ARBs in Patients with Severe Aortic Stenosis for Blood Pressure Control
ARBs can be used to treat hypertension in patients with severe aortic stenosis, starting at a low dose and gradually titrating upward as needed, with careful monitoring and preferably in consultation with a cardiologist. 1
Rationale for Using ARBs in Aortic Stenosis
- Hypertension in aortic stenosis creates "2 resistors in series," increasing complications and cardiovascular mortality, making blood pressure control essential 1
- Renin-angiotensin system (RAS) blockade with ARBs may be advantageous in aortic stenosis due to potentially beneficial effects on LV fibrosis, control of hypertension, reduction of dyspnea, and improved effort tolerance 1, 2
- There is no evidence that antihypertensive medications, including ARBs, produce an inordinate degree of hypotension in patients with aortic stenosis when used appropriately 1
Practical Approach to Using ARBs in Severe Aortic Stenosis
- Start with a low dose of ARB and gradually titrate upward as needed to control blood pressure 1
- Monitor blood pressure closely during initiation and dose adjustments 1, 3
- Target systolic blood pressure between 130-139 mmHg and diastolic pressure between 70-90 mmHg, avoiding lower targets that could compromise coronary perfusion 4
- Consider co-management with a cardiologist, especially in patients with moderate to severe aortic stenosis 1, 3
Evidence Supporting ARB Use in Aortic Stenosis
- ARBs have been shown to improve survival when given before or after valve intervention 4, 5
- RAS inhibition has been associated with less progression of LV mass in patients with aortic stenosis 6
- A retrospective study showed that RAS blockade after transcatheter aortic valve replacement was associated with improved overall survival at 2 years (95% vs. 79%, P = 0.042) 5
Alternative Antihypertensive Options and Considerations
- Beta blockers may be appropriate for patients with aortic stenosis who have reduced ejection fraction, prior MI, arrhythmias, or angina pectoris 1
- Calcium channel blockers should be used with caution, as some studies suggest they may be associated with lower survival in patients with aortic stenosis 4, 7
- Diuretics should be used sparingly in patients with small LV chamber dimensions to avoid excessive preload reduction 1, 3
Pitfalls and Cautions
- Avoid excessive blood pressure reduction that could compromise coronary perfusion, especially in patients with LV hypertrophy 1, 4
- Monitor for symptoms of hypotension, particularly during initiation and dose adjustments 1, 3
- Be aware that patients with severe aortic stenosis may have a blunted blood pressure response to exercise, which could mask the severity of the stenosis 4, 7
- Consider the need for aortic valve replacement in appropriate candidates as definitive therapy rather than focusing solely on medical management 1, 3