What is the recommended blood pressure (BP) goal for a patient with aortic stenosis?

Blood Pressure Management in Aortic Stenosis

In patients with aortic stenosis and hypertension, a systolic blood pressure target of 120-129 mmHg, if tolerated, is recommended to reduce cardiovascular events and mortality. 1

Rationale for BP Control in Aortic Stenosis

Hypertension in patients with aortic stenosis creates a "double-load" situation:

• Increases afterload beyond that already caused by valve stenosis
• Accelerates adverse left ventricular remodeling
• Worsens progression of stenosis
• Associated with poorer outcomes

Specific BP Targets

The optimal blood pressure targets for patients with aortic stenosis are:

• Systolic BP: 120-129 mmHg (Class I, Level A recommendation) 1
• Diastolic BP: 70-90 mmHg is reasonable based on observational data 2, 3

This target is supported by the 2024 ESC guidelines which recommend an SBP target towards 120-129 mmHg for patients with peripheral arterial and aortic diseases 1. The 2022 ACC/AHA guideline similarly recommends a target SBP of <130 mmHg and DBP of <80 mmHg 1.

Important Considerations

1. Titration approach: Start antihypertensive medications at low doses and gradually titrate upward as needed (Class I, Level B-NR) 1

2. Monitoring: If achieving the target BP is difficult due to poor tolerance, use the "ALARA principle" (As Low As Reasonably Achievable) 1

3. More lenient targets (e.g., <140/90 mmHg) should be considered in:

   • Patients ≥85 years old
   • Those with symptomatic orthostatic hypotension
   • Patients with severe frailty
   • Limited life expectancy (<3 years) 1

4. Avoid excessively low BP: Studies show increased mortality with SBP <120 mmHg in aortic stenosis patients 3, 4

Recommended Antihypertensive Medications

First-line options:

• ACE inhibitors or ARBs (Class IIa, Level B) 1
  • Well-tolerated when carefully monitored
  • Associated with improved survival when given before or after valve intervention
  • May have beneficial effects on LV fibrosis and improve effort tolerance 1

Second-line options:

• Beta-blockers (Class I, Level C-EO for thoracic aortic disease) 1
  • Particularly beneficial with concurrent coronary artery disease or arrhythmias
  • Recommended as preferred agents in patients with thoracic aortic disease
  • Reduce valve gradients and myocardial oxygen consumption in moderate-severe AS 1

Medications to use with caution:

• Diuretics: Use sparingly in patients with small LV chamber dimensions 1
• Non-dihydropyridine calcium channel blockers: May be associated with lower survival 2
• Alpha blockers: Increased cardiovascular events in clinical trials 2

Special Considerations

1. BP variability: Higher day-by-day systolic BP variability is associated with complex aortic arch plaques and increased stroke risk in aortic stenosis patients 5

2. Hemodynamic impact: Acute BP elevation can affect the echocardiographic evaluation of AS severity, primarily through changes in transvalvular flow rate 6

3. Consultation: In patients with moderate or severe aortic stenosis, consultation or co-management with a cardiologist is preferred for hypertension management 1

Monitoring Approach

• Regular monitoring with echocardiography every 6 months for severe AS 7
• Regular BP monitoring, including home BP measurements to avoid overtreatment 1
• Consider exercise testing to assess hemodynamic response and symptoms

By maintaining optimal BP control in patients with aortic stenosis, clinicians can help reduce cardiovascular events, slow disease progression, and improve outcomes before and after valve intervention.