Impact of Renin-Angiotensin System Blockade Therapy on Outcome in Aortic Stenosis

Nadir, M. Adnan; Li, Wei; Elder, Douglas; Libianto, Renata; Lim, Tiong Keng; Pauriah, Maheshwar; Pringle, Stuart D.; Doney, Alex S.F.; Choy, Anna Maria; Struthers, Allan D.; Lang, Chim C.

doi:10.1016/j.jacc.2011.01.063

Cited by 145 publications

(80 citation statements)

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“…7,19 In a recent retrospective study, 25 patients with mild, moderate, and severe aortic stenosis who received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers had lower all-cause mortality and cardiovascular event rates during a mean follow-up of 4.2 years than did patients who did not receive these medications. 25 β-Blockers are not routinely used in patients with aortic stenosis and have been considered unsafe because they depress myocardial function and can induce left ventricular failure. 1,7 However, a retrospective study 3 of the use of β-blockers in patients with asymptomatic severe aortic stenosis who were nonsurgically managed indicated that use of β-blockers was an independent predictor of improved survival.…”

Section: Medical Management Of Asymptomatic Patientsmentioning

confidence: 99%

“…1 In patients without coronary artery disease, angina may be due to decreased subendocardial blood flow and/or increased myocardial oxygen demand associated with concentric hypertrophy. 2,25 Blood flow to the myocardium may be limited by insufficient capillary density into the hypertrophied left ventricular muscle and/or by endocardial compression due to increased filling pressures. 7,8 Syncope occurs because of decreased cerebral perfusion associated with decreased cardiac output or during exercise and times of decreased preload, such as after arising from a seated position; dehydration; and use of diuretics.…”

Section: Clinical Manifestationsmentioning

confidence: 99%

“…Surgical repair is the only effective treatment for symptomatic aortic stenosis; however, some patients may not be considered surgical candidates or may require medical stabilization before surgery; other patients refuse surgical options altogether. 6,25 For patients who do not have surgical repair, medical management of angina, exertional syncope, and signs and symptoms of heart failure becomes necessary.…”

Section: Medical Management Of Symptomatic Patientsmentioning

confidence: 99%

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Aortic Stenosis: Pathophysiology, Diagnosis, and Medical Management of Nonsurgical Patients

Cary

Pearce²

2013

Critical Care Nurse

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A ortic stenosis is caused by narrowing of the orifice of the aortic valve and leads to obstruction of left ventricular outflow. This stenosis is rare in persons less than 50 years old.1 Calcification of the aortic valve is the most common cause of aortic stenosis in adults in industrialized countries and affects more than 4% of North American and Europeans more than 75 years old.2 In a study 3 of 338 North American patients with severe asymptomatic aortic stenosis, the mean age was 71 (SD, 15) years. Aortic stenosis was also associated with higher morbidity and mortality rates than were diseases involving other cardiac valves. 4 For example, in a study 5 of 161 patients, patients with moderate and

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Section: Medical Management Of Asymptomatic Patientsmentioning

confidence: 99%

Section: Clinical Manifestationsmentioning

confidence: 99%

Section: Medical Management Of Symptomatic Patientsmentioning

confidence: 99%

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Aortic Stenosis: Pathophysiology, Diagnosis, and Medical Management of Nonsurgical Patients

Cary

Pearce²

2013

Critical Care Nurse

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“…9 However, a growing body of literature has reported that a high percentage of patients with significant AS do take antihypertensive and vasoactive medications without evident adverse effects. 5,10 Additionally, careful hemodynamic studies in patients with severe AS treated with single doses of vasodilating medications (captopril, nitroprusside, and sildenafil) have demonstrated the safety, tolerability, and, indeed, hemodynamic benefit of vasodilation in patients with severe symptomatic AS. [11][12][13] Those studies demonstrated that the particular vasodilating medications used result in a decrease in systemic vascular resistance and pulmonary capillary wedge pressure combined with an increase in stroke volume, but no change in heart rate.…”

Section: Article See P 1349mentioning

confidence: 99%

Time to Treat Hypertension in Patients With Aortic Stenosis

Lindman

Otto

2013

Circulation

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Somewhat analogous to the use of dobutamine to clarify pseudo versus truly severe AS in patients with a small AVA, low gradient, and a preserved EF, 15 they demonstrate that nitroprusside can increase flow and provide insight into the true severity of the AS. However, cut points for determining truly severe AS based on a change in AVA and gradient with pharmacological intervention are not uniform across studies and require further investigation. 15,16 Even so, the current data provide further support for the concept that systemic HTN can influence the evaluation of AS severity. 17 Clinical ImplicationsIn managing patients with AS, it is important to recognize the high prevalence of coexistent systemic HTN, its harmful effects on LV remodeling and function, and its adverse impact on clinical outcomes. Moreover, when determining the severity of AS and making decisions about the timing of valve replacement, it is important to recognize that systemic HTN can influence the assessment of AS severity (generally causing overestimation of severity; Figure).17 After valve replacement is performed, there may be a greater tendency toward systemic HTN because of the increased flow from the relief of valvular afterload, which may mitigate the expected favorable effects of LV unloading with valve replacement and limit symptomatic improvement. For all these reasons, both before and after valve replacement, treatment of systemic HTN should be an important objective of medical therapy.When managing a symptomatic patient with uncontrolled systemic HTN (at the time of the echocardiogram) and a small AVA, low gradient, and preserved EF, it is reasonable to redo the echocardiogram when the patient is normotensive, particularly if the measurements of AS severity are borderline between moderate and severe. It also is prudent to reassess symptoms once the patient is consistently normotensive. When managing an asymptomatic patient with uncontrolled systemic HTN and a small AVA, low gradient, and preserved EF, effective HTN treatment may mitigate the deleterious effects on the LV of increased systemic vascular load and potentially delay symptom onset. Although LV outflow obstruction at the level of the valve is the sine qua non of AS, increased systemic vascular load-identified most readily as systemic HTN-is often coexistent with AS and contributes to the pressure overload, hypertrophic remodeling, and dysfunction of the LV, which underlies much of the morbidity and mortality of the disease. As such, we must remember to treat the patient (including HTN and other cardiovascular comorbidities) and not have a myopic focus on the valve alone to provide the best clinical outcomes. Sources of FundingDr Lindman was supported by K23 HL116660 from the NIH. DisclosuresNone. References

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“…These observations suggest that ACE inhibitors may be used with caution in the treatment of hypertension in patients with AS. If they had been used before the diagnosis of AS with heart failure, hypertension or diabetic nephropathy and had been well tolerated by the patient, they should not be discontinued [21,[45][46][47][48]. Diuretic in AS should be used only in volume overload.…”

Section: Aortic Valve Replacement: When To Perform In Patients With Amentioning

confidence: 99%

Hypertension in aortic stenosis: More questions than answers

Orłowska−Baranowska¹

2013

Cardiol J.

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Impact of Renin-Angiotensin System Blockade Therapy on Outcome in Aortic Stenosis

Abstract: This large observational study suggests that ACEI/ARB therapy is associated with an improved survival and a lower risk of CV events in patients with AS.

Cited by 145 publications

References 35 publications

Aortic Stenosis: Pathophysiology, Diagnosis, and Medical Management of Nonsurgical Patients

Aortic Stenosis: Pathophysiology, Diagnosis, and Medical Management of Nonsurgical Patients

Time to Treat Hypertension in Patients With Aortic Stenosis

Hypertension in aortic stenosis: More questions than answers

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