Renin-Angiotensin System Inhibition Following Transcatheter Aortic Valve Replacement

J Am Coll Cardiol. 2019 Aug 6;74(5):631-641. doi: 10.1016/j.jacc.2019.05.055.

Abstract

Background: Several studies have demonstrated the benefits of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis, but the presence of persistent fibrosis and myocardial hypertrophy has been related to worse prognosis.

Objectives: The aim of this study was to explore the potential benefits of renin-angiotensin system (RAS) inhibitors on left ventricular remodeling and major clinical outcomes following successful transcatheter aortic valve replacement (TAVR).

Methods: Patients from 10 institutions with severe aortic stenosis who underwent TAVR between August 2007 and August 2017 were included. All baseline data were prospectively recorded, and pre-specified follow-up was performed. Doses and types of RAS inhibitors at discharge were recorded, and matched comparison according to their prescription at discharge was performed.

Results: A total of 2,785 patients were included. Patients treated with RAS inhibitors (n = 1,622) presented similar surgical risk scores but a higher rate of all cardiovascular risk factors, coronary disease, and myocardial infarction. After adjustment for these baseline differences, reduction of left ventricular volumes and hypertrophy was greater and cardiovascular mortality at 3-year follow-up was lower (odds ratio: 0.59; 95% confidence interval: 0.41 to 0.87; p = 0.007) in patients treated with RAS inhibitors. Moreover, RAS inhibitors demonstrated a global cardiovascular protective effect with significantly lower rates of new-onset atrial fibrillation, cerebrovascular events, and readmissions.

Conclusions: Post-TAVR RAS inhibitors are associated with lower cardiac mortality at 3-year follow-up and offer a global cardiovascular protective effect that might be partially explained by a positive left ventricular remodeling. An ongoing randomized trial will help confirm these hypothesis-generating findings. (Renin-Angiotensin System Blockade Benefits in Clinical Evolution and Ventricular Remodeling After Transcatheter Aortic Valve Implantation [RASTAVI]; NCT03201185).

Keywords: RAS inhibitors; TAVR; fibrosis; hypertrophy.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged, 80 and over
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Aortic Valve / surgery*
  • Aortic Valve Stenosis / diagnosis
  • Aortic Valve Stenosis / physiopathology
  • Aortic Valve Stenosis / therapy*
  • Echocardiography
  • Female
  • Follow-Up Studies
  • Heart Ventricles / diagnostic imaging
  • Heart Ventricles / drug effects
  • Heart Ventricles / physiopathology
  • Humans
  • Male
  • Postoperative Complications
  • Postoperative Period
  • Retrospective Studies
  • Risk Factors
  • Transcatheter Aortic Valve Replacement / adverse effects*
  • Treatment Outcome
  • Ventricular Dysfunction, Left / diagnosis
  • Ventricular Dysfunction, Left / etiology
  • Ventricular Dysfunction, Left / prevention & control*
  • Ventricular Function, Left / physiology*
  • Ventricular Remodeling*

Substances

  • Angiotensin-Converting Enzyme Inhibitors

Associated data

  • ClinicalTrials.gov/NCT03201185