Administration of angiotensin-converting enzyme inhibitors is associated with slow progression of mild aortic stenosis in Japanese patients

The Complex Relationship between Hypoxia Signaling, Mitochondrial Dysfunction and Inflammation in Calcific Aortic Valve Disease: Insights from the Molecular Mechanisms to Therapeutic Approaches

Calcific aortic valve stenosis (CAVS) is among the most common causes of cardiovascular mortality in an aging population worldwide. The pathomechanisms of CAVS are such a complex and multifactorial process that researchers are still making progress to understand its physiopathology as well as the complex players involved in CAVS pathogenesis. Currently, there is no successful and effective treatment to prevent or slow down the disease. Surgical and transcatheter valve replacement represents the only option available for treating CAVS. Insufficient oxygen availability (hypoxia) has a critical role in the pathogenesis of almost all CVDs. This process is orchestrated by the hallmark transcription factor, hypoxia-inducible factor 1 alpha subunit (HIF-1α), which plays a pivotal role in regulating various target hypoxic genes and metabolic adaptations. Recent studies have shown a great deal of interest in understanding the contribution of HIF-1α in the pathogenesis of CAVS. However, it is deeply intertwined with other major contributors, including sustained inflammation and mitochondrial impairments, which are attributed primarily to CAVS. The present review aims to cover the latest understanding of the complex interplay effect of hypoxia signaling pathways, mitochondrial dysfunction, and inflammation in CAVS. We propose further hypotheses and interconnections on the complexity of these impacts in a perspective of better understanding the pathophysiology. These interplays will be examined considering recent studies that shall help us better dissect the molecular mechanism to enable the design and development of potential future therapeutic approaches that can prevent or slow down CAVS processes.

Association of renin-angiotensin system inhibitors use with short- and long-term mortality in patients with aortic stenosis: A systematic review and meta-analysis

Purpose

The present study aimed to investigate the association of renin-angiotensin system inhibitors (RASi) with short- and long-term mortality in patients with aortic stenosis (AS).

Methods

A systematic search was performed in PubMed, Embase, and Cochrane library databases for relevant studies published before March 2022. Studies meeting the inclusion criteria were included to assess the effect of RASi on short-term (≤30 days) and long-term (≥1 year) mortality in patients with AS.

Results

A total of 11 studies were included in the meta-analysis. Our results demonstrated that RASi reduced short-term mortality (OR = 0.76, 95% CI 0.63-0.93, p = 0.008) after aortic valve replacement (AVR). Subgroup analysis revealed that RASi was still associated with lower short-term mortality after transcatheter aortic valve replacement (TAVR); however, the association was relatively weak in patients who underwent surgical aortic valve replacement (SAVR). For long-term mortality, the pooled OR was 1.04 (95% CI 0.88-1.24, p = 0.63) after sensitivity analysis in patients who did not undergo AVR. In addition, our study confirmed that RASi significantly reduced long-term mortality (OR = 0.57, 95% CI 0.44-0.74, p < 0.0001) in patients who underwent AVR. Subgroup analysis showed that both TAVR and SAVR groups treated with RASi had lower long-term mortality.

Conclusion

Renin-angiotensin system inhibitors did not change long-term mortality in AS patients who did not undergo AVR. However, RASi reduced short- and long-term mortality in patients who underwent AVR.

Arterial Hypertension in Aortic Valve Stenosis: A Critical Update

Aortic stenosis (AS) is a very common valve disease and is associated with high mortality once it becomes symptomatic. Arterial hypertension (HT) has a high prevalence among patients with AS leading to worse left ventricle remodeling and faster degeneration of the valve. HT also interferes with the assessment of the severity of AS, leading to an underestimation of the real degree of stenosis. Treatment of HT in AS has not historically been pursued due to the fear of excess reduction in afterload without a possibility of increasing stroke volume due to the fixed aortic valve, but most recent evidence shows that several drugs are safe and effective in reducing BP in patients with HT and AS. RAAS inhibitors and beta-blockers provide benefit in selected populations based on their profile of pharmacokinetics and pharmacodynamics. Different drugs, on the other hand, have proved to be unsafe, such as calcium channel blockers, or simply not easy enough to handle to be recommended in clinical practice, such as PDE5i, MRA or sodium nitroprusside. The present review highlights all available studies on HT and AS to guide antihypertensive treatment.

