Aortic stenosis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Sara Zand, M.D.[2] Mohammed A. Sbeih, M.D. [3]; Cafer Zorkun, M.D., Ph.D. [4]; Usama Talib, BSc, MD [5] Assistant Editor-In-Chief: Kristin Feeney, B.S. [6]; Rim Halaby, M.D. [7] Synonyms and keywords: AS; Aortic stenosis; AVR; Aortic valve replacement; TAVI; Transcatheter aortic valve implantation; ACEI; Angiotensin-converting enzyme inhibitor; CAD; Coronary artery disease; LV; Left ventricle
Overview
Overview
Medical treatment of hypertension and hyperlipidemia according to the Guidelines is considered for patients with AS. Therapy with ACE inhibitor or ARB may reduce the mortality rate in patients with AS who underwent TAVI.
Medical Therapy
Medical Therapy
- Hypertension is common in patients with AS, may be a risk factor for AS, and increases the total pressure overload on the left ventricle in combination with valve obstruction.[1][2][3]
- 2 small RCTs have not confirmed that antihypertensive medications may reduce the cardiac output because AS does not result in fixed valve obstruction until late stage of the disease.
- The study of asymptomatic AS showed the association of hypertension with higher rate of ischemic cardiovascular events and a 2-fold higher mortality rate than normotensive patients with AS. However, impact on progression of valve stenosis leading to symptoms requiring AVR was not observed.
- Medical therapy for hypertension is based on the standard guidelines, initiating at a low dose and gradually titrated upward as needed to controlling of blood pressure.
- There are no studies considering specific antihypertensive medications in patients with AS, but diuretics may reduce stroke volume, particularly if the LV chamber is small at baseline.
- The advantages of ACE inhibitors include beneficial effects on LV fibrosis, and control of hypertension.[4]
- Target blood pressure should be considered higher for patients with AS than is recommended for the general population.
- Concurrent coronary artery disease is common in patients with AS, and screening of all patients is recommended for hypercholesterolemia, for primary and secondary prevention of CAD.
- In RCTs of statin therapy for mild to moderate AS, the rate of ischemic events was reduced by about 20% in the statin therapy group. Howerer, aortic valve event rates were not reduced.[5][6][7]
- In patients undergoing TAVI, treatment with renin–angiotensin system blocker therapy after the procedure had a lower 1-year mortality rate than those not treated with renin–angiotensin system blocker therapy, with a relative risk reduction of about 20% to 50% and an absolute risk reduction between 2.4% and 5.0%.
- Use of renin–angiotensin system inhibitor, was associated with a lower 1-year mortality rate among patients with preserved LVEF but not among those with reduced LVEF.[8][9][10]
- 3 large well-designed RCTs failed to show a benefit of statins for prevention of progression of AS in terms of hemodynamic severity or clinical outcomes.
| Recommendations for medical therapy in aortic stenosis |
| (Class I, Level of Evidence B): |
|
❑ In patients at risk of developing AS (stage A) or asymptomatic AS (stage B,C), hypertension should be controlled by initiating low dose medications and titration doses based on clinical evaluation |
| (Class I, Level of Evidence A): |
|
❑Statin therapy is recommended in all patients with calcified AS for primary and secondary prevention of atherosclerosis |
| (Class IIb, Level of Evidence B): |
|
❑ACEI or ARB may be considered after TAVI to reduce the long term risk of all cause mortality |
| NO benefit(Class III, Level of Evidence A): |
|
❑Statin is not indicated in calcified AS (stage B,C) for prevention of hemodynamic progression of AS |
| The above table adopted from 2020 AHA-ACC Guideline[11] |
|---|
Abbreviations:
AS: Aortic stenosis;
TAVI: Transcatheter aortic valve implantation;
References
References
- ↑ Nazarzadeh M, Pinho-Gomes AC, Smith Byrne K, Canoy D, Raimondi F, Ayala Solares JR, Otto CM, Rahimi K (August 2019). “Systolic Blood Pressure and Risk of Valvular Heart Disease: A Mendelian Randomization Study”. JAMA Cardiol. 4 (8): 788–795. doi:10.1001/jamacardio.2019.2202. PMC 6624812 Check
|pmc=value (help). PMID 31290937. - ↑ Nielsen OW, Sajadieh A, Sabbah M, Greve AM, Olsen MH, Boman K, Nienaber CA, Kesäniemi YA, Pedersen TR, Willenheimer R, Wachtell K (August 2016). “Assessing Optimal Blood Pressure in Patients With Asymptomatic Aortic Valve Stenosis: The Simvastatin Ezetimibe in Aortic Stenosis Study (SEAS)”. Circulation. 134 (6): 455–68. doi:10.1161/CIRCULATIONAHA.115.021213. PMID 27486164.
