Author + information
- Geoffrey Jao, MD⁎ (, )
- John Lystash, MD and
- David Sane, MD
- ↵⁎Virginia Tech Carilion School of Medicine, Cardiology, 1906 Belleview Avenue, Roanoke, Virginia 24104
We read with interest the study of Herrmann et al. (1) that examined the longitudinal left ventricular (LV) function, degree of myocardial fibrosis, hemodynamic distinctions, and clinical outcomes of symptomatic patients attributed to isolated aortic stenosis (AS). The patients were grouped and analyzed according to aortic valve area, transvalvular gradient, and left ventricular ejection fraction (LVEF); all patients with severe AS, regardless of transvalvular gradient, underwent aortic valve replacement.
We respectfully point out that the proportion of patients on medical therapy with angiotensin-converting enzyme (ACE) inhibitors, aldosterone antagonists, beta-blockers, and/or statins at baseline and on follow-up 9 months later was not reported. This information is important because these medications can potentially affect the outcomes being evaluated. We would like to focus our comments regarding ACE inhibitor use, specifically.
The preoperative use of ACE inhibitors can potentially affect the outcome of the study by altering 2 factors considered for patient assignment: transvalvular gradient and LVEF. Since resistance in a series is additive, ACE inhibitors will decrease systemic vascular resistance through arterial vasodilation, which in turn may increase the transvalvular gradient (2). These agents are also established reverse remodeling agents and can improve the LVEF of patients with systolic dysfunction with long-term use. Although previously thought to be a contraindication for patients with AS because of the theoretical concern for hypotension, decreased coronary perfusion, and renal insufficiency, several prospective studies suggest that medical therapy with ACE inhibitors may be safe (2,3). Dalsgaard et al. (4) recently demonstrated with a small randomized controlled trial that the use of trandolapril among patients with severe AS did not cause adverse outcomes or symptomatic hypotension. Over 8 weeks of follow-up, treatment with trandolapril led to a decrease in LV end-systolic volume and N-terminal pro–B-type natriuretic peptide, suggesting beneficial effect of ACE-induced LV unloading (4). The study of Herrmann et al. (1) also showed that the sickest patient subgroups (i.e., those with low-gradient severe symptomatic AS, regardless of ejection fraction) have the highest systemic vascular resistance and relatively preserved blood pressure. It is plausible that medical therapy with ACE inhibitors could potentially be used as a bridge to aortic valve surgery.
- American College of Cardiology Foundation
- Herrmann H.,
- Stork S.,
- Nieman M.,
- et al.
- Jiménez-Candil J.,
- Bermejo J.,
- Yotti R.,
- et al.
- ↵Dalsgaard M. Acute hemodynamic effects of treatment with ACE inhibitors in severe aortic valve stenosis: a placebo-controlled randomized study. Paper presented at: American College of Cardiology 60th Annual Scientific Session; April 3, 2011; New Orleans, LA.