Safety and efficacy of angiotensin-converting enzyme inhibitors in aortic stenosis: A protocol for systematic review and meta-analysis

BACKGROUND

Although there are many studies showing potential benefit in aortic stenosis (AS) patients taking angiotensin-converting enzyme inhibitors (ACEI), but these studies are subject to significant selection and other biases, making the results challenging to interpret. Furthermore, the evidence on the use of ACEI in AS patients has not been reviewed systematically; we thus conducted this protocol assess the clinical effectiveness and safety of ACEI for patients with AS.

METHODS

The following search terms will be used in PUBMED, Scopus, EMBASE, and Cochrane Library databases on May, 2021, as the search algorithm: (angiotensin-converting enzyme inhibitors) OR (ACEI) AND (aortic stenosis) OR (AS). Two searchers will independently draft and carry out the search strategy, and the third member will further complete it. The studies on cohort study focusing on assessing the efficacy of ACEI on AS patients will be included in our meta-analysis. At least one of the following outcomes should have been measured: left ventricular mass, exercise tolerance, B-type natriuretic peptide, adverse event, functional outcomes, and aortic valve area. All outcomes are pooled on random-effect model. A P value of <.05 is considered to be statistically significant.

RESULTS

The results of this research will be delivered in a peer-reviewed journal.

CONCLUSION

Depending on the previous studies, we assumed that ACEI could possibly improve the clinical symptoms and outcomes of symptomatic AS.

SYSTEMATIC REVIEW REGISTRATION NUMBER

10.17605/OSF.IO/G9KPT.

Current Evidence and Future Perspectives on Pharmacological Treatment of Calcific Aortic Valve Stenosis

Calcific aortic valve stenosis (CAVS), the most common heart valve disease, is characterized by the slow progressive fibro-calcific remodeling of the valve leaflets, leading to progressive obstruction to the blood flow. CAVS is an increasing health care burden and the development of an effective medical treatment is a major medical need. To date, no effective pharmacological therapies have proven to halt or delay its progression to the severe symptomatic stage and aortic valve replacement represents the only available option to improve clinical outcomes and to increase survival. In the present report, the current knowledge and latest advances in the medical management of patients with CAVS are summarized, placing emphasis on lipid-lowering agents, vasoactive drugs, and anti-calcific treatments. In addition, novel potential therapeutic targets recently identified and currently under investigation are reported.

Aortic Stenosis, Aortic Regurgitation and Arterial Hypertension

BACKGROUND

Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.

OBJECTIVE

To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease.

METHODS

We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease.

RESULTS

Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis.

CONCLUSION

Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.

Effects of the coronary artery disease associated LPA and 9p21 loci on risk of aortic valve stenosis

BACKGROUND

Aortic valve stenosis (AVS) and coronary artery disease (CAD) have a significant genetic contribution and commonly co-exist. To compare and contrast genetic determinants of the two diseases, we investigated associations of the LPA and 9p21 loci, i.e. the two strongest CAD risk loci, with risk of AVS.

METHODS

We genotyped the CAD-associated variants at the LPA (rs10455872) and 9p21 loci (rs1333049) in the GeneCAST (Genetics of Calcific Aortic STenosis) Consortium and conducted a meta-analysis for their association with AVS. Cases and controls were stratified by CAD status. External validation of findings was undertaken in five cohorts including 7880 cases and 851,152 controls.

RESULTS

In the meta-analysis including 4651 cases and 8231 controls the CAD-associated allele at the LPA locus was associated with increased risk of AVS (OR 1.37; 95%CI 1.24-1.52, p = 6.9 × 10^-10) with a larger effect size in those without CAD (OR 1.53; 95%CI 1.31-1.79) compared to those with CAD (OR 1.27; 95%CI 1.12-1.45). The CAD-associated allele at 9p21 was associated with a trend towards lower risk of AVS (OR 0.93; 95%CI 0.88-0.99, p = 0.014). External validation confirmed the association of the LPA risk allele with risk of AVS (OR 1.37; 95%CI 1.27-1.47), again with a higher effect size in those without CAD. The small protective effect of the 9p21 CAD risk allele could not be replicated (OR 0.98; 95%CI 0.95-1.02).

