Renin-angiotensin system inhibitor use following aortic valve replacement was associated with significantly reduced all-cause mortality (RR 0.74; 95% CI 0.65-0.83; p<0.0001).
Meta-Analysis (n=44,935)
Does renin-angiotensin system inhibitor (RASi) use reduce mortality and adverse events in patients undergoing aortic valve replacement?
RASi use following aortic valve replacement is associated with lower all-cause and cardiovascular mortality without increasing major adverse clinical events, though prospective randomized trials are needed to confirm.
Effect estimate: RR 0.74 (95% CI 0.65-0.83)
p-value: p=<0.0001
BACKGROUND: Aortic stenosis leads to adverse left ventricular remodeling; aortic valve replacement (AVR) remains the cornerstone of management. We evaluated clinical and echocardiographic outcomes with renin-angiotensin system inhibitor (RASi) use in patients undergoing AVR. METHODS: Five electronic databases were systematically queried for studies comparing outcomes with and without RASi post-AVR. Outcomes were pooled using random-effects models to calculate risk ratios (RRs), mean differences, and standardized mean differences with 95% confidence intervals. Outcomes of interest included all-cause and cardiovascular mortality, heart failure, myocardial infarction, stroke/TIA, arrhythmias, pacemaker requirement, acute kidney injury, and echocardiographic parameters. RESULTS: Seventeen studies (16 observational, 1 RCT) including 44,935 patients RASi: 20,723; no RASi: 24,212 were included. RASi use was associated with significantly reduced all-cause mortality (RR: 0.74; 95% CI: 0.65-0.83; p < 0.0001) and cardiovascular mortality (RR: 0.65; 95% CI: 0.49-0.85; p = 0.002), consistent across TAVR and SAVR subgroups. No significant differences were observed for heart failure, myocardial infarction, stroke, or pacemaker requirement. RASi did not increase acute kidney injury (p = 0.08) or major bleeding (p = 0.67). Echocardiographic outcomes, including peak aortic valve velocity and LV mass index, showed no significant differences between groups. CONCLUSIONS: In predominantly observational studies, RASi use following AVR is associated with lower all-cause and cardiovascular mortality without increasing major adverse clinical events. Survival benefits were not accompanied by consistent echocardiographic improvements. Given substantial heterogeneity and residual confounding inherent to observational data, prospective randomized trials are needed to confirm these associations. SOCIAL MEDIA ABSTRACT: Meta-analysis of 17 studies shows survival benefit with ACEI/ARB in the patients undergoing TAVR/SAVR, with no significant differences in HF, MI, stroke/TIA, AF, pacemaker, or echo outcomes.
Cheema et al. (Fri,) conducted a meta-analysis in Aortic stenosis undergoing aortic valve replacement (n=44,935). Renin-angiotensin system inhibitors (RASi) vs. No RASi was evaluated on All-cause mortality (RR 0.74, 95% CI 0.65-0.83, p=<0.0001). Renin-angiotensin system inhibitor use following aortic valve replacement was associated with significantly reduced all-cause mortality (RR 0.74; 95% CI 0.65-0.83; p<0.0001).