Aortic stenosis medical therapy: Difference between revisions
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==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.<ref name="pmid31290937">{{cite journal |vauthors=Nazarzadeh M, Pinho-Gomes AC, Smith Byrne K, Canoy D, Raimondi F, Ayala Solares JR, Otto CM, Rahimi K |title=Systolic Blood Pressure and Risk of Valvular Heart Disease: A Mendelian Randomization Study |journal=JAMA Cardiol |volume=4 |issue=8 |pages=788–795 |date=August 2019 |pmid=31290937 |pmc=6624812 |doi=10.1001/jamacardio.2019.2202 |url=}}</ref><ref name="pmid27486164">{{cite journal |vauthors=Nielsen OW, Sajadieh A, Sabbah M, Greve AM, Olsen MH, Boman K, Nienaber CA, Kesäniemi YA, Pedersen TR, Willenheimer R, Wachtell K |title=Assessing Optimal Blood Pressure in Patients With Asymptomatic Aortic Valve Stenosis: The Simvastatin Ezetimibe in Aortic Stenosis Study (SEAS) |journal=Circulation |volume=134 |issue=6 |pages=455–68 |date=August 2016 |pmid=27486164 |doi=10.1161/CIRCULATIONAHA.115.021213 |url=}}</ref><ref name="pmid16022957">{{cite journal |vauthors=Briand M, Dumesnil JG, Kadem L, Tongue AG, Rieu R, Garcia D, Pibarot P |title=Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment |journal=J Am Coll Cardiol |volume=46 |issue=2 |pages=291–8 |date=July 2005 |pmid=16022957 |doi=10.1016/j.jacc.2004.10.081 |url=}}</ref> | * [[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.<ref name="pmid31290937">{{cite journal |vauthors=Nazarzadeh M, Pinho-Gomes AC, Smith Byrne K, Canoy D, Raimondi F, Ayala Solares JR, Otto CM, Rahimi K |title=Systolic Blood Pressure and Risk of Valvular Heart Disease: A Mendelian Randomization Study |journal=JAMA Cardiol |volume=4 |issue=8 |pages=788–795 |date=August 2019 |pmid=31290937 |pmc=6624812 |doi=10.1001/jamacardio.2019.2202 |url=}}</ref><ref name="pmid27486164">{{cite journal |vauthors=Nielsen OW, Sajadieh A, Sabbah M, Greve AM, Olsen MH, Boman K, Nienaber CA, Kesäniemi YA, Pedersen TR, Willenheimer R, Wachtell K |title=Assessing Optimal Blood Pressure in Patients With Asymptomatic Aortic Valve Stenosis: The Simvastatin Ezetimibe in Aortic Stenosis Study (SEAS) |journal=Circulation |volume=134 |issue=6 |pages=455–68 |date=August 2016 |pmid=27486164 |doi=10.1161/CIRCULATIONAHA.115.021213 |url=}}</ref><ref name="pmid16022957">{{cite journal |vauthors=Briand M, Dumesnil JG, Kadem L, Tongue AG, Rieu R, Garcia D, Pibarot P |title=Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment |journal=J Am Coll Cardiol |volume=46 |issue=2 |pages=291–8 |date=July 2005 |pmid=16022957 |doi=10.1016/j.jacc.2004.10.081 |url=}}</ref> | ||
* 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]]. | * 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]]. | ||
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* 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]].<ref name="pmid28986405">{{cite journal |vauthors=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 |title=Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation |journal=Heart |volume=104 |issue=8 |pages=644–651 |date=April 2018 |pmid=28986405 |doi=10.1136/heartjnl-2017-311738 |url=}}</ref><ref name="pmid28956773">{{cite journal |vauthors=Hansson NH, Sörensen J, Harms HJ, Kim WY, Nielsen R, Tolbod LP, Frøkiær J, Bouchelouche K, Dodt KK, Sihm I, Poulsen SH, Wiggers H |title=Metoprolol Reduces Hemodynamic and Metabolic Overload in Asymptomatic Aortic Valve Stenosis Patients: A Randomized Trial |journal=Circ Cardiovasc Imaging |volume=10 |issue=10 |pages= |date=October 2017 |pmid=28956773 |doi=10.1161/CIRCIMAGING.117.006557 |url=}}</ref><ref name="pmid30512100">{{cite journal |vauthors=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 |title=Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement |journal=JAMA |volume=320 |issue=21 |pages=2231–2241 |date=December 2018 |pmid=30512100 |pmc=6583475 |doi=10.1001/jama.2018.18077 |url=}}</ref> | * 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]].