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Renin-angiotensin blockade improves outcomes of aortic stenosis

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Patients with aortic stenosis fare better when they’re treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), results of a population-based study indicate.

“This large observational study suggests that ACEI/ARB therapy is associated with an improved survival and a lower risk of cardiovascular events in patients with aortic stenosis,” the researchers conclude.

Writing in the August 2 issue of the Journal of the American College of Cardiology, Dr. Chim C. Lang and colleagues at the Medical School of the University of Dundee, UK, note that not all patients with aortic stenosis are candidates for surgical valve replacement and the availability of transcatheter valve implantation is limited – so there’s a need for medical treatment.

They point out that ACEIs and ARBs have beneficial effects on left ventricular hypertrophy, but the medications are perceived as contraindicated in aortic stenosis.

To investigate, the team linked databases for the population of Tayside in Scotland and identified 2117 patients with aortic stenosis, 699 of whom were taking an ACEI or ARB.

Over 4 years of follow up, there were 1087 deaths from all causes and 1018 cardiovascular events (ie, deaths or hospitalizations) in this cohort, according to the report. ACEI/ARB therapy was associated with significantly lower all-cause mortality (adjusted hazard ratio: 0.76, p<0.0001) and cardiovascular events (aHR: 0.77, p<0.0001), the researchers found.

They also performed a propensity score-matched cohort analysis that included 266 patients from the ACEI/ARB group and 266 from the control group. This yielded adjusted hazard ratios of 0.67 and 0.71 for all-cause mortality and for cardiovascular events, respectively.

“Despite concerns over safety of ACEIs and ARBs, we have found evidence to suggest that therapy with ACEIs or ARBs is associated with an improved survival and a reduction in CV events in patients with varying degrees of aortic stenosis,” Dr. Lang and colleagues conclude. “Prospective, randomized, controlled trials are warranted to confirm these findings.”

The authors of a related editorial comment, “There has been a long-standing concern that vasodilation in the face of fixed left ventricular outflow obstruction is contraindicated and life threatening, and discussion of the role of vasodilator therapy does not find its way into the valve disease guidelines for aortic stenosis.”

They conclude, “Perhaps the importance of the current data is that they make us rethink this notion.”

J Am Coll Cardiol 2011;58:570-580.