CONCLUSIONS

Our study confirms the association of the LPA locus with risk of AVS, with a higher effect in those without concomitant CAD. Overall, 9p21 was not associated with AVS.

Lipoprotein(a) Induces Human Aortic Valve Interstitial Cell Calcification

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Lp(a) significantly increased alkaline phosphatase activity, phosphate and calcium content, and matrix vesicle formation and induced apoptosis and calcification of normal human aortic valve interstitial cells.

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The type of minerals induced by Lp(a) resembles that seen in calcified human aortic valves as shown by Raman spectroscopy.

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Lp(a)-induced calcification of human aortic valve interstitial cells is mediated by activation of MAPK38, GSK3β, and Wnt signaling.

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Inhibition of GSK3β and MAPK38 significantly reduced lipoprotein(a)-induced aortic valve interstitial cell calcification.

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Lp(a)is abundant in calcified aortic valves, and lipoprotein(a) immunoreactivity colocalized with that of oxidized phospholipids.

Lipoprotein(a), or Lp(a), significantly increased alkaline phosphatase activity, release of phosphate, calcium deposition, hydroxyapatite, cell apoptosis, matrix vesicle formation, and phosphorylation of signal transduction proteins; increased expression of chondro-osteogenic mediators; and decreased SOX9 and matrix Gla protein (p < 0.001). Inhibition of MAPK38 and GSK3β significantly reduced Lp(a)-induced calcification of human aortic valve interstitial cells (p < 0.001). There was abundant presence of Lp(a) and E06 immunoreactivity in diseased human aortic valves. The present study demonstrates a causal effect for Lp(a) in aortic valve calcification and suggests that interfering with the Lp(a)pathway could provide a novel therapeutic approach in the management of this debilitating disease.

Drug Therapy for Heart Valve Diseases

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.

Risk Factors for Progression of Degenerative Aortic Valve Disease in the Japanese- The Japanese Aortic Stenosis Study (JASS) Prospective Analysis

BACKGROUND

Because of ethnic difference in the risk of degenerative aortic valve disease (DAVD), risk factors should be clarified in each race to establish prophylactic strategies for severe aortic valve stenosis (AS).

METHODS AND RESULTS

This study prospectively followed 359 Japanese subjects with DAVD and age ≥50 years for 3 years. As both patients with peak aortic transvalvular flow velocity ≥2 m/s and <2 m/s were enrolled, subgroup analysis was also conducted. Most patients were under treatment for their comorbidities. The use of warfarin, but none of the traditional risk factors for atherosclerosis, was related to greater reduction in aortic valve area indexed to body surface area (iAVA). In patients with peak aortic transvalvular flow velocity <2 m/s, the use of an angiotensin-receptor blocker (ARB) was associated with less decrease in iAVA. In patients with peak velocity ≥2 m/s, changes in iAVA were not related to any baseline characteristics, but peak velocity was less increased under treatment with an angiotensin-converting enzyme inhibitor (ACEI).

CONCLUSIONS

In Japanese, the use of warfarin may exacerbate DAVD, and augmented management of atherosclerotic risk factors beyond the recommendations in the current guidelines is unlikely to exert additional benefit. The prescription of ARB for DAVD patients before the development of AS or ACEI after the development of AS may be useful.

A prospective, double-blind, randomized controlled trial of the angiotensin-converting enzyme inhibitor Ramipril In Aortic Stenosis (RIAS trial)

Aims

Angiotensin-converting enzyme (ACE) inhibitors improve left ventricular (LV) remodelling and outcome in heart failure and hypertensive heart disease. They may be similarly beneficial in patients with aortic stenosis (AS), but historical safety concerns have limited their use, and no prospective clinical trials exist.