<ref name="pmid28986405">{{cite journal |vauthors=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 |title=Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation |journal=Heart |volume=104 |issue=8 |pages=644–651 |date=April 2018 |pmid=28986405 |doi=10.1136/heartjnl-2017-311738 |url=}}</ref><ref name="pmid28956773">{{cite journal |vauthors=Hansson NH, Sörensen J, Harms HJ, Kim WY, Nielsen R, Tolbod LP, Frøkiær J, Bouchelouche K, Dodt KK, Sihm I, Poulsen SH, Wiggers H |title=Metoprolol Reduces Hemodynamic and Metabolic Overload in Asymptomatic Aortic Valve Stenosis Patients: A Randomized Trial |journal=Circ Cardiovasc Imaging |volume=10 |issue=10 |pages= |date=October 2017 |pmid=28956773 |doi=10.1161/CIRCIMAGING.117.006557 |url=}}</ref><ref name="pmid30512100">{{cite journal |vauthors=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 |title=Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement |journal=JAMA |volume=320 |issue=21 |pages=2231–2241 |date=December 2018 |pmid=30512100 |pmc=6583475 |doi=10.1001/jama.2018.18077 |url=}}</ref> | ||
* 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. | * 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. | ||
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2)''' | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑ [[PMC]] is recommended in [[symptomatic]] [[patients]] with favourable [[characteristics]] for [[PMC]]<br> | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence C]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑[[PMC]] is recommended in any [[symptomatic]] [[patients]] who are high risk for [[surgery]] | |||
❑[[Mitral valve surgery]] is recommended in symptomatic [[patients]] who are not appropriate for [[PMC]] in the absence of [[futility]]<br> | |||
|- | |||
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):''' | |||
|- | |||
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left| | |||
❑[[PMC]] should be considered as initial treatment in [[symptomatic]] [[patients]] with suboptimal [[anatomy]] and favourable clinical characteristics for [[PMC]] <br> | |||
❑[[PMC]] should be considered in asymptomatic [[patients]] with favourable clinical and anatomical characteristicsc for [[PMC]] and: | |||
* High [[thromboembolic]] risk (history of systemic [[embolism]], spontaneous contrast in the [[left artium]], new-onset or paroxysmal [[AF]]), and/or | |||
* High risk of [[hemodynamic]] decompensation ([[systolic pulmonary pressure]] >50 mmHg at [[rest]], need for major [[non-cardiac surgery]], desire for [[pregnancy]])<br> | |||
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{| | |||
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref> | |||
|- | |||
|} | |||
<span style="font-size:85%">'''Abbreviations:''' | |||
'''[[PMC]]:''' [[ Percutaneous mitral commissurotomy]]; | |||
'''AF:''' [[Atrial fibrillation]]; | |||
'''LA:''' [[Left atrium]]; | |||
'''MVA:'''[[Mitral valve area]] ; | |||
</span> | |||
<br> | |||
==References== | ==References== | ||
Revision as of 13:40, 30 June 2022
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Resident Survival Guide |
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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: 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
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
- 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 including beneficial effects on LV fibrosis, 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 percutaneous mitral commissurotomy and mitral valve surgery in moderate or severe mitral stenosis (valve area <1.5 cm2) | |
| (Class I, Level of Evidence B): | |
|
❑ PMC is recommended in symptomatic patients with favourable characteristics for PMC | |
| (Class I, Level of Evidence C): | |
|
❑PMC is recommended in any symptomatic patients who are high risk for surgery
❑Mitral valve surgery is recommended in symptomatic patients who are not appropriate for PMC in the absence of futility | |
| (Class IIa, Level of Evidence C): | |
|
❑PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy and favourable clinical characteristics for PMC
|
| The above table adopted from 2021 ESC Guideline[11] |
|---|
Abbreviations:
PMC: Percutaneous mitral commissurotomy;
AF: Atrial fibrillation;
LA: Left atrium;
MVA:Mitral valve area ;
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. - ↑ Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check
|pmid=value (help).