The Impact of Renin-Angiotensin-Aldosterone System Blockade on Heart Failure Outcomes and Mortality in Patients Identified to Have Aortic Regurgitation

Chemogenetic ablation and regeneration of arterial valve in zebrafish

Aortic valve diseases are prevalent and severe cardiovascular conditions with limited treatment options beyond surgical intervention. The ability to regenerate aortic valves would revolutionize the management of these diseases. Utilizing the zebrafish model, which possesses remarkable regenerative capacities, we developed a chemogenetic arterial valve ablation model using a zebrafish-codon optimized nitroreductase. We found that arterial valve ablation led to blood regurgitation and impaired cardiac function, which are commonly associated with aortic valve diseases. Following ablation, zebrafish arterial valve could fully regenerate and restore valvular and cardiac function. Moreover, suppression of blood flow significantly impedes valve regeneration, indicating the importance of hemodynamic forces in this process. Our research has successfully established a robust aortic valve injury model to study the cellular and molecular mechanisms underlying its regeneration process which will facilitate the development of innovative therapeutic strategies tailored for aortic valve diseases.

Medical therapy after surgical aortic valve replacement for aortic regurgitation

OBJECTIVES

Current clinical guidelines have no specific recommendations regarding medical therapy after surgical aortic valve replacement in patients with aortic regurgitation (AR). We studied the association between medical therapy with renin-angiotensin system (RAS) inhibitors, statins and β-blockers and long-term major adverse cardiovascular events.

METHODS

All patients undergoing valve replacement due to AR between 2006 and 2017 in Sweden and alive 6 months after discharge were included. Time-dependent multivariable Cox regression models adjusted for age, sex, patient characteristics, comorbidities, other medications and year of surgical aortic valve replacement were used. Primary outcome was a composite of all-cause mortality, myocardial infarction and stroke. Subgroup analyses based on age, sex, heart failure, low ejection fraction, hyperlipidaemia and hypertension were performed.

RESULTS

A total of 2204 patients were included [median follow-up 5.0 years (range 0.0-11.5)]. At baseline, 68% of the patients were dispensed RAS inhibitors, 80% β-blockers and 35% statins. Dispense of RAS inhibitors and β-blockers declined over time, especially during the first year after baseline, while dispense of statins remained stable. Treatment with RAS inhibitors or statins was associated with a reduced risk of the primary outcome [adjusted hazard ratio (aHR) 0.71, 95% confidence interval (CI) 0.57-0.87 and aHR 0.78, 95% CI 0.62-0.99, respectively]. The results were consistent in subgroups based on age, sex and comorbidities. β-Blocker treatment was associated with an increased risk for the primary outcome (aHR 1.35, 95% CI 1.07-1.70).

CONCLUSIONS

The results indicate a potential beneficial association of RAS inhibitors and statins as part of a secondary preventive treatment regime after aortic valve replacement in patients with AR. The role of β-blockers needs to be further investigated.

A Retrospective Study on Drug and Dietary Patterns in Patients With Severe Rheumatic Valvular Heart Disease in Eastern India

Background India has a high prevalence of rheumatic valvular heart diseases. Empirical treatment in rheumatic heart disease curtails morbidity and mortality. Less is known about the drug and dietary management of severe rheumatic heart disease at the pretertiary care level, which forms the building stone in the management of rheumatic heart disease. The present study was carried out to evaluate the drug and dietary patterns of patients with severe rheumatic valvular heart disease at a pretertiary care level, which is the backbone of the management of rheumatic heart disease. Methodology This cross-sectional study was carried out in a tertiary care center in Eastern India between May 2020 and May 2022 across 1,264 study subjects. The drug and dietary patterns of the patients with severe rheumatic valvular heart disease during their index visit to the cardiac department were studied and analyzed. Patients aged less than 18 years; patients with mild or moderate rheumatic valvular heart diseases; patients with coexisting end-stage organ disease (chronic liver disease and chronic kidney disease), malignancy, and sepsis; and patients not willing to participate in the study were excluded. Results Most of the patients were on diuretic therapy, and diuretic therapy was overprescribed across the patients with mitral regurgitation, aortic stenosis, and aortic regurgitation. Most of the patients across each spectrum of rheumatic valvular heart disease were lacking the cornerstone therapy such as beta-blockers in mitral stenosis and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation. The recommended injectable benzathine penicillin prophylaxis was prescribed in a very small number of patients (5%), and most of the patients were on oral penicillin prophylaxis (95%) in spite of its reported high failure rate in prophylaxis. Empirical rationale prescriptions in severe rheumatic valvular heart disease were lacking in the pretertiary care level in Eastern India. Conclusion Each spectrum of severe valvular heart disease was lacking the cornerstone therapy such as beta-blockers in mitral stenosis and ACE inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation along with recommended injectable benzathine penicillin prophylaxis. Diuretics and digoxin were overprescribed across the spectrum of rheumatic heart disease. Improvement of this essential gap in the treatment of severe rheumatic heart disease would bring down morbidity and improve mortality in the future.