Methods and results

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 100 patients with moderate or severe asymptomatic AS to examine the physiological effects of ramipril, particularly LV mass (LVM) regression. Subjects were randomized to ramipril 10 mg daily (n = 50) or placebo (n = 50) for 1 year, and underwent cardiac magnetic resonance, echocardiography, and exercise testing at 0, 6, and 12 months, with follow-up data available in 77 patients. There was a modest but progressive reduction in LVM (the primary end point) in the ramipril group vs. the placebo group (mean change −3.9 vs. +4.5 g, respectively, P = 0.0057). There were also trends towards improvements in myocardial physiology: the ramipril group showed preserved tissue Doppler systolic velocity compared with placebo (+0.0 vs. −0.5 cm/s, P = 0.04), and a slower rate of progression of the AS (valve area 0.0 cm² in the ramipril group vs. −0.2 cm² in the placebo arm, P = 0.067). There were no significant differences in major adverse cardiac events.

Conclusion

ACE inhibition leads to a modest, but progressive reduction in LVM in asymptomatic patients with moderate–severe AS compared with placebo, with trends towards improvements in myocardial physiology and slower progression of valvular stenosis. A larger clinical outcome trial to confirm these findings and explore their clinical relevance is required.

Longitudinal strain predicts left ventricular mass regression after aortic valve replacement for severe aortic stenosis and preserved left ventricular function

We explored the influence of global longitudinal strain (GLS) measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR). The study population included 83 patients with severe AS (aortic valve area <1 cm(2)) treated with AVR. Bioprostheses were implanted in 58 patients (69.8 %), and the 25 remaining patients (30.2 %) received mechanical prostheses. Peak systolic longitudinal strain was measured in four-chamber (PLS4ch), two-chamber (PLS2ch), and three-chamber (PLS3ch) views, and global longitudinal strain was obtained by averaging the peak systolic values of the 18 segments. Median follow-up was 66.6 months (interquartile range 49.7-86.3 months). At follow-up, values of PLS4ch, PLS2ch, PLS3ch, and GLS were significantly lower (less negative) in patients who did not show left ventricular (LV) mass regression (all P < 0.001). Baseline global strain was the strongest predictor of lack of LVMR (odds ratio 3.5 (95 % confidence interval 3.0-4.9), P < 0.001), and GLS value ≥-9.9 % predicted lack of LVMR with 95 % sensitivity and 87 % specificity (P < 0.001). Other multivariable predictors were the preoperative LV mass value (cutoff value ≥147 g/m(2), P < 0.001), baseline effective orifice area index (cutoff ≤0.35 cm(2)/m(2), P = 0.01), and baseline mean gradient (cutoff ≥58 mmHg, P = 0.01). Finally, we failed to find interactions between GLS and other significant parameters (all P < 0.05). Global longitudinal strain accurately predicts LV mass regression in patients with pure AS undergoing AVR. Our findings must be confirmed by further larger studies.

Aortic valve stenosis and arterial hypertension: a synopsis in 2013

Systemic hypertension and aortic valve stenosis (AVS) are both age-related diseases. The pathophysiology of AVS shares some similarities with essential hypertension, which might be the link between the two diseases. Although AS is usually related with low blood pressure levels, approximately one third of patients with severe AS suffer from arterial hypertension, a percentage that can increase up to 50 % according some studies. This review will summarize various aspects regarding the prevalence the pathophysiology and the natural history of those two diseases that seems to be linked, as well as the effect of blood pressure and antihypertensive treatment on various echocardiographic parameters in patients with AVS.

Aortic valvular heart disease: Is there a place for angiotensin-converting-enzyme inhibitors?

Aortic valve disease (AVD) is the most common form of valvular heart disease in the western world. The only proven therapy for severe AVD is open aortic valve replacement, with trans-catheter aortic valve implantation emerging as a promising modality to treat severe aortic stenosis in a selected group of patients. AVD has a long asymptomatic phase with symptoms occurring late in the disease and once symptoms develop, prognosis is poor. There is a growing appreciation that aortic valvular heart disease incorporates a disease process that extends beyond the valve itself leading to an aortic valvular 'heart' disease. The renin-angiotensin system is known to modulate adverse left ventricular remodeling and myocardial fibrosis, which could be caused by increased load caused by the AVD. In this review, the authors explore evidence that suggest that drugs that target the renin-angiotensin system may have a potential therapeutic role in AVD.