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ACEI/ARB Treatment and Outcomes Post-TAVR
Study Questions:
What is the association between treatment with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) at baseline and clinical outcomes in patients with symptomatic, severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR)?
Methods:
The investigators included a total of 3,979 intermediate, high, or prohibitive risk patients who underwent TAVR in the PARTNER 2 trial and registries (excluding the valve-in-valve registry) in the study. Clinical outcomes at 2 years were compared according to baseline ACEI/ARB treatment status using Kaplan-Meier event rates and study-stratified multivariable Cox proportional hazards regression models. Sensitivity analysis was conducted using propensity score matching.
Results:
Of 3,979 patients who were included in the current analysis, 1,736 (43.6%) were treated and 2,243 (56.4%) were not treated with ACEI/ARB at baseline. Treatment with ACEI/ARB was associated with lower 2-year all-cause mortality (18.6% vs. 27.5%, p < 0.0001), cardiovascular mortality (12.3% vs. 17.9%, p < 0.0001), and noncardiovascular mortality (7.2% vs. 11.7%, p < 0.0001). ACEI/ARB treatment at baseline remained independently associated with a lower hazard of 2-year all-cause and cardiovascular mortality after multivariable adjustment, and propensity score matching.
Conclusions:
The authors concluded that in a large cohort of patients with severe symptomatic AS from the PARTNER 2 trial and registries, ACEI/ARB treatment at baseline was independently associated with a lower risk of 2-year all-cause and cardiovascular mortality.
Perspective:
The current retrospective study reports that among patients with severe symptomatic AS, treatment with ACEI/ARB at baseline was safe and independently associated with decreased 2-year risks of all-cause and cardiovascular mortality after TAVR. Of note, the survival benefit was seen regardless of the baseline left ventricular ejection fraction or presence of hypertension but not observed in patients with chronic kidney disease, and was less pronounced in patients with coronary artery disease. Given the retrospective nature of the current analysis, it needs to be validated in prospective randomized studies, and assessed as to whether treatment pre- or post-TAVR (or both) with ACEI/ARB is more influential. The RASTAVI trial (NCT03201185) will randomize patients who have received TAVR to ramipril versus placebo and will provide additional insight.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Structural Heart Disease, Hypertension
Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Aortic Valve Stenosis, Coronary Artery Disease, Heart Valve Diseases, Hypertension, Renal Insufficiency, Chronic, Transcatheter Aortic Valve Replacement, Ventricular Function, Left, Secondary Prevention, Treatment Outcome
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