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Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients Undergoing Aortic Valve
Husnain Abid1, Yusuf Khan1, Nazish Khan2
1Midland Metropolitan University Hospital, Sandwell and West Birmingham NHS Trust, Birmingham B66 2QT, UK.
Insights
Preoperative use of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in severe aortic stenosis patients was not linked to increased mortality after valve replacement. While unadjusted data suggested lower mortality, adjusted analysis showed no significant association.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Historically, angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) were contraindicated in severe aortic stenosis (AS) due to theoretical hemodynamic risks.
- Contemporary evidence challenges this, but data on preoperative use and postoperative outcomes after aortic valve replacement remain limited.
- This study investigates the association between preoperative ACEi/ARB use and mortality following transcatheter or surgical aortic valve replacement.
Purpose of the Study:
- To examine the association between preoperative ACEi/ARB use and one-year all-cause mortality in patients undergoing aortic valve replacement (AVR).
- To determine if ACEi/ARB use is associated with increased mortality risk in severe AS patients undergoing AVR.
Main Methods:
- Retrospective cohort study of 198 patients undergoing transcatheter aortic valve replacement (TAVI) or surgical aortic valve replacement (SAVR).
- One-year all-cause mortality was the primary outcome.
- Multivariable logistic regression was used, adjusting for age, sex, hypertension, diabetes, LVEF, and procedure type.
Main Results:
- 80 patients (40%) received ACEi/ARB therapy preoperatively, exhibiting higher rates of hypertension and diabetes.
- Unadjusted one-year mortality was lower in the ACEi/ARB group (7% vs. 19%, p=0.030).
- After multivariable adjustment, this association did not reach statistical significance (adjusted OR 0.33, 95% CI 0.10-1.12, p=0.075), with residual confounding possible.
Conclusions:
- Preoperative ACEi/ARB use was not associated with increased mortality in patients undergoing AVR.
- The observed association with lower unadjusted mortality did not persist after multivariable adjustment.
- These hypothesis-generating findings require confirmation in larger, prospective trials.
Abstract:
Background: Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) were historically considered contraindicated in severe aortic stenosis (AS) due to theoretical haemodynamic risks. Contemporary evidence increasingly challenges this paradigm, yet data on preoperative use and postoperative outcomes remain limited. We examined the association between preoperative ACEi/ARB use and mortality following aortic valve replacement. Methods: We conducted a retrospective cohort study of 198 consecutive patients undergoing transcatheter (TAVI) or surgical aortic valve replacement (SAVR) at a single tertiary centre between May 2020 and March 2025. Complete one-year follow up was available for 185 patients (93%). The primary outcome was one-year all-cause mortality. Multivariable logistic regression adjusted for age, sex, hypertension, diabetes, LVEF, and procedure type. Results: Of 198 patients, 80 (40%) were receiving ACEi/ARB therapy preoperatively. ACEi/ARB users had a higher prevalence of hypertension (82% vs. 53%, p < 0.001) and diabetes (48% vs. 27%, p = 0.005) but similar age, valve area, and ejection fraction. Unadjusted one-year mortality was lower in the ACEi/ARB group (7% vs. 19%; odds ratio [OR] 0.33, 95% CI 0.12-0.91, p = 0.030). After multivariable adjustment for confounders including age, diabetes, and hypertension, the association did not reach statistical significance (adjusted OR 0.33, 95% CI 0.10-1.12, p = 0.075). Among diabetic patients, unadjusted one-year mortality was numerically lower in the ACEi/ARB group (12% vs. 35%, p = 0.038); however, six subgroup comparisons were performed and this result would not survive Bonferroni correction (threshold p < 0.008). This exploratory finding should be interpreted with caution given the small sample size and absence of adjustment for confounders. Conclusions: Preoperative ACEi/ARB use was associated with lower unadjusted one-year mortality, but this association did not reach statistical significance after multivariable adjustment and residual confounding cannot be excluded. ACEi/ARB use was not associated with increased mortality in this cohort. These hypothesis-generating findings from a single-centre observational study require confirmation in adequately powered prospective trials.
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