How to manage hypertension after Transcatheter Aortic Valve Implantation (TAVI)?

Management of Hypertension After TAVI

Hypertension after TAVI should be treated with renin-angiotensin system blockers (ACE inhibitors or ARBs), which may reduce long-term all-cause mortality, particularly in patients with preserved left ventricular ejection fraction. 1

Initial Approach to Post-TAVI Hypertension

Understanding the Hemodynamic Changes

Unique adaptive hemodynamic changes occur immediately after TAVI that are important to recognize:

• Systolic blood pressure increases significantly in the immediate post-TAVI period (from 132±21 mmHg at baseline to 147±23 mmHg after TAVI), accompanied by increased total peripheral resistance (from 1751±512 to 2084±762 dynes*s/cm⁵) 2
• Cardiac output and stroke volume transiently decrease in the immediate post-procedure period (cardiac output from 4.2±1.5 to 3.9±1.3 L/min; stroke volume from 61.4±14.8 to 56.2±15.9 mL) 2
• These hemodynamic parameters typically normalize by approximately 2 months post-procedure (median 59 days), returning to baseline values 2

Immediate Post-Procedure Management (First 24-72 Hours)

Prevention of postoperative hypertension is crucial, particularly in transapical TAVI patients, to decrease the risk of bleeding or ventricular rupture 1

Key monitoring priorities include:

• Vital parameters with careful attention to blood pressure control 1
• Fluid balance therapy and renal status 1
• Resume preoperative beta-blockers within the first 24 hours after operation 1

Long-Term Antihypertensive Management

First-Line Therapy: Renin-Angiotensin System Blockers

ACE inhibitors or ARBs may be considered to reduce long-term all-cause mortality (Class 2b recommendation, Level B-NR evidence) 1

The evidence supporting this recommendation:

• Observational and registry data demonstrate that renin-angiotensin system blocker therapy after TAVI is associated with lower 1-year mortality compared to no treatment 1
• Relative risk reduction of approximately 20-50% with absolute risk reduction between 2.4% and 5.0% 1
• Benefit is most pronounced in patients with preserved LVEF: When stratified by ejection fraction, renin-angiotensin system inhibitors were associated with lower 1-year mortality among patients with preserved LVEF but not among those with reduced LVEF 1

Initiation and Titration Strategy

Start antihypertensive medications at low doses and gradually titrate upward with appropriate clinical monitoring 1

This cautious approach is recommended because:

• Historical concerns about decreased cardiac output with antihypertensive medications have not been corroborated in studies 1
• Aortic stenosis does not result in "fixed" valve obstruction until late in disease, and this concern is largely resolved after TAVI 1

Additional Antihypertensive Considerations

Standard guideline-directed medical therapy (GDMT) for hypertension is appropriate in post-TAVI patients 1

Specific agents to consider based on comorbidities:

• Calcium channel blockers (e.g., amlodipine): Safe and effective for blood pressure control, with documented benefits in coronary artery disease patients including reduced hospitalizations for angina and revascularization procedures 3
• Thiazide diuretics (e.g., hydrochlorothiazide): Can be used but require careful monitoring of electrolytes, particularly in elderly patients; start with lowest dose (12.5 mg) in patients >65 years 4

Management of Concurrent Conditions

Pulmonary Hypertension

Pulmonary artery systolic pressure (PASP) decreases significantly after TAVI and this improvement is sustained:

• Immediate post-TAVI decrease from 63.1±16.2 to 48.8±12.4 mmHg (p<0.0001) 5
• Sustained reduction at 1 year (50.1±13.1 mmHg) 5
• Approximately 57% of patients with pre-procedural pulmonary hypertension experience reduction in PASP to below 50 mmHg 6

COPD is the most powerful predictor for persistent pulmonary hypertension post-TAVI (hazard ratio 3.9,95% CI 1.5-9.9, p=0.005), requiring closer monitoring in these patients 6

Concurrent Coronary Artery Disease

All patients should be screened and treated for hypercholesterolemia with GDMT for primary and secondary prevention of CAD (Class 1, Level A recommendation) 1

Statin therapy is indicated for atherosclerosis prevention based on standard risk scores, though it does not prevent hemodynamic progression of aortic stenosis 1

Common Pitfalls and Caveats

Avoid Overreacting to Immediate Post-TAVI Hypertension

Do not aggressively treat the transient blood pressure elevation that occurs immediately after TAVI, as this represents a normal adaptive response that resolves within approximately 2 months 2

Antiplatelet Therapy Considerations

Continue aspirin therapy perioperatively to reduce thrombotic risks in patients with prior TAVI 1

Standard antithrombotic regimen:

• Dual antiplatelet therapy (aspirin + clopidogrel) for 3-6 months after TAVI in patients without other indications for anticoagulation 7
• Lifelong single antiplatelet therapy (typically aspirin) after the initial 3-6 month period 7
• For high bleeding risk patients, single antiplatelet therapy alone may be considered immediately after TAVI 7

Special Populations

Patients with atrial fibrillation or other indications for anticoagulation require lifelong oral anticoagulation, which takes precedence over standard antiplatelet regimens 7

Elderly patients (>65 years) may experience greater blood pressure reduction and increased side effects with antihypertensive medications; start with lowest available doses and use small increments for titration 4

Monitoring Requirements

Regular follow-up is essential to assess:

• Blood pressure control and medication tolerance 1
• Renal function (metabolic panel) 1
• Echocardiography at 30 days then annually 1
• ECG at 30 days and annually, with consideration for 24-hour monitoring if bradycardia develops 1