Aortic stenosis medical therapy: Difference between revisions
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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 taken in the administration of [[vasodilator]]s 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. | 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 taken in the administration of [[vasodilator]]s 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. | ||
==Pharmacotherpay== | |||
====Lipid-Lowering==== | ====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]]. | 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]] have demonstrated an association between low cholesterol levels and decreased progression of aortic stenosis,<ref>{{cite journal |author=Moura LM, Ramos SF, Zamorano JL, ''et al'' |title=Rosuvastatin affecting aortic valve endothelium to slow the progression of aortic stenosis |journal=J. Am. Coll. Cardiol. |volume=49 |issue=5 |pages=554-61 |year=2007 |pmid=17276178 |doi=10.1016/j.jacc.2006.07.072}}</ref> randomized clinical trials have failed to corroborate the effect of statin on halting the progression of calcific aortic stenosis. Nevertheless, many patients with AS have concomitant atherosclerotic disease which require statin therapy. | ||
====Vasodilators==== | ====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.'' | ''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 [[ | [[Nitroglycerin]] is helpful in relieving [[angina pectoris]] symptoms but should be used cautiously to avoid [[hypotension]] and excess vasodilation. | ||
====Diuretics==== | ====Diuretics==== | ||
Revision as of 15:25, 31 August 2014
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Aortic Stenosis Microchapters |
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Case Studies |
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Aortic stenosis medical therapy On the Web |
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American Roentgen Ray Society Images of Aortic stenosis medical therapy |
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Directions to Hospitals Treating Aortic stenosis medical therapy |
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Risk calculators and risk factors for Aortic stenosis medical therapy |
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 taken 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.
Pharmacotherpay
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 have demonstrated an association between low cholesterol levels and decreased progression of aortic stenosis,[1] randomized clinical trials have failed to corroborate the effect of statin on halting the progression of calcific aortic stenosis. Nevertheless, many patients with AS have concomitant atherosclerotic disease which require statin therapy.
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 hypotension 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 2008 Guidelines for the Management of Adults with Congenital Heart Disease (DO NOT EDIT)[2]
| 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)" |
AHA/ACC 2014 Guideline for the Management of Patients With Valvular Heart Diseases [3]
| Class I |
| "1. Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed with frequent clinical monitoring. (Level of Evidence:B) " |
| Class IIb |
| "1. Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with New York Heart Association (NYHA) class IV heart failure symptoms. (Level of Evidence: C)" |
| Class III |
| "1. Statin therapy is not indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B to D) (54-56). (Level of Evidence: A) " |
References
- ↑ Moura LM, Ramos SF, Zamorano JL; et al. (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. PMID 17276178.
- ↑ Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham TP, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Page RL, Riegel B, Tarkington LG, Yancy CW (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 52 (23): e143–263. doi:10.1016/j.jacc.2008.10.001. PMID 19038677. Retrieved 2013-01-09. Unknown parameter
|month=ignored (help) - ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.