Aortic stenosis medical therapy

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

Overview

Aortic valve replacement is the mainstay of treatment of symptomatic aortic stenosis (AS), as it improves both the symptoms and life expectancy in aortic stenosis patients, in contrast to medical therapy alone which may improve the symptoms without prolonging life expectancy. When pharmacological therapies are used; Caution must be taken in avoiding complications such as excess vasodilation, as it could lead to functional decline in the patient. Medical treatment is primarily symptomatic.

Lipid-Lowering

• Based on the similarities that exists between calcific aortic stenosis and atherosclerosis in terms of 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; large randomized clinical trial, (published in 2005) failed to demonstrate any such predictable effect.

• More recently, in 2007, researchers demonstrated slowing of aortic stenosis progression with a statin such as rosuvastatin . Therefore, more randomized control trial data is required to further clarify the specific mechanisms of disease onset and the influence of interventional methodologies on overall causation.

Aortic stenosis may be medically treated to control symptoms. 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. Medications that may be used to control the symptoms of aortic stenosis includes:

• Beta blockers and angiotensin-converting enzyme inhibitors, they are generally safe for asymptomatic patients with preserved left ventricular systolic function.
• Nitroglycerin is helpful in relieving angina pectoris symptoms but should be used cautiously to avoid hypotention.
• Some studies showed that patients with calcific AS who receive HMG-CoA reductase inhibitors (statins) exhibit slower progression of leaflet calcification and aortic valve area reduction than those who do not.

Patients with severe AS (< 1.0 cm2) should avoid strenuous physical activity. If the patient has symptoms of heart failure, the symptoms should be controlled and he should have sodium restriction. The physician may administer diuretics and digoxin cautiously to avoid dehydration, hypovolemia and significant reduction in cardiac output.