Rheumatic Heart Disease: JACC Focus Seminar 2/4

It is a sad reality that although eminently preventable, and despite possessing such knowledge for >70 years, rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and early mortality in young people worldwide. A disease of the poor, RHD is one of the most neglected diseases. Several challenges are unique to the acute rheumatic fever/RHD continuum and contribute to its persistence, including its sequestration among the poorest, its protracted natural history, the erratic availability of penicillin, and the lack of a concerted effort in endemic regions. However, there is cause for optimism following a resurgence in scientific interest over the last 15 years. This review presents the latest advancements in epidemiology, diagnosis, and management. It also discusses pressing research questions on disease pathophysiology, the barriers to implementation of effective management strategies, and pragmatic policy solutions required for translation of current knowledge into meaningful action.

Predictors of heart failure and all-cause mortality in asymptomatic patients with moderate and severe aortic regurgitation

BACKGROUND

Class I indications for aortic valve replacement (AVR) for severe chronic aortic regurgitation (AR) include AR attributable symptoms or left ventricular (LV) ejection fraction <50%. As noninvasive estimates of elevated LV filling pressures (LVFP's) have been noted to predict heart failure (HF) readmission and all-cause mortality (ACM) in HF patients, we hypothesize that elevated LVFP's may also be independent predictors of HF and ACM in chronic AR.

METHODS

We developed a single center patient database of moderate or greater AR diagnoses between 2003 and 2008 and followed each patient through January 2013. We included patients with >30 days follow-up with interpretable Doppler-echocardiograms. We recorded demographic variables, EuroScore II, incident HF and ACM, and Doppler-echo variables of LV size, systolic and diastolic function.

RESULTS

Patients with severe AR (105 patients) and moderate AR (201 patients) had similar EuroScore II values and similar incident HF and ACM. For the 180 patients who developed HF, effective arterial elastance (aHR = 1.70 (1.01-2.83), p = .041), LV end-diastolic dimension (aHR = 1.83, (1.11-3.03), p = .0176), E/e' (aHR = 3.04, (1.83-5.05), p < .0001), eccentric hypertrophy (EH) (aHR = 2.39, (1.62-5.12), p = .0004), and tricuspid regurgitation (TR) velocity (aHR = 5.75, (3.70-10.36), p < .0001) were independent predictors. For the 118 patients with ACM, EH (aHR = 1.73, (1.02-3.28), p = .0414), systolic blood pressure (aHR = .58, (.33-.95), p = .0301), left atrial volume index (aHR = 1.82, (1.06-3.06), p = .0293), E/e' (aHR = 1.83, (1.07-3.08), p = .0280), and TR velocity (aHR = 4.14, (2.22-6.49), p < .0001) were independent predictors.

CONCLUSIONS

Elevated TR velocity and EH were strong markers of HF and ACM in patients with asymptomatic severe AR and in moderate AR.

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Care of the patient after valve intervention

This review aims to outline the current evidence base and guidance for care of patients post-valve intervention. Careful follow-up, optimisation of medical therapy, antithrombotics, reduction of cardiovascular risk factors and patient education can help improve patient outcomes and quality of life. Those with mechanical valves should receive lifelong anticoagulation with a vitamin K antagonist but in certain circumstances may benefit from additional antiplatelet therapy. Patients with surgical bioprosthetic valves, valve repairs and transcatheter aortic valve implantation also benefit from antithrombotic therapy. Additionally, guideline-directed medical therapy for coexistent heart failure should be optimised. Cardiovascular risk factors such as hyperlipidaemia, hypertension and diabetes should be treated in the same way as those without valve intervention. Patients should also be encouraged to exercise regularly, eat healthily and maintain a healthy weight. Currently, there is not enough evidence to support routine cardiac rehabilitation in individuals post-valve surgery or intervention but this may be considered on a case-by-case basis. Women of childbearing age should be counselled regarding future pregnancy and the optimal management of their valve disease in this context. Patients should be educated regarding meticulous oral health, be encouraged to see their dentist regularly and antibiotics should be considered for high-risk dental procedures. Evidence shows that patients post-valve intervention or surgery are best treated in a dedicated valve clinic where they can undergo clinical review and surveillance echocardiography, be provided with heart valve education and have access to the multidisciplinary valve team if needed.

