Key result
Post-AVR RASi use linked to ~32% lower 5-year mortality, with similar benefits for MRA and SGLT2i.
Why the study?
Patients with severe AS remain at increased risk of HF and death after successful AVR, and evidence on the efficacy of conventional HF medications in this setting is limited.
Does treatment with heart failure medications (RASi, MRA, SGLT2i, BB) at discharge reduce all-cause and cardiovascular mortality at 60 months in patients with severe aortic stenosis undergoing surgical or transcatheter aortic valve replacement?
Cohort (n=4,882)
Does treatment with heart failure medications (RASi, MRA, SGLT2i, BB) at discharge reduce all-cause and cardiovascular mortality at 60 months in patients with severe aortic stenosis undergoing surgical or transcatheter aortic valve replacement?
In patients with severe aortic stenosis undergoing surgical or transcatheter aortic valve replacement, discharge prescription of RASi, MRA, and SGLT2i, but not beta-blockers, is independently associated with reduced 5-year all-cause and cardiovascular mortality across LVEF and procedural subgroups.
Supports selective HF pharmacotherapy after AVR while questioning routine beta-blockade; leaves open whether these observational survival benefits hold in randomized post-AVR trials.
Background In the setting of aortic stenosis (AS), long-standing pressure overload leads to myocardial damage and subjects patients to an increased risk of heart failure (HF) and death even after successful aortic valve replacement (AVR). Conventional HF medications may have the potential to target this residual HF component, but current evidence on the efficacy in severe AS after AVR is limited. Aims The aims of this study were to assess HF medication prescription patterns and their association with outcomes in severe AS after AVR. Methods Consecutive patients with severe AS undergoing successful AVR between 2013 and 2024 were included. Treatment status with HF medications (Renin-angiotensin-system inhibitors [RASi], Mineralocorticoid receptor antagonists [MRA], beta-blockers [BB], Sodium glucose co-transporter 2 inhibitors [SGLT2i]) at discharge after AVR was recorded. Nearest neighbor propensity score (PS) matching for age, sex, N-terminal pro-B-type natriuretic peptide [NT-proBNP], estimated glomerular filtration rate [eGFR], glycated hemoglobin [HbA1c], hypertension and coronary artery disease was performed. All-cause and cardiovascular (CV) mortality at month 60 were assessed in the overall population and prespecified subgroups: a) surgical (SAVR) vs. transcatheter aortic valve replacement (TAVR) b) left ventricular ejection fraction (LVEF) ≥50% vs. <50%. Results In total, 4,882 patients (75.9 years, 56.4% male, 51.8% TAVR, 48.2% SAVR) were included. RASi were prescribed in 35.1%, MRA in 30.5%, SGLT2i in 14.3%, and BB in 10.4%. Patients receiving RASi (LVEF <50%: 17.2% vs. 10.1%; NT-proBNP: 1,238 pg/ml vs. 971 pg/ml), MRA (LVEF <50%: 18.7% vs. 9.8%; NT-proBNP: 1,372 pg/ml vs. 962 pg/ml) and SGLT2i (LVEF <50%: 20.6 vs. 11.1; NT-proBNP: 1,450 pg/ml vs. 1,037 pg/ml) were at a more advanced stage of cardiac disease compared to patients not receiving respective medications. Treatment with RASi (HR: 0.68; 95%CI: 0.59-0.78; HR: 0.68; 95%CI: 0.56-0.82), MRA (HR: 0.74; 95%CI: 0.63-0.86; HR: 0.70; 95%CI: 0.57-0.85), and SGLT2i (HR: 0.69; 95%CI: 0.53-0.91; HR: 0.56; 95%CI: 0.38-0.80) was independently associated with a reduced hazard for all-cause and CV mortality, respectively. Treatment benefits were confirmed across evaluated subgroups. Conversely, no outcome signals for BB treatment were found. Conclusions Prescription of HF medications in AS undergoing AVR is impacted by the stage of cardiac disease. Treatment with RASi, MRA and SGLT2i, but not BB, is associated with favourable clinical outcomes, including subgroups of TAVR/SAVR and reduced/preserved LVEF.
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Autherith et al. (2026) conducted a cohort in Severe aortic stenosis undergoing surgical or transcatheter aortic valve replacement (n=4,882). Heart failure medications at discharge (RASi, MRA, SGLT2i, beta-blockers) vs. Patients not receiving respective heart failure medications at discharge (propensity score-matched) was evaluated on All-cause mortality at month 60 (shown for RASi; also assessed for MRA, SGLT2i, BB, and cardiovascular mortality) (HR 0.68, 95% CI 0.59-0.78). Treatment with RASi (HR 0.68), MRA (HR 0.74), and SGLT2i (HR 0.69), but not beta-blockers, was associated with lower 60-month all-cause mortality after aortic valve replacement.
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