- ↑ Briand M, Dumesnil JG, Kadem L, Tongue AG, Rieu R, Garcia D, Pibarot P (July 2005). “Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment”. J Am Coll Cardiol. 46 (2): 291–8. doi:10.1016/j.jacc.2004.10.081. PMID 16022957.
- ↑ O’Brien KD, Zhao XQ, Shavelle DM, Caulfield MT, Letterer RA, Kapadia SR, Probstfield JL, Otto CM (April 2004). “Hemodynamic effects of the angiotensin-converting enzyme inhibitor, ramipril, in patients with mild to moderate aortic stenosis and preserved left ventricular function”. J Investig Med. 52 (3): 185–91. doi:10.1136/jim-52-03-33. PMID 15222408.
- ↑ Rossebø AB, Pedersen TR, Boman K, Brudi P, Chambers JB, Egstrup K, Gerdts E, Gohlke-Bärwolf C, Holme I, Kesäniemi YA, Malbecq W, Nienaber CA, Ray S, Skjaerpe T, Wachtell K, Willenheimer R (September 2008). “Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis”. N Engl J Med. 359 (13): 1343–56. doi:10.1056/NEJMoa0804602. PMID 18765433.
- ↑ Chan KL, Teo K, Dumesnil JG, Ni A, Tam J (January 2010). “Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial”. Circulation. 121 (2): 306–14. doi:10.1161/CIRCULATIONAHA.109.900027. PMID 20048204.
- ↑ Moura LM, Ramos SF, Zamorano JL, Barros IM, Azevedo LF, Rocha-Gonçalves F, Rajamannan NM (February 2007). “Rosuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis”. J Am Coll Cardiol. 49 (5): 554–61. doi:10.1016/j.jacc.2006.07.072. PMC 3951859. PMID 17276178.
- ↑ Ochiai T, Saito S, Yamanaka F, Shishido K, Tanaka Y, Yamabe T, Shirai S, Tada N, Araki M, Naganuma T, Watanabe Y, Yamamoto M, Hayashida K (April 2018). “Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation”. Heart. 104 (8): 644–651. doi:10.1136/heartjnl-2017-311738. PMID 28986405.
- ↑ Hansson NH, Sörensen J, Harms HJ, Kim WY, Nielsen R, Tolbod LP, Frøkiær J, Bouchelouche K, Dodt KK, Sihm I, Poulsen SH, Wiggers H (October 2017). “Metoprolol Reduces Hemodynamic and Metabolic Overload in Asymptomatic Aortic Valve Stenosis Patients: A Randomized Trial”. Circ Cardiovasc Imaging. 10 (10). doi:10.1161/CIRCIMAGING.117.006557. PMID 28956773.
- ↑ Inohara T, Manandhar P, Kosinski AS, Matsouaka RA, Kohsaka S, Mentz RJ, Thourani VH, Carroll JD, Kirtane AJ, Bavaria JE, Cohen DJ, Kiefer TL, Gaca JG, Kapadia SR, Peterson ED, Vemulapalli S (December 2018). “Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement”. JAMA. 320 (21): 2231–2241. doi:10.1001/jama.2018.18077. PMC 6583475 Check
|pmc=value (help). PMID 30512100. - ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). “2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check
|pmid=value (help).
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