Aortic stenosis medical therapy

Aortic Stenosis Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Overview

While medical therapy may improve the symptoms of patients with aortic stenosis, medical therapy does not prolong life expectancy. Aortic valve replacement remains the definitive treatment of symptomatic aortic stenosis and it improves both the symptoms and life expectancy of patients with aortic stenosis. When pharmacological therapies are used, extreme caution must be exercised in the administration of vasodilators as excess vasodilation may lead to hypotension, a reduction in perfusion pressure to the heart, a further decline in cardiac output and further hypotension. This downward spiral can be fatal and must be avoided at all costs.

Lipid-Lowering

• More rapid progression of aortic stenosis has been associated with traditional risk factors for atherosclerosis. Based on the similarities that exist between calcific aortic stenosis and atherosclerosis in terms of their pathological features and risk factors, there has been a substantial interest to modify the progression of calcific aortic stenosis with the administration of cholesterol lowering agents such as statins.

• Although a number of small, observational studies demonstrated an association between low cholesterol levels and decreased progression, and even regression of calcific aortic stenosis. Administration of rosuvastatin has been associated with a slowing of aortic stenosis progression .

Vasodilators

Extreme care should be taken to avoid excess vasodilation in the patient with critical aortic stenosis which could precipitate a downward spiral of low forward output, impaired subendocardial perfusion, ischemia and further reduction in forward output.

• Nitroglycerin is helpful in relieving angina pectoris symptoms but should be used cautiously to avoid hypotention and excess vasodilation.

Diuretics

Diuretics should be administered cautiously to avoid dehydration, hypovolemia and a significant reduction in cardiac output.

Other Therapies

• Beta blockers and angiotensin-converting enzyme inhibitors are generally safe for asymptomatic patients with preserved left ventricular systolic function.

Sodium Restriction

• If the patient has symptoms of heart failure, the patient should be placed on sodium restriction.

ACC / AHA Guidelines- Recommendations for Medical Therapy for Left Ventricular Outflow Tract Obstruction and Associated Lesions (DO NOT EDIT)

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Class III 1. Vasodilator therapy is not indicated for long-term therapy in AR for the following: a. The asymptomatic patient with only mild to moderate AR and normal LV function. (Level of Evidence: B) b. The asymptomatic patient with LV systolic dysfunction who is otherwise a candidate for aortic valve replacement (AVR). (Level of Evidence: B) c. The asymptomatic patient with either LV systolic function or mild to moderate LV diastolic dysfunction who is otherwise a candidate for AVR. (Level of Evidence: C) Class IIa 1. It is reasonable to treat systemic hypertension in patients with AS while monitoring diastolic blood pressure to avoid reducing coronary perfusion. (Level of Evidence: C) 2. It is reasonable to administer beta blockers in patients with BAV and aortic root dilatation. (Level of Evidence: C) 3. It is reasonable to use long-term vasodilator therapy in patients with AR and systemic hypertension while carefully monitoring diastolic blood pressure to avoid reducing coronary perfusion. (Level of Evidence: C) Class IIb 1. It may be reasonable to treat patients with BAV and risk factors for atherosclerosis with statins with the aim of ‘‘slowing down degenerative changes in the aortic valve and preventing atherosclerosis. (Level of Evidence: C)

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