Prognostic Impact of Systolic Hypertension on Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Initially Normal Left Ventricular Performance at Rest

Supino, Phyllis G.; Borer, Jeffrey S.; Herrold, Edmund M.; Hochreiter, Clare; Preibisz, J; Schuleri, Karlheinz; Roman, Mary J.; Kligfield, Paul

doi:10.1016/j.amjcard.2005.05.054

Cited by 15 publications

(11 citation statements)

References 20 publications

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“…We have previously shown that treatment with indirect vasodilators predicts increased risk of adverse events among initially asymptomatic patients with chronic severe aortic regurgitation [3]. The primary objective of the present study was to determine the relation of chronic vasodilator use to subsequent cardiac events (CE) among initially asymptomatic patients with chronic severe nonischemic MR. We also sought to explore a potential relation between vasodilator effects and the presence or absence of concomitant systolic HTN in this patient population.…”

Section: Introductionmentioning

confidence: 99%

Relation of Indirect Vasodilator Use to Prognosis in Patients with Chronic Severe Mitral Regurgitation

et al. 2014

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Objectives: The relation of indirect vasodilator use to cardiac events (CE) is undefined for chronic severe nonischemic mitral regurgitation (MR). The aim of this study was to resolve this knowledge deficiency. Methods: Data from 52 consecutive patients in our prospective natural history study with isolated chronic severe nonischemic MR were assessed post hoc over 19 years to examine the relation of indirect vasodilator use to subsequent CE (death or indications for valve surgery). At entry, no patient had surgical indications, 14% had hypertension (HTN) and 7 chronically received vasodilators (5 angiotensin-converting enzyme inhibitor, 1 receptor blocker and 1 α-adrenergic blocker). CE differences were assessed by log-rank comparison of Kaplan-Meier curves. Results: During follow-up, CE included sudden death (1 patient), heart failure (7 patients), atrial fibrillation (6 patients), left ventricular (LV) systolic dimension >4.5 cm (12 patients), LV ejection fraction (EF) <60% (7 patients), right ventricular EF <35% (2 patients) and combination CE (7 patients). Overall, vasodilator use did not predict CE (not significant). However, patients without HTN had higher CE rates with vasodilators than without (p = 0.007), while those with HTN and vasodilators had lower CE rates than those without vasodilators (p = 0.04). Conclusion: Vasodilator use appears to confer no survival benefit in patients with chronic severe MR. The small number of patients with HTN precludes conclusions about modulation of vasodilator effect by HTN. Randomized trials are needed to conclusively evaluate this association.

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Section: Introductionmentioning

confidence: 99%

Relation of Indirect Vasodilator Use to Prognosis in Patients with Chronic Severe Mitral Regurgitation

et al. 2014

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“…Though a role in AR genesis is not rigorously established, experimental models suggest a causal association between hypertension and AR 39 , AR prevalence is higher in hypertensive than in normotensive patients 40, 41 and normotensive patients with moderate AR have less longitudinal axis dysfunction than analogous hypertensive patients 42 . Also, systolic hypertension (>140mmHg) accelerates the progression of valve dysfunction, worsens cardiac function and is a risk factor for AVR indications and for adverse clinical outcomes, irrespective of AR etiology 43-46 . Thus, in a prospective assessment of outcomes among 80 consecutive asymptomatic patients with AR and normal LVEF, during a 7.2 year event-free follow-up, 24 subjects developed heart failure symptoms, subnormal LVEF at rest or death.…”

Section: Aortic Regurgitation (Table 1)mentioning

confidence: 99%

“…Thus, in a prospective assessment of outcomes among 80 consecutive asymptomatic patients with AR and normal LVEF, during a 7.2 year event-free follow-up, 24 subjects developed heart failure symptoms, subnormal LVEF at rest or death. 46 It is surprising, then, that long-term antihypertensive therapies as a group are associated with heightened risk of subsequent cardiac events, though the effect of individual drug types may vary 46 . Indeed, among the 30 subjects with systolic hypertension in the prospective study, antihypertensive therapy was associated with average annual event risk 15.5%, four-fold the risk (4%) of hypertensive subjects who did not receive such drugs (p <0.02); the difference remained significant when analysis was adjusted for blood pressure at entry 46 .…”

