High Blood Pressure and Chest Pain in Severe Aortic Stenosis
High blood pressure does not directly cause chest pain in severe aortic stenosis, but it significantly worsens the underlying mechanisms that produce angina by increasing left ventricular afterload, exacerbating left ventricular hypertrophy, and intensifying coronary microvascular dysfunction. 1
Mechanism of Chest Pain in Aortic Stenosis
The chest pain in patients with severe aortic stenosis occurs through two primary pathways:
- Coronary microvascular dysfunction is the most common cause, resulting from very elevated left ventricular pressure caused by high left ventricular afterload, combined with associated left ventricular hypertrophy 1
- Coexisting obstructive epicardial coronary artery disease may also contribute to angina in these patients 1
How Hypertension Exacerbates the Problem
When hypertension coexists with severe aortic stenosis, it creates a "two resistors in series" phenomenon that compounds the hemodynamic burden:
- Increased total left ventricular afterload from both the stenotic valve and elevated systemic vascular resistance 2, 3
- Worsened left ventricular remodeling with more severe hypertrophy and fibrosis 4, 5
- Elevated left ventricular filling pressures that can reach 19±5 mm Hg at baseline in hypertensive patients with low-gradient severe AS 3
- Reduced stroke volume (33±8 mL/m²) due to the combined afterload burden 3
- Accelerated progression of the aortic stenosis itself 5, 6
Clinical Implications
Treating hypertension in severe aortic stenosis is crucial and safe when done appropriately, contrary to historical concerns:
- Vasodilator therapy reduces total left ventricular afterload, decreasing LV filling pressures from 19±5 mm Hg to 11±5 mm Hg 3
- Blood pressure reduction lowers pulmonary artery pressures from 39±12 mm Hg to 25±10 mm Hg 3
- Target blood pressure should be 130-139 mmHg systolic and 70-90 mmHg diastolic 7, 5
Preferred Antihypertensive Approach
RAS inhibitors (ACE inhibitors or ARBs) are first-line agents for hypertension in severe aortic stenosis:
- They provide beneficial effects on left ventricular fibrosis 2, 7
- They improve blood pressure control, reduce dyspnea, and improve effort tolerance 2, 7
- They improve survival both before and after valve intervention 5, 6
- They are the most well-studied agents in this population 4
Beta blockers should be reserved for compelling indications only:
- Heart failure with reduced ejection fraction 2, 7
- Post-myocardial infarction status 2, 7
- Arrhythmias requiring rate control 2, 7
- Angina pectoris (they reduce myocardial oxygen consumption and valve gradients) 2, 7
Critical Management Points
- Start antihypertensive therapy at low doses and titrate gradually 7
- Cardiology consultation or co-management is mandatory for hypertension management in moderate-to-severe aortic stenosis 8, 7
- Use diuretics sparingly in patients with small LV chamber dimensions and LV hypertrophy 2
- Avoid calcium channel blockers, as they may be associated with lower survival 5, 6