Impact of renin-angiotensin system inhibitors on long-term clinical outcomes of patients with rheumatic heart disease

AIMS

Rheumatic heart disease (RHD) remains a major global health problem. Renin-angiotensin-aldosterone system inhibitors (RAASi) are commonly administered in the treatment of cardiovascular disease, but its role in RHD patients is still limited. We performed a retrospective study to determine the effect of RAASi on long-term outcomes for RHD patients.

METHODS AND RESULTS

A 1:1 propensity score matching was implemented to balance baseline characteristics between groups RAASi and non-RAASi. Cox proportional hazards regression model was used to investigate the associations of RAASi with the risks of all-cause mortality, cardiovascular death (CVD), and cerebrovascular death. Binary logistic regression analysis was used to evaluate the associations of RAASi with the risks of 1, 3, and 5 year heart failure (HF) rehospitalization, new-onset atrial fibrillation (AF), and new-onset stroke. A total of 734 RHD patients were enrolled as study participants; nearly half of these participants had combined valve damage (54.4%), worse New York Heart Association functional class status (III and IV, 55.2%), surgical treatment (54.2%), and AF (65.0%). After propensity score matching, 514 RHD patients were finally analysed. RAASi treatment was associated with decreased risks of all-cause mortality [adjusted hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.37-0.73, P < 0.001], CVD (adjusted HR = 0.48, 95% CI: 0.30-0.76, P = 0.002), and cerebrovascular death (adjusted HR = 0.22, 95% CI: 0.08-0.60, P = 0.003). Further subgroup analysis showed that RAASi treatment was associated with decreased risks of all-cause mortality (adjusted HR = 0.50, 95% CI: 0.31-0.79, P = 0.004), CVD (adjusted HR = 0.48, 95% CI: 0.25-0.91, P = 0.025), and cerebrovascular death (adjusted HR = 0.19, 95% CI: 0.05-0.65, P = 0.008) in RHD patients without surgical treatment, and better effect was observed in RHD patients with surgical treatment on the risks of all-cause mortality (adjusted HR = 0.47, 95% CI: 0.26-0.85, P = 0.012) and CVD (adjusted HR = 0.43, 95% CI: 0.21-0.90, P = 0.024) except cerebrovascular death (adjusted HR = 0.52, 95% CI: 0.08-3.36, P = 0.491). RAASi treatment was associated with decreased HF rehospitalization risk of 1 year [adjusted odds ratio (OR) = 0.38, 95% CI: 0.23-0.61, P < 0.001], 3 year (adjusted OR = 0.43, 95% CI: 0.28-0.68, P < 0.001), and 5 year (adjusted OR = 0.48, 95% CI: 0.30-0.77, P = 0.002) as well as new-onset AF risk (adjusted OR = 0.38, 95% CI: 0.21-0.68, P = 0.001). RAASi treatment had nothing to do with new-onset stroke risk (adjusted OR = 0.80, 95% CI: 0.47-1.38, P = 0.428).

CONCLUSION

Renin-angiotensin-aldosterone system inhibitor treatment was significantly associated with decreased risks of mortality, HF rehospitalization, and new-onset AF in RHD patients in median 5.9 year follow-up.

Optimal Management of Chronic Severe Aortic Regurgitation - How to Determine Cutoff Values for Surgical Intervention?

Aortic regurgitation (AR) is a common valvular heart disease, but the optimal timing of surgical intervention remains controversial. In the natural history of chronic severe AR, sudden death is rare, and the annual mortality rate is comparatively low. Considering the hemodynamic features of combined volume and pressure overload and long-term compensation in patients with chronic AR, symptoms related to AR do not frequently occur. Therefore, the progression of left ventricular (LV) dysfunction is a key factor in determining the timing of surgical intervention in patients with severe chronic AR. In addition to symptoms, an ejection fraction <50% and an LV endsystolic diameter (LVESD) >45 mm are appropriate cutoff values for surgical intervention in Japanese patients, whereas LV end-diastolic diameter is not a good indicator. An LVESD index of 25 mm/m²is controversial, because adjusting for body size may cause overcorrection in Japanese patients who have a small body size compared with Westerners. Accumulation of data from the Japanese population is indispensable for establishing guidelines on optimal management of patients with chronic AR.

