Key PointsQuestion听
Has the sudden death rate after myocardial infarction and the characteristics of people dying suddenly changed over time?
Findings听
In this secondary analysis of the VALIANT (Valsartan in Acute Myocardial Infarction) and PARADISE-MI (Prospective ARNi vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI) trials including 30鈥�364 participants, PARADISE-MI results revealed that contemporarily managed patients had higher rates of revascularization, 尾-blockers, and mineralocorticoid receptor antagonists than people in the VALIANT trial. In the PARADISE-MI study, the rate of sudden death was highest up to 1 month after myocardial infarction but was 2- to 3-fold lower than in the VALIANT trial.
Meaning听
Results suggest that contemporary treatments have substantially reduced the rate of sudden death, yet the first month after infarction remains a particularly high-risk period.
Importance听
Sudden death is a leading cause of death after acute myocardial infarction (AMI). The Prospective ARNi vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI (PARADISE-MI) and Valsartan in Acute Myocardial Infarction (VALIANT) trials enrolled patients with pulmonary congestion and/or left ventricular dysfunction after AMI. Whether the prognosis in such patients has changed over time has not been examined.
Objective听
To compare the rate of sudden death/resuscitated cardiac arrest (RCA) after AMI in the PARADISE-MI and VALIANT trials.
Design, Setting, and Participants听
This was a secondary analysis of multicenter randomized clinical trials enrolling patients after AMI. In the primary analysis, the VALIANT cohort was restricted to patients with 鈥淧ARADISE-MI鈥搇ike鈥� characteristics (eg, at least 1 augmenting risk factor and no history of heart failure). The baseline characteristics of people in both trials were compared. The VALIANT trial enrolled from December 1998 to June 2001, and the PARADISE-MI trial enrolled between December 2016, and March 2020. The median follow-up in the VALIANT and PARADISE-MI trials was 24.7 and 22 months, respectively. People with AMI, complicated by pulmonary congestion and/or left ventricular dysfunction, were included in the analysis.
Exposure听
Sudden death after AMI.
Results听
A total of 5661 patients were included in the PARADISE-MI cohort (mean [SD] age, 63.7 [11.5] years; 4298 male [75.9%]), 9617 were included in the VALIANT (PARADISE-MI鈥搇ike) cohort (mean [SD] age, 66.1 [11.5] years; 6504 male [67.6%]), and 14鈥�703 patients were included in the VALIANT (total) cohort (mean [SD] age, 64.8 [11.8] years; 10鈥�133 male [68.9%]). In the PARADISE-MI鈥搇ike cohort of the VALIANT trial, 707 of 9617 participants (7.4%) experienced sudden death/RCA. A total of 148 of 5661 people (2.6%) in the PARADISE-MI trial experienced sudden death/RCA. Sudden death rates were highest in the first month after infarction in both trials: 19.3 (95% CI, 16.4-22.6) per 100 person-years in the VALIANT trial and 9.5 (95% CI, 7.0-12.7) per 100 person-years in the PARADISE-MI trial, and these rates declined steadily thereafter. Compared with the VALIANT cohort, people in the PARADISE-MI trial were more often treated with percutaneous coronary intervention for their qualifying AMI and received a 尾-blocker, statin, and mineralocorticoid receptor antagonist more frequently.
Conclusions and Relevance听
After AMI, the risk of sudden death/RCA was highest in the first month, declining rapidly thereafter. Results revealed that compared with counterparts from 20 years ago, the rate of sudden death/RCA in patients with a reduced left ventricular ejection fraction and/or pulmonary congestion was 2- to 3-fold lower in people receiving contemporary management. Interventions to further protect people in the highest risk first month after infarction are needed.
Trial Registration听
ClinicalTrials.gov Identifier: