Effects of angiotensin converting enzyme inhibitors in hypertensive patients with aortic valve stenosis: a drug withdrawal study

OBJECTIVE: To determine the effects of angiotensin converting enzyme (ACE) inhibitors in hypertensive patients with aortic valve stenosis (AS). DESIGN: Observational, drug withdrawal, single blinded study, with randomisation of the order of tests. SETTING: Hypertension and asymptomatic AS. PATIENTS AND INTERVENTIONS: 20 patients (aged 73 (9) years, valve area 0.7 (0.3) cm2, left ventricular ejection fraction > or = 45%) were enrolled. Each patient underwent two sets of tests (with and without taking the drug), each of which included clinical evaluation, Doppler echocardiogram, and symptom limited exercise echocardiography. MAIN OUTCOME MEASURES: Functional and haemodynamic variables while taking and not taking ACE inhibitors. RESULTS: Drug intervention induced no change in patients' subjective functional class. While taking ACE inhibitors, patients had a lower systolic blood pressure (140 (18) mm Hg with ACE inhibitors v 159 (12) mm Hg without ACE inhibitors, p = 0.02), a higher mean pressure gradient (34 (15) mm Hg v 28 (18) mm Hg, p = 0.037), and a higher left ventricular stroke work loss (19 (6)% v 14 (10)%, p = 0.009). Other baseline functional and haemodynamic parameters were unmodified. Five patients had an abnormal blood pressure response during one of the exercise tests (two patients while taking the drug and three patients while not taking the drug). When taking ACE inhibitors, patients had a higher stroke volume at peak stress (59 (11) ml v 54 (25) ml, p = 0.046). All other stress variables remained constant. CONCLUSIONS: In AS, the afterload relief caused by ACE inhibitors is blunted by a parallel increase in the pressure gradient. However, ACE inhibitors favourably affect stress haemodynamic function in most hypertensive patients with AS and should not be discontinued.