Elsevier

The American Journal of Cardiology

Volume 141, 15 February 2021, Pages 62-71
The American Journal of Cardiology

Optimal Medical Therapy Following Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.amjcard.2020.11.010Get rights and content

Highlights

  • Late cardiovascular events are still significant after transcatheter aortic valve implantation.

  • Renin-angiotensin system inhibitor (RASi) treatment following transcatheter aortic valve implantation, but not beta-blocker, was associated with a lower rate of mid-term composite outcome defined as all-cause mortality and rehospitalization for heart failure.

  • Combination therapy with beta-blocker to RASi did not add any significant benefit over RASi alone.

  • These effects were independent of left ventricular ejection fraction and were similar even in patients with reduced left ventricular systolic function.

Limited data exist on optimal medical therapy post-transcatheter aortic valve implantation (TAVI) for late cardiovascular events prevention. We aimed to evaluate the benefits of beta-blocker (BB), renin-angiotensin system inhibitor (RASi), and their combination on outcomes following successful TAVI. In a consecutive cohort of 1,684 patients with severe aortic stenosis undergoing TAVI, the status of BB and RASi treatment at discharge was collected, and patients were classified into 4 groups: no-treatment, BB alone, RASi alone, and combination groups. The primary outcome was a composite of all-cause mortality and rehospitalization for heart failure (HHF) at 2-year. There were 415 (25%), 462 (27%), 349 (21%), and 458 (27%) patients in no-treatment, BB alone, RASi alone, and combination groups, respectively. The primary outcome was lower in RASi alone (21%; adjusted hazard ratio [HR]adj: 0.58; 95% confidence interval [CI]: 0.42 to 0.81) and combination (22%; HRadj: 0.53; 95% CI: 0.39 to 0.72) groups than in no-treatment group (34%) but no significant difference between RASi alone and combination groups (HRadj: 1.14; 95% CI: 0.80 to 1.62). The primary outcome results were maintained in a sensitivity analysis of patients with reduced left ventricular systolic function. Furthermore, RASi treatment was an independent predictor of 2-year all-cause mortality (HRadj: 0.68; 95% CI: 0.51 to 0.90), while that was not observed in BB therapy (HRadj: 0.94; 95% CI: 0.71 to 1.25). In conclusion, post-TAVI treatment with RASi, but not with BB, was associated with lower all-cause mortality and HHF at 2-year. The combination of RASi and BB did not add an incremental reduction in the primary outcome over RASi alone.

Section snippets

Methods

We retrospectively reviewed medical records of consecutive patients with native severe AS who underwent TAVI at Cedars-Sinai Medical center from January 2013 to November 2017 and included in our TAVI database. We excluded patients if they (1) died during the index hospitalization, (2) were discharged against medical advice, (3) were referred to other hospitals or hospice care, (4) had a contraindication for BB or RASi, or (5) if the data of medication at discharge was missing. The remaining

Results

We identified 1756 consecutive patients with native severe AS who underwent TAVI during the study period and excluded 72 patients who met the exclusion criteria. The remaining 1,684 patients constituted our study population, which was categorized based on the status of BB and RASi at discharge as no-treatment group in 415 (25%), BB alone group in 462 (27%), RASi alone group in 349 (21%), and combination group in 458 (27%) patients. The distribution of patients from baseline to 1-year follow-up

Discussion

The main findings of this study are as follows: (1) Compared with patients with no treatment, RASi prescription at discharge was associated with lower composite outcome of all-cause mortality and HHF. This association was not significant for BB; (2) Combination therapy with RASi and BB did not add any significant benefits over RASi alone; (3) These effects were independent of LVEF and were similar even in patients with reduced LV systolic function (Figure 3).

Long-standing AS can lead to

Authors’ Contributions

Danon Kaewkes: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft. Tomoki Ochiai: Conceptualization, Methodology, Writing - Review & Editing. Nir Flint: Conceptualization, Writing - Review & Editing. Vivek Patel: Investigation, Writing - Review & Editing. Sahar Mahani: Investigation, Writing - Review & Editing. Isic Kim: Investigation, Writing - Review & Editing. Dhairya Patel: Writing - Review & Editing. Tracy Salseth: Writing - Review & Editing. Michelle

Disclosures

Dr. Makkar has received grant support from Edwards Lifesciences Corporation; is a consultant for Abbott Vascular, Cordis, and Medtronic, and holds equity in Entourage Medical. Dr. Chakravarty is a consultant, proctor, and speaker for Edwards Lifesciences and Medtronic; he is a consultant for Abbott Lifesciences, and he is a consultant and speaker for Boston Scientific. Other authors have no conflicts of interest to disclose.

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