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Review
. 2020 Sep 15;9(18):e016911.
doi: 10.1161/JAHA.120.016911. Epub 2020 Sep 6.

Renin-Angiotensin System Blockade in Aortic Stenosis: Implications Before and After Aortic Valve Replacement

Sachin S Goel  1 , Neal S Kleiman  1 , William A Zoghbi  1 , Michael J Reardon  2 , Samir R Kapadia  3
Affiliations
Review

Renin-Angiotensin System Blockade in Aortic Stenosis: Implications Before and After Aortic Valve Replacement

Sachin S Goel et al. J Am Heart Assoc. .

Abstract

Aortic stenosis (AS) is a common valvular heart disease in the aging population that is characterized by a variable period of asymptomatic phase before development of symptoms and severe AS. Mortality and morbidity is substantial even after aortic valve replacement, in part related to persistent left ventricular hypertrophy, diastolic dysfunction, and heart failure. Renin-angiotensin system (RAS) blockade therapy is associated with modulation of adverse left ventricular remodeling, reduction in myocardial hypertrophy, and fibrosis, resulting in clinical improvements in patients with congestive heart failure There are emerging data to suggest benefit of RAS blockade in patients with AS before and after AVR with regard to potentially slower progression of aortic valve calcification, left ventricular mass and survival benefit in favor of RAS blockade group before AVR, and also survival benefit in patients after AVR. We review the available data to understand the role of RAS blockade before AVR and in patients undergoing surgical AVR and transcatheter AVR. There are significant survival advantages of RAS inhibition in patients with AS undergoing surgical AVR or transcatheter AVR. On the basis of existing literature, adequately powered randomized trials are needed to evaluate the role of RAS inhibition in patients with AS.

Keywords: aortic stenosis; aortic valve replacement; renin‐angiotensin system; transcatheter aortic valve replacement.

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Conflict of interest statement

Dr Goel is on the Speakers Bureau for Abbott Structural Heart. Dr Reardon is a consultant for Medtronic. The remaining authors have no disclosures to report.

Figures

Figure 1
Figure 1. Pathophysiology of aortic stenosis and potential steps where RAS inhibition could be beneficial.
ACE indicates angiotensin‐converting enzyme; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; AT1, angiotensin 1. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2020. All Rights Reserved.
Figure 2
Figure 2. Potential mechanisms of clinical benefit associated with RAS inhibition in aortic stenosis.
AS indicates aortic stenosis; CHF, congestive heart failure; K‐sparing, potassium sparing; LV, left ventricular; LVH, left ventricular hypertrophy; RAS, renin‐angiotensin system; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography ©2020. All Rights Reserved.
Figure 3
Figure 3. Summary of published data on impact of RAS inhibition in AS.
ACEI indicates angiotensin‐converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AS, aortic stenosis; AV, aortic valve; AVR, aortic valve replacement; CHF, congestive heart failure; CV, cardiovascular; LV, left ventricular; LVH, left ventricular hypertrophy; Rx, treatment; SAVR, surgical aortic valve replacement; and TAVR, transcatheter aortic valve replacement.
See this image and copyright information in PMC

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