Is the combination of valsartan and captopril better than captopril alone in patients with heart failure and left ventricular systolic dysfunction after myocardial infarction? results of VALIANT

Abstract

Purpose: In the VALIANT trial, the combination of valsartan and captopril was not superior to either monotherapy in reducing mortality or morbidity after acute MI complicated by heart failure (HF) and/or left ventricular systolic dysfunction (LVSD); valsartan and captopril were equally effective. Combination therapy might still be more effective in certain high-risk subsets such as patients with both HF and LVSD. Methods: VALIANT randomized 14,703 patients from 0.5 to 10 days (median 4.9 days) post-MI; median follow-up was 24.7 months. HF occurrence and severity, defined by Killip class (KC) and degree of LVSD, measured by left ventricular ejection fracture (LVEF), were reported between MI onset and randomization. Cox proportional hazards models for death and the composite of cardiovascular death, HF or MI, as time-dependent covariates adjusted for KC≥2 and LVEF<0.40, were used to test for differential treatment effects across subgroups. We examined 4 subgroups, defined by the presence or absence of KC≥2 and LVEF<0.40. Results: LVEF measurements (median 0.34) were available in 11,338 (77.1%) patients. Patients in KC≥2 with a LVEF<0.40 had the worst prognosis. Outcomes were comparable with all 3 treatments; there was no heterogeneity of treatment effect across the 4 subgroups. Conclusions: After MI, the combination of HF and low LVEF is associated with a much worse prognosis. Valsartan is as effective as captopril regardless of HF presence or absence and/or LVSD. In the highest-risk patients, combination therapy provides no advantage over captopril.