The advantages, pitfalls and limitations of guideline-directed medical therapy in patients with valvular heart disease

Heart failure is an inevitable end-stage consequence of significant valvular heart disease (VHD) that is left untreated and increasingly encountered in an ageing society. Recent advances in transcatheter procedures and improved outcomes after valve surgery mean that intervention can (and should) be considered in all patients - even the elderly and those with multiple comorbidities - at earlier stages of the natural history of primary VHD, before the onset of irreversible left ventricular dysfunction (and frequently before the onset of symptoms). All patients with known VHD should be monitored carefully in the setting of a heart valve clinic and those who meet guideline criteria for surgical or transcatheter intervention referred for intervention without delay. High quality evidence for the use of medical therapy in VHD is limited and achieving target doses in an elderly and comorbid population frequently challenging. Furthermore, determining whether the valve or ventricle is the principal disease driver is crucial (although the distinction is not always binary, and often unclear). Guideline-directed medical therapy remains the mainstay of treatment for secondary mitral regurgitation - although up to 50% of patients may fail to respond and should be considered for cardiac resynchronization, transcatheter or surgical valve intervention. Early and definitive management strategies are essential and should be overseen by a specialist Heart Team that includes a Heart Failure specialist. In this article, we provide an evidence-based summary of approaches to the medical treatment of VHD and clinical guidance for the best management of patients in situations where high quality evidence is lacking.

Current trends in aortic valve-preserving surgery

The natural history of aortic regurgitation is not as benign as once believed, even in asymptomatic patients with preserved left ventricular function. Aortic valve surgery can prolong survival in these patients. However, both mechanical and biological aortic valve replacement have major disadvantages, especially in young patients. Aortic valve-preserving surgery has attracted a great deal of attention because it has a significant survival benefit over replacement. Nonetheless, aortic valve-preserving surgery has not been widely adopted due to the complexity of the technique and assessment (i.e., long learning curve). With recent technical and theoretical advances, aortic valve-preserving surgery has increasingly been performed with better outcomes, and therefore earlier surgical intervention in cases of aortic regurgitation has been considered. Recent advances in aortic valve-preserving surgery include repair-oriented classification of the etiology of aortic regurgitation, objective assessment of the cusp configuration (i.e., effective height and geometric height), use of aortic annuloplasty, introduction of two reproducible valve-sparing root replacement procedures (i.e., aortic valve reimplantation and aortic root remodeling techniques), standardization of aortic valve-preserving surgery, and assessment of cusp configuration with aortoscopy. A number of prospective multicenter studies are currently underway and will clarify the role of aortic valve-preserving surgery in the treatment of aortic regurgitation in the near future.

Contemporary Diagnosis and Management of Rheumatic Heart Disease: Implications for Closing the Gap: A Scientific Statement From the American Heart Association

The global burden of rheumatic heart disease continues to be significant although it is largely limited to poor and marginalized populations. In most endemic regions, affected patients present with heart failure. This statement will seek to examine the current state-of-the-art recommendations and to identify gaps in diagnosis and treatment globally that can inform strategies for reducing disease burden. Echocardiography screening based on World Heart Federation echocardiographic criteria holds promise to identify patients earlier, when prophylaxis is more likely to be effective; however, several important questions need to be answered before this can translate into public policy. Population-based registries effectively enable optimal care and secondary penicillin prophylaxis within available resources. Benzathine penicillin injections remain the cornerstone of secondary prevention. Challenges with penicillin procurement and concern with adverse reactions in patients with advanced disease remain important issues. Heart failure management, prevention, early diagnosis and treatment of endocarditis, oral anticoagulation for atrial fibrillation, and prosthetic valves are vital therapeutic adjuncts. Management of health of women with unoperated and operated rheumatic heart disease before, during, and after pregnancy is a significant challenge that requires a multidisciplinary team effort. Patients with isolated mitral stenosis often benefit from percutaneous balloon mitral valvuloplasty. Timely heart valve surgery can mitigate the progression to heart failure, disability, and death. Valve repair is preferable over replacement for rheumatic mitral regurgitation but is not available to the vast majority of patients in endemic regions. This body of work forms a foundation on which a companion document on advocacy for rheumatic heart disease has been developed. Ultimately, the combination of expanded treatment options, research, and advocacy built on existing knowledge and science provides the best opportunity to address the burden of rheumatic heart disease.

