Medication Summary
Treatment of valvular aortic stenosis is interventional. Medical treatment in aortic stenosis essentially is reserved for patients who have complications of the disorder, such as heart failure, infective endocarditis, hypertension, or arrhythmias.
The medical treatment options are limited in symptomatic patients with aortic stenosis who are not candidates for surgery. In patients with pulmonary congestion, cautious use of digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors might be attempted, whereas beta-blockers might be used if the predominant symptom is angina.
Antibiotic prophylaxis for the prevention of bacterial endocarditis is no longer recommended in patients with valvular aortic stenosis.
Beta-Adrenergic Receptor Blockers
Class Summary
The medical treatment options are limited in symptomatic patients with aortic stenosis who are not candidates for surgery. Beta-blockers may be used if the predominant symptom is angina.
Esmolol (Brevibloc)
Esmolol is an ultra–short-acting that selectively blocks beta1-receptors with little or no effect on beta2-receptor types. It is particularly useful in patients with elevated arterial pressure, especially if surgery is planned.
Metoprolol (Lopressor, Toprol XL)
Metoprolol is a selective beta1-adrenergic receptor blocker that decreases the automaticity of contractions. During intravenous (IV) administration, carefully monitor blood pressure (BP), heart rate, and electrocardiogram (ECG).
Cardiac Glycoside
Class Summary
Cardiac glycosides slow AV nodal conduction primarily by increasing vagal tone. Patients with aortic stenosis who are not candidates for surgery and present with pulmonary congestion may be treated with digoxin. Digoxin can also be used as an inotropic agent to control the ventricular rate in patients with atrial fibrillation.
Digoxin (Lanoxin)
Digoxin enhances myocardial contractility by inhibition of Na+/K+ ATPase, a cell membrane enzyme that extrudes sodium and brings potassium into the myocyte. The resulting increase in intracellular sodium stimulates the sodium-calcium exchanger in the cell membrane, which extrudes sodium and brings in calcium, leading to an increase in intracellular calcium in the sarcoplasmic reticulum of cardiac cells, thereby increasing the contractility of myocytes.
Loop Diuretics
Class Summary
Loop diuretics act on the ascending limb of the loop of Henle, inhibiting the reabsorption of sodium and chloride. Prehospital and emergency department management is focused on acute exacerbations of the symptoms of aortic stenosis. A patient presenting with uncontrolled heart failure should be treated supportively with loop diuretics.
Furosemide (Lasix)
Furosemide increases the excretion of water by interfering with the chloride-binding co-transport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and the distal renal tubule.
Bumetanide (Bumex)
Bumetanide increases the excretion of water by interfering with chloride-binding co-transport system, which, in turn, inhibits sodium, potassium, and chloride reabsorption in the ascending loop of Henle. These effects increase urinary excretion of sodium, chloride, and water, resulting in profound diuresis. Renal vasodilation occurs following administration, renal vascular resistance decreases, and renal blood flow is enhanced.
Angiotensin-converting Enzyme (ace) Inhibitor
Class Summary
These agents are competitive inhibitors of angiotensin-converting enzyme (ACE). They reduce angiotensin II levels, thus decreasing aldosterone secretion.
Captopril (Capoten)
Captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Enalapril (Vasotec)
Enalapril prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion. It helps control blood pressure and proteinuria. Enalapril decreases pulmonary-to-systemic flow ratio in the catheterization laboratory and increases systemic blood flow in patients with relatively low pulmonary vascular resistance.
Opioid Analgesics
Class Summary
Opioid analgesics such as morphine act by binding to opioid receptors on neurons distributed throughout the nervous system and immune system. They can also help patient anxiety, distress, and dyspnea.
Morphine sulfate (MS Contin, Astramorph, Avinza)
Morphine is a drug of choice for analgesia due to reliable and predictable effects and safety profile. A patient presenting with uncontrolled heart failure due to aortic stenosis should be treated supportively with morphine.
-
Stenotic aortic valve (macroscopic appearance).
Tables
Age < 70 years (n=324) |
Age >70 years (n=322) |
Bicuspid AV (50%) Postinflammatory (25%) Degenerative (18%) Unicommissural (3%) Hypoplastic (2%) Indeterminate (2%) |
Degenerative (48%) Bicuspid (27%) Postinflammatory (23%) Hypoplastic (2%) |
Severity |
Mean gradient (mmHg) |
Aortic valve area (cm2) |
Mild |
< 25 |
>1.5 |
Moderate |
25-40 |
1-1.5 |
Severe |
>40 |
< 1 (or < 0.5 cm2/m2 body surface area) |
Critical |
>80 |
< 0.5 |
Indication |
Class |
Symptomatic severe high-gradient AS (Stage D1) |
I |
Asymptomatic severe AS (Stage C2) with and LVEF < 50% |
I |
Severe AS (Stage C or D) undergoing other cardiac surgery |
I |
Asymptomatic, very severe AS (Stage C1, aortic velocity ≥5.0 m/s) and low surgical risk |
IIa |
| Asymptomatic, severe AS (Stage C1) and decreased expercise tolerance or an exercise fall in blood pressure | IIa |
| Symptomatic severe low flow/low gradient AS with reduced LVEF (Stage D2) with a low-dose dobutamine stress study with aortic velocity ≥4.0 m/s with a value are ≤1.0 cm2 at any dobutamine dose | IIa |
| Symptomatic severe low flow/low gradient AS (Stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic and anatomic data support valve obstruction as the most likely cause of symptoms | IIa |
| Moderate AS (Stage B) who are undergoing other cardiac surgery | IIa |
| Asymptomatic severe AS (Stage C1) with rapid disease progression and low surgical risk | IIb |
Intervention Selection |
AHA/ACC (2014) [6] |
ESC/EACTS (2012) [5] |
STS(2013) [56] |
Surgical AVR in patients with low or intermediate surgical risk |
Class I |
Class I |
|
Transcatheter aortic valve replacement (TAVR) for patients who have a prohibitive surgical risk and a predicted post-TAVR survival >12 mo |
Class I |
Class I |
Class I |
TAVR for patients who have high surgical risk |
Class IIa-Reasonable |
Class IIa-Reasonable |
|
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS |
Class III |
Class III |
|
Balloon aortic valvuloplasty (BAV) as a bridge to surgical AVR or TAVR in severely symptomatic patients |
Class IIb-Consider |
Class IIb-Consider |
Class IIa-Reasonable |
BAV as bridge to AVR in hemodynamically unstable patients with severe AS where immediate AVR is not feasible |
Class IIb-Consider |
Class IIa-Reasonable |
|
BAV in severely symptomatic patients where AVR is not an option for symptom relief |
Class IIb-Consider |
||
BAV as a palliative measure when surgery is contraindicated because of severe comorbidities |
Class IIb-Consider |
Class IIb-Consider |
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Guidelines
- 2021 ACC/AHA Valvular Heart Disease Clinical Practice Guidelines
- 2021 ESC/EACTS Management of Valvular Heart Disease (VHD) Clinical Practice Guidelines
- 2017 Multisociety Appropriate Use Criteria
- 2017 AHA/ACC Guidelines for the Management of Patients with Valvular Heart Disease
- 2014 Multisociety Guidelines for the Management of Valvular Heart Disease
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