Heart Failure Pharmacotherapy Across the Transcatheter Aortic Valve Replacement Continuum

Transcatheter aortic valve replacement (TAVR) is an increasingly common treatment option for severe symptomatic aortic stenosis. However, heart failure often persists because of incomplete reversal of myocardial remodeling, fibrosis, and diastolic dysfunction. TAVR corrects valvular afterload but does not resolve the underlying myocardial disease. Guideline-directed medical therapy (GDMT), including renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, mineralocorticoid receptor antagonists, and beta-blockers, has a strong mechanistic rationale and potential clinical benefit, although evidence in TAVR populations remains heterogeneous and is largely observational. Nonetheless, accumulating data support the continuation and early optimization of GDMT in the pre-, peri-, and post-TAVR periods, with the most consistent benefit observed for renin-angiotensin system inhibitors and sodium-glucose cotransporter-2 inhibitors. Key uncertainties remain regarding optimal timing, patient selection, and class-specific effects. This state-of-the-art review integrates current evidence and proposes a framework to guide GDMT use across the TAVR continuum while defining priorities for future randomized trials.