From the Guidelines
Hypertension is generally harmful in patients with aortic stenosis and should be carefully managed. Blood pressure control is important in these patients, but treatment must be approached cautiously. According to the most recent guideline 1, hypertension is common in patients with AS, may be a risk factor for AS, and adds to the total pressure overload on the LV in combination with valve obstruction.
Key Considerations
- Mild to moderate hypertension should be treated with medications that can be titrated slowly, such as ACE inhibitors (like enalapril 2.5-5mg daily), ARBs (such as losartan 25-50mg daily), or calcium channel blockers (amlodipine 2.5-5mg daily) 1.
- Start with low doses and gradually increase while monitoring for symptoms of hypotension.
- Diuretics should be used carefully as excessive preload reduction can decrease cardiac output in severe aortic stenosis.
- Beta-blockers may be used if there are other indications but should be initiated at low doses.
Rationale
The harm from hypertension in aortic stenosis comes from increased afterload, which compounds the obstruction already caused by the stenotic valve, forcing the left ventricle to work harder against two barriers (the narrowed valve and high systemic vascular resistance) 2, 3. This increases myocardial oxygen demand and accelerates left ventricular hypertrophy, potentially leading to heart failure, arrhythmias, and increased mortality. Regular monitoring of blood pressure, symptoms, and cardiac function is essential in these patients. As noted in the 2021 ACC/AHA guideline 1, concurrent CAD is common in patients with AS, and all patients should be screened and treated for hypercholesterolemia, with GDMT used for primary and secondary prevention of CAD.
From the Research
Importance of Hypertension in Aortic Stenosis
- Hypertension is a significant risk factor for cardiovascular disease and can exacerbate the severity of aortic stenosis, leading to worse prognosis 4, 5.
- The presence of hypertension in patients with aortic stenosis can accelerate the progression of the stenosis and worsen adverse left ventricular remodeling 4.
- Proper management of hypertension is crucial in patients with aortic stenosis, but there are concerns about the safety and efficacy of antihypertensive medications 4, 6.
Antihypertensive Treatment in Aortic Stenosis
- Antihypertensive treatment may be safe and beneficial in reducing the progression of left ventricular pressure overload and retarding the progression of valvular aortic stenosis 6.
- Renin-angiotensin system inhibitors may be beneficial in patients with aortic stenosis, as they can improve survival and reduce the progression of valvular stenosis 4, 6, 5.
- Beta-blockers may be well-tolerated and a better choice for patients with concomitant coronary artery disease and arrhythmias, but their use should be cautious in patients with severe aortic stenosis 4, 6.
- Diuretics may have disadvantages in patients with left ventricular hypertrophy and smaller left ventricular cavity dimensions 4.
Optimal Blood Pressure Targets
- The optimal blood pressure target in patients with aortic stenosis is not well-established, but observational evidence suggests that values between 130 and 139 mmHg systolic and 70-90 mmHg diastolic may be beneficial 4.
- Lower blood pressure targets should probably be avoided in patients with aortic stenosis, as they may lead to inadequate coronary perfusion and worsen symptoms 4.