From the Guidelines
Blood pressure management in patients with severe aortic stenosis requires careful balance, with a general recommendation to maintain adequate preload while avoiding hypotension, and individualized blood pressure targets should generally accept slightly higher readings (systolic 130-150 mmHg) than in the general population, with close monitoring for symptoms of heart failure or hypoperfusion. This approach 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.
Key Considerations
- Beta-blockers should be used cautiously at low doses (such as metoprolol 12.5-25 mg twice daily or carvedilol 3.125-6.25 mg twice daily) and only when necessary for rate control in atrial fibrillation or for angina symptoms.
- ACE inhibitors and ARBs should generally be avoided or used at very low doses (like lisinopril 2.5-5 mg daily or valsartan 40-80 mg daily) due to the risk of reducing preload and cardiac output.
- Diuretics should be used minimally and cautiously (furosemide 20-40 mg daily as needed) to manage congestive symptoms while avoiding volume depletion.
- Calcium channel blockers with negative inotropic effects (verapamil, diltiazem) are contraindicated.
Rationale
The rationale for this cautious approach is that patients with severe aortic stenosis have fixed obstruction to left ventricular outflow, making them dependent on adequate preload to maintain cardiac output, while being vulnerable to hypotension which can precipitate syncope or even sudden death. According to the European Society of Cardiology guidelines 1, medical treatment should be optimized, although vasodilators (ACE inhibitors, ARBs, renin inhibitors, CCBs, hydralazine, and nitrates) may cause substantial hypotension in patients with severe aortic stenosis and should only be used with great caution.
Monitoring and Management
Close monitoring for symptoms of heart failure or hypoperfusion is essential, and consultation or co-management with a cardiologist is preferred for hypertension management in patients with moderate or severe aortic stenosis 1. The goal is to balance the need to control blood pressure with the risk of reducing cardiac output and precipitating hypotension, and to individualize management based on the patient's specific clinical characteristics and needs.
From the Research
Blood Pressure Management in Severe Aortic Stenosis
- The presence of hypertension in patients with aortic stenosis negatively affects the hemodynamic severity of the stenosis and worsens adverse left ventricular remodeling, accelerating the progression of the stenosis and associating with worse prognosis 2.
- Proper management of hypertension is crucial, but there are concerns about the safety and efficacy of antihypertensive medications, as well as uncertainty about optimal blood pressure targets and their impact on left ventricular mass regression and survival benefits 2, 3.
Optimal Blood Pressure Targets
- Observational evidence suggests that blood pressure targets between 130 and 139 mmHg systolic and 70-90 mmHg diastolic might represent the best option for patients with aortic stenosis, and lower blood pressure targets should probably be avoided 2.
- There is no consensus on the ideal target blood pressure and antihypertensive regimens in severe aortic stenosis, and future clinical trials are essential to establish these guidelines 3.
Antihypertensive Treatment
- Antihypertensive treatment with β-blockers has generally been avoided in patients with severe aortic stenosis due to concerns for inducing left ventricular dysfunction and hemodynamic compromise, but recent studies have shown that the use of β-blockers may be safe and even beneficial 3.
- Renin-angiotensin system (RAS) blockade therapy with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) has been associated with improved outcomes after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) 3, 4.
- RAS blockade after TAVR has been shown to improve intermediate survival and reduce heart failure exacerbations in patients with severe aortic stenosis 4.
Clinical Implications
- Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease is crucial to achieve optimal outcomes in patients with severe aortic stenosis 5.
- Transcatheter aortic valve implantation (TAVI) has been shown to increase coronary flow and improve cardiac output in patients with severe aortic stenosis 6.