Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-2 receptor blockers (ARBs) are used extensively in the treatment of arterial hypertension. There is a widespread belief that these drugs are contraindicated in patients with underlying aortic stenosis due to their vasodilatory effect, which could result in hypotension and syncope. Nonetheless, these drugs may significantly benefit such patients with their proven cardioprotective benefits and positive effects on left ventricular remodelling. Despite widespread concerns about their safety, the currently available studies do not report any significant side effects. Оn the contrary, they find improved survival rates, a reduction in adverse cardiovascular events, and a reduction in symptoms.
Further clinical studies and trials are necessary to assess the safety of ACEIs in patients with hypertension and underlying aortic stenosis and their effects on cardiac function and survival.
Ancona R., Pinto S. Epidemiology of aortic valve stenosis (AS) and of aortic valve incompetence (AI): is the prevalence of AS/AI similar in different parts of the world?. e-Journal of Cardiology Practice. Vol. 18, N° 10 - 12 Feb 2020
Osnabrugge RL, Mylotte D, Head SJ, Van Mieghem NM, Nkomo VT, LeReun CM, Bogers AJ, Piazza N, Kappetein AP. Aortic stenosis in the elderly: disease prevalence and number of candidates for transcatheter aortic valve replacement: a meta-analysis and modeling study. J Am Coll Cardiol. 2013 Sep 10;62(11):1002-12. doi: 10.1016/j.jacc.2013.05.015. Epub 2013 May 30. PMID: 23727214.
Liakos C, Grassos C, Papadopoulos D, Dimitriadis K, Tsioufis C, Tousoulis D. Arterial hypertension and aortic valve stenosis: Shedding light on a common “liaison”, Hellenic Journal of Cardiology. 2017;58(4):261-266.
Herman LL, Padala SA, Ahmed I, et al. Angiotensin Converting Enzyme Inhibitors (ACEI) [Updated 2022 Jul 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431051/
Laurent D. ACE inhibitors in aortic stenosis: no fear just hope, European Heart Journal - Cardiovascular Imaging. 2015;16(8):828–830.
Xu C, Xu J, MM, Yang J, MM Safety and efficacy of angiotensin-converting enzyme inhibitors in aortic stenosis: A protocol for systematic review and meta-analysis. Medicine. 2021;100(15):e25537 doi: 10.1097/MD.0000000000025537
Dalsgaard M, Iversen K, Kjaergaard J, et al. Short-term hemodynamic effect of angiotensin-converting enzyme inhibition in patients with severe aortic stenosis: a placebo-controlled, randomized study. Am Heart J. 2014;167(2):226-34. doi: 10.1016/j.ahj.2013.11.002. Epub 2013 Nov 9. PMID: 24439984.
Kisheva A, Yotov Y, Angelov A, Penev A. Upstream therapy in atrial fibrillation. Heart-Lung (Varna). 2011;17(3-4):3-13.
Cleland JG, Erhardt L, Murray G, et al. Effect of ramipril on morbidity and mode of death among survivors of acute myocardial infarction with clinical evidence of heart failure. A report from the AIRE Study Investigators. Eur Heart J. 1997;18(1):41-51. PMID: 9049514.
Kang TS, Park S. Antihypertensive Treatment in Severe Aortic Stenosis. J Cardiovasc Imaging. 2018;26(2):45-53. doi: 10.4250/jcvi.2018.26.e9. Epub 2018 Jun 22. PMID: 29971263; PMCID: PMC6024830.
Bull, S, Loudon M, Francis J. A prospective, double-blind, randomized controlled trial of the angiotensin-converting enzyme inhibitor Ramipril In Aortic Stenosis (RIAS trial) - European Heart Journal – Cardiovascular Imaging, March 21, 2015, doi:10.1093/ehjci/jev043
Goel SS, Kleiman NS, Zoghbi WA, Reardon MJ, Kapadia SR. Renin-Angiotensin System Blockade in Aortic Stenosis: Implications Before and After Aortic Valve Replacement. J Am Heart Assoc. 2020 Sep 15;9(18):e016911. doi: 10.1161/JAHA.120.016911. Epub 2020 Sep 6. PMID: 32893727; PMCID: PMC7727008.
