Why deny ACE inhibitors to patients with aortic stenosis?

Autor: Ahmed R Abdul-Hamid, Niall L T Cox, Graham P Mulley
Rok vydání: 1998
Předmět:
Zdroj: The Lancet. 352:111-112
ISSN: 0140-6736
DOI: 10.1016/s0140-6736(98)85016-2
Popis: Angiotensin-converting enzyme (ACE) inhibitors benefit patients with chronic heart failure, heart failure after myocardial infarction, hypertension, and diabetic nephropathy. However, most doctors do not use them in patients with aortic stenosis. We investigated current recommendations for the use of ACE inhibitors in patients with aortic stenosis. In the UK, two commonly used prescribing guides—the British National Formulary and Mims Monthly Index of Medical Specialities—state that ACE inhibitors are contraindicated in patients with aortic stenosis. Most UK data sheets for ACE inhibitors list aortic stenosis under “Precautions” but phrase this in the form of a contraindication “. . . should not be used in aortic stenosis . . .”. In the US, the captopril data sheet lists valvular stenosis under “General Precautions” and advises: “There is concern, on theoretical grounds, that patients with aortic stenosis might be at particular risk of decreased coronary perfusion when treated with vasodilators . . .”. We contacted medical directors of pharmaceutical companies producing ACE inhibitors. Some, but not all, were concerned that patients with aortic stenosis were at particular risk of hypotensive reactions with ACE inhibitors. Most stated that aortic stenosis produces a fixed obstruction to left ventricular outflow so that when vasodilation occurs, cardiac output cannot be increased and hypotension ensues. We did a Medline-based literature search and wrote to the Committee on Safety of Medicines in the United Kingdom and medical advisors of pharmaceutical companies producing ACE inhibitors. We found no randomised controlled trials of ACE-inhibitor treatment in patients with aortic stenosis, nor were there any case reports of hypotensive reactions. There are a few studies which evaluate effects of ACE inhibitors in people with aortic stenosis. There is more research in animals evaluating the relation between the renin-angiotensin system and left ventricular hypertrophy. Rats studied had experimentallyinduced stenosis of the ascending aorta distal to the coronary arteries and so do not exactly simulate most clinical aortic stenosis. Two clinical series (table) showed no evidence of severe first-dose hypotension in patients with aortic stenosis treated with captopril. This suggests that patients with aortic stenosis are able to increase cardiac output in response to vasodilation. Martinez-Sanchez et al treated 22 patients with aortic stenosis; seven had heart failure. There was a small fall in systolic blood pressure but there were no clinically apparent detrimental effects. Mean cardiac output (CO) increased by 41% in those with heart failure; there was a 46% rise in CO (p=0·04). Grace et al treated eight patients
Databáze: OpenAIRE
Externí odkaz:
Nepřihlášeným uživatelům se plný text nezobrazuje