Relationship Between Mortality and Use of Statins or RAAS Inhibitors After Aortic Valve Replacement

Introduction

The incidence of aortic stenosis increases with age. In the population of patients older than 65 years, the incidence of severe aortic stenosis is 4.4%. Transcatheter aortic valve replacement has become the standard therapeutic approach for a wide range of patients regardless of surgical risk. The use of statins and RAAS inhibitors (i.e., angiotensin-converting enzyme inhibitors /ACEis/ or angiotensin II type 1 receptor blockers /ARBs; sartans/) in patients who underwent TAVR has shown benefits in small clinical studies. However, data from real clinical practice from a larger number of patients were still missing. 

Study Population

The cited analysis included 9,012 adult patients who underwent TAVR between 2014 and 2018 and survived at least 90 days after discharge from the hospital post-TAVR. Data were obtained from the registry of a commercial health insurance company in the USA. Most of the patients (62%) were older than 80 years, 53% were men, and 84% were white.

After undergoing TAVR, 35% of the patients were prescribed ACEi/ARB (n = 3172) and 52% were prescribed statins (n = 4697). Among those who were given RAAS inhibitors, 69% (n = 2180) had been using this medication before TAVR, and 31% (n = 992) started using it only after the procedure. Among patients who were prescribed statins, 73% (n = 3435) had been using them before surgery, and 27% (n = 1262) started using them only after the procedure. Most continued taking the prescribed drugs even one year after the procedure. 

After TAVR, 24% (n = 679) of the patients discontinued previous RAAS inhibitor treatment and 13% (n = 497) discontinued previous statin treatment. 

Results

For patients with prescribed medication who actually collected the drugs from the pharmacy, significantly lower 3-year mortality was observed compared to those who were not prescribed these medications: for ACEi/ARBs, the hazard ratio [HR] was 0.82 (95% confidence interval [CI] 0.74−0.91; p = 0.0003), and for statins, HR was 0.85 (95% CI 0.77−0.94; p = 0.0018).

Subgroup analysis revealed that the benefit of the medication was not influenced by other factors, and for ACEi/ARBs, it was independent of left ventricular systolic function or type of heart failure. Survival was not influenced by the use of beta-blockers. The only other factor affecting mortality was the use of ACEi/ARBs before TAVR, which was associated with lower morality than the use of these drugs only after the surgery. This was not the case for statins.

Conclusion

Data from a large number of patients after transcatheter aortic valve replacement showed a significant benefit of using ACEis/sartans and statins within 90 days after the procedure in terms of 3-year mortality. 

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Source: Cubeddu R. J., Murphy S. M. E., Asher C. R. et al. Association of ACEI/ARB and statin prescribing patterns with mortality after transcatheter aortic valve replacement (TAVR): findings from real-world claims data. Am Heart J 2022; 258: 27−37, doi: 10.1016/j.ahj.2022.12.012.