Impact of renin–angiotensin system inhibitors on clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis of from the PARTNER 2 trial and registries
Why the study?
LV pressure overload activates the cardiac renin-angiotensin system, potentially promoting myocardial fibrosis and adverse outcomes, but the clinical impact of ACEI or ARB therapy in patients undergoing TAVR was unclear.
Does baseline ACEI/ARB treatment reduce mortality in intermediate to prohibitive risk patients with severe symptomatic AS undergoing TAVR?
Structured PICO
Does baseline ACEI/ARB treatment reduce mortality in intermediate to prohibitive risk patients with severe symptomatic AS undergoing TAVR?
P
Population
3979 intermediate, high, or prohibitive risk patients with symptomatic, severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) in the PARTNER 2 trial and registries
I
Intervention
Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) at baseline
C
Comparator
No ACEI/ARB treatment at baseline
O
Outcome
2-year all-cause mortalityhard clinical
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The next step is going to be a prospective randomized trial looking at the role of renin-angiotensin inhibitor treatment post-transcatheter aortic valve replacement and possibly [after] surgical aortic valve replacement to see what impact it has”
“If your patient already has an indication for RAS inhibition, you should definitely strongly be considering that post-TAVR. So that's probably the safe recommendation.”
“Our finding generates the hypothesis that a RAS inhibitor is a potential medical therapy to improve clinical outcomes in patients undergoing TAVR. Due to a retrospective nature, our study has a potential selection bias; therefore, the finding requires further investigation in randomized trials.”
Implication
Baseline ACEI/ARB treatment in patients undergoing TAVR for severe symptomatic aortic stenosis is associated with significantly lower 2-year all-cause and cardiovascular mortality.
Abstract
AIMS: Left ventricular pressure overload is associated with activation of the cardiac renin-angiotensin system, which may contribute to myocardial fibrosis and worse clinical outcomes. We sought to assess 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) in the PARTNER 2 trial and registries. METHODS AND RESULTS: A total of 3979 intermediate, high, or prohibitive risk patients who underwent TAVR in the PARTNER 2 trial and registries (excluding the valve in valve registry) were included 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. Of 3979 patients who were included in the current analysis, 1736 (43.6%) were treated and 2243 (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 non-cardiovascular mortality (7.2% vs. 11.7%, P < 0.0001). Angiotensin-converting enzyme inhibitor/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. CONCLUSION: 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.
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Cite This Study
Chen et al. (2019) studied this question.