Can verapamil be used to treat aortic dilation?

Verapamil for Aortic Dilation

Verapamil is not a standard or recommended treatment for aortic dilation, and the evidence supporting its use is limited to specific populations, primarily patients with Marfan syndrome where it may slow aortic root dilation, though beta-blockers and angiotensin receptor blockers remain the preferred medical therapies. 1

Evidence-Based Medical Management of Aortic Dilation

First-Line Therapies

Beta-blockers are the established first-line medical therapy for aortic dilation, particularly in Marfan syndrome, where they slow the rate of aortic root dilation (0.023 vs 0.084 per year, P<0.001) and should be continued even after surgical intervention. 1

Angiotensin receptor blockers (ARBs) have emerged as highly effective agents, with losartan reducing the rate of aortic root enlargement from 3.54±2.87 mm/year to 0.46±0.62 mm/year (P<0.001) in pediatric Marfan patients with severe aortic root enlargement. 1

ACE inhibitors also show benefit, with perindopril demonstrating significant reductions in ascending aortic diameter during both systole and diastole in Marfan patients already on beta-blocker therapy. 1

Limited Role of Verapamil

The evidence for verapamil in aortic dilation is sparse and context-specific:

• In Marfan syndrome, one randomized crossover trial showed verapamil 240 mg daily reduced central systolic pressure by 9.2 mmHg (P=0.003) and showed a trend toward reducing augmentation pressure (-5.5%, P=0.07), though it did not slow heart rate or delay aortic wave travel like atenolol did. 2

• Verapamil reduced both peripheral and central systolic pressure comparably to perindopril and atenolol in this Marfan population, but the study did not directly measure aortic dilation progression as an outcome. 2

• The 2007 ESC guidelines mention that dihydropyridine calcium channel blockers (not verapamil specifically) are warranted for antihypertensive treatment in asymptomatic patients with high blood pressure and aortic regurgitation, but the role of vasodilators in delaying surgery in normotensive patients is unproven. 1

Critical Contraindications

Verapamil must be avoided in patients with:

• Systolic heart failure or severe left ventricular dysfunction, as it has pronounced negative inotropic effects that can precipitate hemodynamic collapse. 3
• Aortic regurgitation with severe LV dysfunction, where verapamil and diltiazem should be specifically avoided. 1
• Second- or third-degree AV block without a pacemaker, PR interval >0.24 seconds, or increased risk for cardiogenic shock. 1

Clinical Algorithm for Medical Management of Aortic Dilation

For Marfan syndrome or genetic aortopathy:

1. Initiate beta-blocker therapy (propranolol or atenolol) as first-line treatment 1
2. Consider adding or switching to ARB (losartan) if inadequate response or beta-blocker intolerance 1
3. ACE inhibitors can be added to beta-blocker therapy for additional benefit 1
4. Verapamil may be considered only if beta-blockers and ARBs are contraindicated or not tolerated, and only in patients without LV dysfunction 2

For bicuspid aortic valve with dilation:

• Beta-blockers are recommended, though evidence is less robust than in Marfan syndrome 1
• Whether ACE inhibitors or calcium channel blockers provide similar benefits is unknown 1

For hypertensive patients with aortic dilation:

• Antihypertensive treatment with vasodilators (ACE inhibitors or dihydropyridine calcium channel blockers) is warranted to control blood pressure below 140/90 mmHg 1
• The primary goal is reducing shear stress by controlling blood pressure and cardiac contractility 1

Important Caveats

The main therapeutic goal is reducing blood pressure and shear stress on the diseased aortic segment, not specifically using verapamil. 1

Surgical intervention remains the definitive treatment when aortic diameter reaches 55 mm (or 45 mm in Marfan syndrome, 50 mm with bicuspid valve), especially with rapid progression (≥5 mm/year) or family history of dissection. 1

Serial imaging is essential: patients with dilated aortic root, especially with Marfan syndrome or bicuspid valves, require yearly examination with closer intervals if enlargement is detected. 1

Competitive sports should be avoided in patients with enlarged aorta to prevent blood pressure spikes. 1