Lund O, Knud E. Cardiac Pathology After Isolated Valve Replacement for Aortic Stenosis in Relation to Preoperative Patient Status: Early and Late Autopsy Findings. Larsen Pages 263-270 | 18 Jan 1989 https://doi.org/10.3109/14017438909106006
Peychev Y, Georgiev S, Panayotov P, et al. Preoperative permanent atrial fibrillation and late survival after surgical, primary aortic valve replacement in patients with isolated, hemodynamically significant, calcified, pure aortic valve stenosis, without coronary artery disease. Bulgarian Cardiology. 2015;21(3):
Dahl JS, Videbaek L, Poulsen MK, et al. Effect of candesartan treatment on left ventricular remodeling after aortic valve replacement for aortic stenosis. Am J Cardiol. 2010;106(5):713-9. doi: 10.1016/j.amjcard.2010.04.028. Epub 2010 Jul 23. PMID: 20723651.
Valkov V, Kalchev D, Kostadinov A, et al. Durability of biological prostheses used for management of degenerative aortic stenosis – TAVR vs. SAVR. J of IMAB. 2018;24(2):2055-2057. DOI: 10.5272/jimab.2018242.2055
Ochiai T, Saito S, Yamanaka F, et al. Renin-angiotensin system blockade therapy after transcatheter aortic valve implantation. Heart. 2018;104(8):644-651. doi: 10.1136/heartjnl-2017-311738. Epub 2017 Oct 6. PMID: 28986405.
Rodriguez-Gabella T, Catala P, Munoz-Garcia AJ, et al. Renin-angiotensin system inhibition following transcatheter aortic valve replacement. J Am Coll Cardiol. 2019;74:631–641.
Slavov M, Panayotova D, Peychev Y, et al. Three-year results from the surgical treatment of diseases of the aortic valve and aortic root. Scripta Scientifica Medica. 2013;45(4):50-55.
Routledge H. ACE inhibition in aortic stenosis: Dangerous medicine or golden opportunity? Journal of Human Hypertension. 2001;15(10):659-67 DOI:10.1038/sj.jhh.1001260
Martínez Sánchez C, Henne O, Arceo A, et al. Efectos hemodinámicos del captopril oral en pacientes con estenosis aórtica crítica [Hemodynamic effects of oral captopril in patients with critical aortic stenosis]. Arch Inst Cardiol Mex. 1996 Jul-Aug;66(4):322-30. Spanish. PMID: 8984953.
Friedrich SP, Lorell BH, Rousseau MF, et al. Intracardiac angiotensin-converting enzyme inhibition improves diastolic function in patients with left ventricular hypertrophy due to aortic stenosis. Circulation. 1994;90(6):2761-71. doi: 10.1161/01.cir.90.6.2761. PMID: 7994819.
O'Brien KD, Zhao XQ, Shavelle DM, et al. Hemodynamic effects of the angiotensin-converting enzyme inhibitor, ramipril, in patients with mild to moderate aortic stenosis and preserved left ventricular function. J Investig Med. 2004;52(3):185-91. doi: 10.1136/jim-52-03-33. PMID: 15222408.
Chockalingam A, Venkatesan S, Subramaniam T, et al. Symptomatic Cardiac Obstruction-Pilot Study of Enalapril in Aortic Stenosis. Safety and efficacy of angiotensin-converting enzyme inhibitors in symptomatic severe aortic stenosis: Symptomatic Cardiac Obstruction-Pilot Study of Enalapril in Aortic Stenosis (SCOPE-AS). Am Heart J. 2004;147(4):E19. doi: 10.1016/j.ahj.2003.10.017. PMID: 15077102.
Jiménez-Candil J, Bermejo J, et al. Effects of angiotensin converting enzyme inhibitors in hypertensive patients with aortic valve stenosis: a drug withdrawal study. Heart. 2005;91(10):1311-8. doi: 10.1136/hrt.2004.047233. PMID: 16162624; PMCID: PMC1769141.
Email this article (Login required) 