Update on Prevention and Management of Rheumatic Heart Disease

Rheumatic heart disease (RHD) remains the most common cause of cardiovascular morbidity and mortality globally in children and young adults. This article focuses on prevention and management of RHD. Pregnancy can unmask previously undiagnosed RHD and poses high risk for mother and fetus. Management of anticoagulation is important. Definitive catheter and surgical intervention are the only treatments that can improve outcomes of patients with moderate or severe RHD. Access to intervention remains very limited in RHD endemic regions. There are ongoing global efforts to increase awareness, public policy adoption, and greater access to treatment.

Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use prior to medical intensive care unit admission and in-hospital mortality: propensity score-matched cohort study

BACKGROUND

The aim of this study was to evaluate whether angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) use prior to medical intensive care unit (ICU) admission was associated with in-hospital mortality and length of ICU stay.

METHODS

A propensity score-matched cohort study was conducted at single center from 2004 to 2016. We included all adult patients who were admitted to the ICU due to internal medicine-related conditions. We compared patients who had used ACEIs/ARBs prior to ICU admission to patients who had not. Our primary and secondary outcomes were in-hospital mortality and length of stay among survivors and the deceased. Propensity scores were calculated via logistic regression analyses with forward stepwise selection. An odds ratio (OR) for primary outcome was calculated via logistic regression. Sensitivity analyses were performed using conditional logistic regression models including different sets of covariates to confirm our results.

RESULTS

3095 patients were admitted to the ICU. Overall, 693 patients were identified via matching, 231 of whom had used ACEIs/ARBs and 462 of whom had not. None of the baseline characteristics differed significantly between groups. Among them, 131 (18.9%) died. Those who had used ACEIs/ARBs had a lower rate of mortality (p < 0.01). Length of ICU stay did not differ significantly between those with ACEIs/ARBs and those without among survivors (p = 0.43) and the deceased (p = 0.14). The OR for mortality was 0.51 (95% confidence interval 0.32-0.79). The results of the sensitivity analyses confirmed the results (ORs 0.4 6-0.53; all were statistically significant).

CONCLUSION

Prior ACEI/ARB use may be related to in-hospital mortality among medical ICU patients.

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.

Renin–angiotensin system blockade therapy after transcatheter aortic valve implantation

Objective

The persistence of left ventricular (LV) hypertrophy is associated with poor clinical outcomes after transcatheter aortic valve implantation (TAVI) for aortic stenosis. However, the optimal medical therapy after TAVI remains unknown. We investigated the effect of renin−angiotensin system (RAS) blockade therapy on LV hypertrophy and mortality in patients undergoing TAVI.

Methods

Between October 2013 and April 2016, 1215 patients undergoing TAVI were prospectively enrolled in the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI registry. This cohort was stratified according to the postoperative usage of RAS blockade therapy with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Patients with at least two prescriptions dispensed 180 days apart after TAVI and at least a 6-month follow-up constituted the RAS blockade group (n=371), while those not prescribed any ACE inhibitors or ARBs after TAVI were included in the no RAS blockade group (n=189).

Results

At 6 months postoperatively, the RAS blockade group had significantly greater LV mass index regression than the no RAS blockade group (−9±24% vs −2±25%, p=0.024). Kaplan-Meier analysis revealed a significantly lower cumulative 2-year mortality in the RAS blockade than that in the no RAS blockade group (7.5% vs 12.5%; log-rank test, p=0.031). After adjusting for confounding factors, RAS blockade therapy was associated with significantly lower all-cause mortality (HR, 0.45; 95% CI 0.22 to 0.91; p=0.025).

Conclusions

Postoperative RAS blockade therapy is associated with greater LV mass index regression and reduced all-cause mortality. These data need to be confirmed by a prospective randomised controlled outcome trial.