Section: Aortic Regurgitation (Table 1)mentioning

confidence: 99%

“…46 It is surprising, then, that long-term antihypertensive therapies as a group are associated with heightened risk of subsequent cardiac events, though the effect of individual drug types may vary 46 . Indeed, among the 30 subjects with systolic hypertension in the prospective study, antihypertensive therapy was associated with average annual event risk 15.5%, four-fold the risk (4%) of hypertensive subjects who did not receive such drugs (p <0.02); the difference remained significant when analysis was adjusted for blood pressure at entry 46 . Most patients received ACEIs or ARBs and/or diuretics and some, direct vasodilators (none received calcium channel blockers).…”

Section: Aortic Regurgitation (Table 1)mentioning

confidence: 99%

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Drug Therapy for Heart Valve Diseases

Borer

Sharma

2015

Circulation

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Valvular heart diseases (VHDs) are progressive. When not caused by acute comorbidities they are generally characterized by long asymptomatic phases during which hemodynamic severity may progress leading to morbidity and mortality. Treatment depends on VHD type and severity but when severe and symptomatic, usually involves mechanical intervention. Asymptomatic patients, and those who lack objective descriptors associated with high risk, are closely observed clinically with optimization of associated cardiovascular risk factors until surgical indications develop. Though often prescribed based on theory, no rigorous evidence supports pharmacological therapy in most chronic situations though drugs may be appropriate in acute valvular diseases, or as a bridge to surgery in severely decompensated patients. Herein, we examine evidence supporting drug use for chronic VHDs.

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“…4,5 Vasodilator therapy has been shown to reduce LV volume and mass and to improve hemodynamics and LV function in patients with severe AR, [6][7][8][9] but controversy exists as to the utility of vasodilators in patients with volume overload cardiomyopathy. [10][11][12] Indeed, 2 long-term randomized trials to determine whether vasodilators reduce or delay the need for valve surgery in patients with severe AR produced conflicting results. 13, 14 The results of several clinical trials clearly demonstrate that interruption of the renin -angiotensin system (RAS) activity with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor (AT1) blockers improves long-term survival in patients with heart failure.…”

mentioning

confidence: 99%

Genetic Disruption of Angiotensin II Type 1a Receptor Improves Long-Term Survival of Mice With Chronic Severe Aortic Regurgitation

Nakanishi

Hara

Kishimoto³

et al. 2007

Circ J

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Background Aortic regurgitation (AR) causes left ventricular (LV) volume overload, leading to progressive LV dilatation and dysfunction. In the present study it was examined whether blockade of angiotensin II type 1 receptor (AT1) could improve survival in cases of chronic severe AR. Methods and Results AR was induced by puncturing the aortic valves of wild-type (WT) and AT1a knockout (KO) mice. Mice that survived for 4 weeks after the operation were deemed to be a model of chronic severe AR and were followed up for 50 weeks (WT, n=29; KO, n=31). Baseline measurements made 4 weeks after surgery showed similar LV cavity and function in both genotypes. These conditions progressively worsened in both genotypes, but 16 weeks after baseline, KO mice showed significantly less LV dilatation, hypertrophy and interstitial fibrosis than WT mice. Cardiac mRNA expression of B-type natriuretic peptide and type I collagen was lower in KO than WT mice. The 50-week mortality rate was significantly lower among KO (45.2%) than WT (86.2%) mice, and postmortem findings indicated that the lower mortality was attributable to a lower incidence of congestive heart failure. Conclusions In cases of chronic severe AR, blockade of AT1 attenuates the progression of LV dilatation, hypertrophy and fibrosis, thereby mitigating heart failure and improving long-term survival. (Circ J 2007; 71: 1310 -1316)

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Prognostic Impact of Systolic Hypertension on Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Initially Normal Left Ventricular Performance at Rest

Cited by 15 publications

References 20 publications

Relation of Indirect Vasodilator Use to Prognosis in Patients with Chronic Severe Mitral Regurgitation

Relation of Indirect Vasodilator Use to Prognosis in Patients with Chronic Severe Mitral Regurgitation

Drug Therapy for Heart Valve Diseases

Genetic Disruption of Angiotensin II Type 1a Receptor Improves Long-Term Survival of Mice With Chronic Severe Aortic Regurgitation

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