotensin-converting enzyme inhibitors, indicating that prevention of late remodeling and the subsequent attenuation of HF is a key efficacy signal of these agents (2). Dr. Torabi and colleagues used a unique definition of HF, including HF signs or symptoms in patients on a diuretic agent or who died shortly after developing major cardiac dysfunction, for example, cardiogenic shock or pulmonary edema. Both warrant exploration in other datasets to ensure their external validity; the coding of HF by our method has undergone validation in multiple jurisdictions (3,4).
The authors assert that death is not a single entity, and we agree; hence, we did not classify cause of death. Given the complexity of HF, adjudication by a clinical events committee using rigorous and published methodology, as shown in a recent clinical trial in patients with high-risk ST-segment elevation myocardial infarction (5), is a key strategy to facilitate inclusion of HF as an end point. In this trial (6) and others, development of HF at 90 days occupies a key position in the primary composite end point.
- American College of Cardiology Foundation