From the Guidelines
In aortic stenosis, vasodilators, negative inotropes, and aggressive diuretics are relatively contraindicated due to their potential to worsen hemodynamics and clinical status, as they can cause excessive peripheral vasodilation, reduce myocardial contractility, or decrease preload, leading to hypotension, decreased coronary perfusion, and worsening heart failure symptoms. These medications can be dangerous because patients with aortic stenosis have fixed obstruction to left ventricular outflow, making them dependent on adequate preload and afterload to maintain cardiac output 1.
Key Considerations
- Vasodilators, such as nitrates, ACE inhibitors, ARBs, and nesiritide, can cause excessive peripheral vasodilation, reducing venous return and blood pressure, which may precipitate hypotension and decreased coronary perfusion.
- Negative inotropes, such as beta-blockers, non-dihydropyridine calcium channel blockers like verapamil and diltiazem, reduce myocardial contractility, which is needed to overcome the valvular obstruction.
- Aggressive diuresis can reduce preload too much, decreasing stroke volume across the stenotic valve.
Management Approach
When treating patients with aortic stenosis who have comorbidities requiring these medications, careful titration with close monitoring is essential, starting with low doses and gradually increasing while watching for signs of hemodynamic compromise such as hypotension, syncope, or worsening heart failure symptoms 1.
Additional Guidance
The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends careful use of antihypertensive agents to achieve BP control in patients with hypertension and aortic stenosis, with consideration of the potential benefits and risks of different medication classes 1.
From the Research
Relative Contraindications in Aortic Stenosis
- The use of certain antihypertensive medications, such as β-blockers, in patients with severe aortic stenosis was previously considered a relative contraindication due to concerns about inducing left ventricular dysfunction and hemodynamic compromise 2.
- However, recent studies have shown that β-blockers may be safe and even beneficial in patients with aortic stenosis, although the evidence is still limited 2, 3.
- Renin-angiotensin system (RAS) inhibitors, such as angiotensin-converting enzyme (ACE) inhibitors, were also considered contraindicated in patients with aortic stenosis, but recent studies have suggested that they may be beneficial in retarding the progression of valvular stenosis and improving left ventricular remodeling 2, 3, 4.
- The potential benefits of RAS inhibitors in patients with aortic stenosis include prevention of left ventricular hypertrophy, improved diastolic function, reduction of arrhythmias, and preservation of left ventricular function 3, 4.
Current Evidence and Recommendations
- Despite the potential benefits of antihypertensive therapy in patients with aortic stenosis, there is still a lack of consensus regarding the safety and efficacy of these medications in this population 5.
- Further studies are needed to establish the ideal target blood pressure and antihypertensive regimens in patients with severe aortic stenosis 2, 6.
- The selection of antihypertensives in patients with aortic stenosis should be individualized and based on the patient's specific clinical characteristics and comorbidities 5.