From the Guidelines
Beta-blockers are the preferred antihypertensive agents for patients with aortic stenosis, as they reduce myocardial oxygen demand without significantly reducing preload and help control heart rate, which is beneficial in this condition. The use of beta-blockers in patients with aortic stenosis is supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. According to this guideline, beta-blockers may be appropriate for patients with aortic stenosis who have reduced ejection fraction, prior MI, arrhythmias, or angina pectoris.
The guideline also suggests that RAS blockade may be advantageous due to its potentially beneficial effects on LV fibrosis, control of hypertension, reduction of dyspnea, and improved effort tolerance 1. However, the most recent and highest quality study, which is the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline, does not provide specific recommendations for the use of RAS blockade in patients with aortic stenosis.
Some key points to consider when managing hypertension in patients with aortic stenosis include:
- Maintaining adequate preload is crucial, so vasodilators like ACE inhibitors, ARBs, and nitrates should generally be avoided as they can cause dangerous hypotension by reducing systemic vascular resistance without allowing the stenotic valve to accommodate increased cardiac output.
- Diuretics should be used sparingly in patients with small LV chamber dimensions, as they may cause a fall in cardiac output.
- Beta-blockers should be used cautiously, starting at low doses and monitoring closely for hypotension.
- Non-dihydropyridine calcium channel blockers like verapamil or diltiazem may be considered as second-line options, though they should be used with caution.
- Regular monitoring of symptoms, blood pressure, and heart rate is essential, as both hypertension and hypotension can be problematic in patients with aortic stenosis.
It is also important to note that the 2014 AHA/ACC guideline for the management of patients with valvular heart disease recommends treating hypertension in patients with asymptomatic AS according to standard guidelines, starting at a low dose, and gradually titrating upward as needed with frequent clinical monitoring 1. However, this guideline is older and lower in quality compared to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline.
In terms of specific medications, metoprolol (starting at 25-50 mg twice daily) or bisoprolol (2.5-5 mg once daily) are good options, with doses titrated gradually based on blood pressure response and heart rate. The choice of medication should be individualized based on the patient's specific needs and medical history.
From the FDA Drug Label
5 WARNINGS AND PRECAUTIONS
5.1 Hypotension Symptomatic hypotension is possible, particularly in patients with severe aortic stenosis. Because of the gradual onset of action, acute hypotension is unlikely.
The FDA drug label does not answer the question.
From the Research
Antihypertensive Treatment in Aortic Stenosis
- The optimal antihypertensive treatment for patients with aortic stenosis is still unclear, as no randomized clinical trials have been performed and no definite treatment guidelines exist 2.
- Previously, antihypertensive treatment in severe aortic stenosis was considered a relative contraindication, but recent studies have shown that it may be safe and even beneficial in reducing the progression of left ventricular pressure overload and valvular aortic stenosis 2.
Beta-Blockers and Aortic Stenosis
- Beta-blockers have generally been avoided in patients with severe aortic stenosis due to concerns about inducing left ventricular dysfunction and hemodynamic compromise 2.
- However, recent studies have shown that the use of beta-blockers may be safe and even beneficial in patients with aortic stenosis, although the evidence is still limited 2, 3.
Renin-Angiotensin System Inhibition and Aortic Stenosis
- The renin-angiotensin system (RAS) is upregulated in aortic stenosis and has been shown to be involved in valve calcification and progression 2.
- RAS inhibition may be beneficial in retarding the progression of valvular stenosis and left ventricle remodeling, although further studies are needed to confirm this 2.
Calcium Channel Blockers and Aortic Stenosis
- The safety of calcium channel blockers (CCBs) in patients with aortic stenosis is still debated, with some studies suggesting an increased risk of all-cause mortality 4 and others finding no significant difference in clinical outcomes 5.
- A study comparing the effects of losartan and metoprolol on left ventricular and aortic function found that metoprolol was associated with a greater reduction in aortic distensibility during exercise, although the clinical significance of this finding is unclear 3.
Comparison of Antihypertensive Agents
- A study comparing the efficacy and tolerability of a fixed-dose combination of metoprolol extended release/amlodipine with losartan plus amlodipine found that both treatments were effective and well-tolerated in patients with mild-to-moderate hypertension 6.
- However, the study did not specifically address the use of these agents in patients with aortic stenosis, and further studies are needed to determine the optimal antihypertensive treatment for this population.