What medications are used to manage aortic stenosis?

Medication Management for Aortic Stenosis

In patients with aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose and gradually titrating upward, with RAS blockers (ACE inhibitors or ARBs) being preferred first-line agents due to their beneficial effects on left ventricular fibrosis and symptom improvement. 1, 2

First-Line Medications for Aortic Stenosis

RAS Blockers (ACE Inhibitors/ARBs)

• Preferred first-line agents for hypertension in aortic stenosis patients 1
• Provide beneficial effects on LV fibrosis, control of hypertension, reduction of dyspnea, and improved effort tolerance 1
• Clinical evidence supports their safety and efficacy:
  • SCOPE-AS trial showed enalapril (2.5 mg BID titrated to 10 mg BID) was well-tolerated in symptomatic severe AS patients 1
  • Ramipril (10 mg/day) effectively reduced blood pressure and LV mass at 12 months 1

Beta Blockers

• Appropriate for AS patients with specific indications:
  • Reduced ejection fraction
  • Prior myocardial infarction
  • Angina pectoris
  • Cardiac arrhythmias 1, 2
• Metoprolol reduces valve gradients and myocardial oxygen consumption in moderate-severe AS 1
• SEAS study showed patients on beta-blockers had reduced cardiovascular events (-23%) and all-cause mortality (HR 0.5) 1

Blood Pressure Targets

• Target systolic blood pressure: 130-139 mmHg 1
• Target diastolic blood pressure: 70-90 mmHg 1
• In critical aortic stenosis, target systolic BP should be 100-120 mmHg 2

Medications to Use with Caution or Avoid

Diuretics

• Use sparingly in patients with small LV chamber dimensions 1
• Loop diuretics should be used cautiously in severe AS with LV hypertrophy and small ventricular cavities 1
• Loop diuretic use before TAVI was associated with worse outcomes and identified a higher-risk population 3

Calcium Channel Blockers

• Should generally be avoided in AS patients with hypertension 1
• Associated with a sevenfold increase in mortality in patients with moderate-severe AS 1
• Non-dihydropyridine CCBs (verapamil, diltiazem) can be used for heart rate control if beta blockers are contraindicated 2
• Dihydropyridine CCBs can be added to beta blockers if BP targets aren't achieved 2

Alpha Blockers

• Should be avoided where possible 1
• Associated with increased cardiovascular events in the SEAS cohort 1

Special Considerations

Aortic Regurgitation

• For patients with chronic aortic insufficiency, treat systolic hypertension with agents that do not slow heart rate (avoid beta blockers) 1
• Vasodilator therapy can reduce LV volume/mass and improve LV performance 1

Moderate to Severe Aortic Stenosis

• Consultation or co-management with a cardiologist is preferred for hypertension management 1
• Regular monitoring is essential:
  • Severe AS (Vmax > 4.0 m/s or EOA < 1.0 cm²): every 6 months 1
  • Moderate AS (Vmax 3.0-4.0 m/s or EOA 1.0-1.5 cm²): every 12 months 1

Pitfalls to Avoid

• Abrupt medication changes that could cause hypotension
• Excessive diuresis in patients with small LV chambers
• Assuming all antihypertensives will cause dangerous hypotension in AS (evidence shows careful titration is safe) 1
• Delaying treatment of hypertension, which can accelerate LV remodeling and increase complications 1
• Using calcium channel blockers or alpha blockers as first-line agents 1

Algorithm for Medication Selection in Aortic Stenosis

1. Assess severity of AS and presence of symptoms
2. Evaluate for specific indications (prior MI, reduced EF, arrhythmias, angina)
3. For hypertension in AS:
   • First choice: ACE inhibitor or ARB (start low dose, gradually titrate)
   • If specific indications exist: Add beta blocker
   • If BP targets not achieved: Consider adding dihydropyridine CCB
4. For patients with aortic regurgitation: Use vasodilators that don't slow heart rate
5. Avoid or use with extreme caution: Alpha blockers, non-dihydropyridine CCBs, high-dose diuretics