Aortic stenosis medical therapy: Difference between revisions
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* 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.<ref name="pmid18765433">{{cite journal |vauthors=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 |title=Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis |journal=N Engl J Med |volume=359 |issue=13 |pages=1343–56 |date=September 2008 |pmid=18765433 |doi=10.1056/NEJMoa0804602 |url=}}</ref><ref name="pmid20048204">{{cite journal |vauthors=Chan KL, Teo K, Dumesnil JG, Ni A, Tam J |title=Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial |journal=Circulation |volume=121 |issue=2 |pages=306–14 |date=January 2010 |pmid=20048204 |doi=10.1161/CIRCULATIONAHA.109.900027 |url=}}</ref><ref name="pmid17276178">{{cite journal |vauthors=Moura LM, Ramos SF, Zamorano JL, Barros IM, Azevedo LF, Rocha-Gonçalves F, Rajamannan NM |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 |date=February 2007 |pmid=17276178 |pmc=3951859 |doi=10.1016/j.jacc.2006.07.072 |url=}}</ref> | * 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.<ref name="pmid18765433">{{cite journal |vauthors=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 |title=Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis |journal=N Engl J Med |volume=359 |issue=13 |pages=1343–56 |date=September 2008 |pmid=18765433 |doi=10.1056/NEJMoa0804602 |url=}}</ref><ref name="pmid20048204">{{cite journal |vauthors=Chan KL, Teo K, Dumesnil JG, Ni A, Tam J |title=Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial |journal=Circulation |volume=121 |issue=2 |pages=306–14 |date=January 2010 |pmid=20048204 |doi=10.1161/CIRCULATIONAHA.109.900027 |url=}}</ref><ref name="pmid17276178">{{cite journal |vauthors=Moura LM, Ramos SF, Zamorano JL, Barros IM, Azevedo LF, Rocha-Gonçalves F, Rajamannan NM |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 |date=February 2007 |pmid=17276178 |pmc=3951859 |doi=10.1016/j.jacc.2006.07.072 |url=}}</ref> | ||
*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%. | *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]]. | * 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> | ||
* 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. | ||
Revision as of 13:22, 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: Mohammed A. Sbeih, M.D. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Usama Talib, BSc, MD [4] Assistant Editor-In-Chief: Kristin Feeney, B.S. [5]; Rim Halaby, M.D. [6]
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 in 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]
- 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.
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.