Current Management of Patients with Severe Aortic Regurgitation

OPINION STATEMENT

Chronic aortic regurgitation can result from various congenital and acquired anomalies and can be associated with proximal aortic disease. As the number of aortic valve procedures is growing, the incidence of post-procedural regurgitation also increases with associated morbidity. Typical evolution is characterized by a clinically silent phase of variable duration followed by a rather rapid decline with high incidence of adverse events. A challenge remains to find the optimal timing for an intervention: Patients are exposed to unnecessary surgical risks if treated prematurely, but peri- and post-operative prognosis is worse when the intervention is performed too late. Clinical evaluation and serial imaging tests can optimize the timing for intervention. Clinical follow-up should try to elucidate associated symptoms, with quantitative measurement of functional capacity as needed. Serial imaging examinations are required to identify sub-clinical left ventricular dysfunction or severe dilatation that should prompt a surgery. At least in selected cases, newer imaging modalities (MRI, 3D echocardiography) and/or biomarkers can help for the management of these patients, and more research is needed to determine if their systematic use can be beneficial. Medical treatment with vasodilators and anti-remodeling drugs can be helpful in some patients but should not replace or delay aortic valve surgery when indicated. Most patients will eventually be treated with surgical aortic valve replacement. Although possible in selected cases, transcatheter aortic valve replacement is not commonly used for patients with pure aortic regurgitation. For patients with prior aortic valve replacement and aortic regurgitation (paravalvular or intravalvular), emerging percutaneous approaches can be considered when available, especially for those at high surgical risk.

Delayed protective effect of telmisartan on lung ischemia/reperfusion injury in valve replacement operations

The present study aimed to investigate the delayed protective effect of telmisartan on lung ischemic/reperfusion injury in patients undergoing heart valve replacement operations. In total, 180 patients diagnosed with rheumatic valve diseases were randomly divided into the telmisartan (T), captopril (C) and placebo (P) groups. In the telmisartan group, the patients were pretreated with telmisartan (1 mg/kg/day), at the time period 96-48 h before the operation, whereas in the C group, the patients were treated with captopril (1 mg/kg/day) at the time period 96-48 h prior to the operation control group. Each drug treatment group included a corresponding placebo treatment. The variables pulmonary vascular resistance (PVR) and A-aDO₂ were measured prior to CPB and at 1, 3, 6 and 12 h after CPB. Pulmonary neutrophil (PMN) count in the left and right atrium blood as well as SOD malondialdehyde (MDA), NO, angiotensin II (AngII) value in the left atrium blood, were measured 30 min prior to and after CPB. The PVR parameters of the telmisartan and captopril groups were significantly lower than those of the placebo group (P<0.05). The A-aDO₂ values in the telmisartan and captopril groups were significantly lower than those in the placebo group at 1, 3 and 6 h following CPB treatment. The difference between the right and left atrium blood PMN was significantly lower in the telmisartan and captopril intervention groups compared to that in the placebo group 30 min following CPB treatment. The left atrium blood SOD and NO values were significantly higher, whereas the MDA value was significantly lower in the telmisartan group compared to the control group 30 min following CPB treatment. As for AngII, there was no difference between the C and T groups, compared with the P group. In the two groups 30 min after treatment with CPB, 24 patients experienced varying degrees of cough, with the telmisartan group showing a significant difference (P<0.05). The hospitalization time was compared in the three groups of patients and it was found to be significantly shorter in the telmisartan group than the captopril and placebo groups (P<0.05). In conclusion, it was found that for the time period 96-48 h before heart valve replacement operations telmisartan (1 mg/kg/day) delayed the protective effect on lung ischemia/reperfusion injury in patients with rheumatic valve diseases. The results of the present study indicated that the protective effect may be associated with the increment of endogenetic NO and the enhanced ability against lipid peroxidation.

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.

Both high and low HbA1c predict incident heart failure in type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus is an independent risk factor for heart failure development, but the relationship between incident heart failure and antecedent glycemia has not been evaluated.

METHODS AND RESULTS

The Genetics of Diabetes Audit and Research in Tayside Study study holds data for 8683 individuals with type 2 diabetes mellitus. Dispensed prescribing, hospital admission data, and echocardiography reports were linked to extract incident heart failure cases from December 1998 to August 2011. All available HbA1c measures until heart failure development or end of study were used to model HbA1c time-dependently. Individuals were observed from study enrolment until heart failure development or end of study. Proportional hazard regression calculated heart failure development risk associated with specific HbA1c ranges accounting for comorbidities associated with heart failure, including blood pressure, body mass index, and coronary artery disease. Seven hundred and one individuals with type 2 diabetes mellitus (8%) developed heart failure during follow up (mean 5.5 years, ±2.8 years). Time-updated analysis with longitudinal HbA1c showed that both HbA1c <6% (hazard ratio =1.60; 95% confidence interval, 1.38-1.86; P value <0.0001) and HbA1c >10% (hazard ratio =1.80; 95% confidence interval, 1.60-2.16; P value <0.0001) were independently associated with the risk of heart failure.

CONCLUSIONS

Both high and low HbA1c predicted heart failure development in our cohort, forming a U-shaped relationship.