Heart Failure Pharmacotherapy Across the Transcatheter Aortic Valve Replacement Continuum

Take Home Illustration. Heart Failure Pharmacotherapy Across the TAVR Continuum. GDMT recommendations across the pre-, peri-, and post-procedural phases of TAVR. The recommendations are based on available evidence for each drug class regarding safety, efficacy, and impact on clinical outcomes. BB = beta blocker; HF = heart failure; GDMT = guideline directed medical therapy; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; RASi = renin angiotensin system inhibitor; SGLT2i = sodium glucose transporter 2 inhibitor; TAVR = transcatheter aortic valve replacement. Transcatheter aortic valve replacement (TAVR) is an increasingly common treatment option for severe symptomatic aortic stenosis. However, heart failure often persists because of incomplete reversal of myocardial remodeling, fibrosis, and diastolic dysfunction. TAVR corrects valvular afterload but does not resolve the underlying myocardial disease. Guideline-directed medical therapy (GDMT), including renin-angiotensin system inhibitors (RASi), sodium-glucose cotransporter-2 inhibitors (SGLT2i), mineralocorticoid receptor antagonists (MRAs), and beta-blockers (BBs), has a strong mechanistic rationale and potential clinical benefit, although evidence in TAVR populations remains heterogeneous and is largely observational. Nonetheless, accumulating data support continuation and early optimization of GDMT in the pre-, peri-, and post-TAVR periods, with the most consistent benefit observed for RASi and SGLT2i. Key uncertainties remain regarding optimal timing, patient selection, and class-specific effects. This State-of-the-Art Review integrates current evidence and proposes a framework to guide GDMT use across the TAVR continuum while defining priorities for future randomized trials Condensed Abstract: Post-TAVR heart failure frequently persists because of residual myocardial disease. GDMT, including RASi, SGLT2i, MRAs, and BBs, may improve outcomes but remains underutilized and inconsistently addressed in current guidelines. GDMT should ideally be continued when tolerated and optimized early across the TAVR continuum, particularly RASi and SGLT2i. Therapy should be tailored to heart failure phenotype across the TAVR continuum. Randomized trials are needed to define optimal implementation strategies.