Systemic hypertension in patients with severe aortic stenosis: does the severity of hypertension make a difference?

Introduction: The detrimental impact of coexistent systemic hypertension (HTN) on aortic stenosis (AS) progression, left ventricular (LV) remodeling and clinical outcome in patients (pts) with mild or moderate AS was previously demonstrated. It was also suggested that symptoms of AS develop with larger valve area and lower stroke work loss in hypertensive pts. However, data regarding the influence of HTN on clinical status and LV function in pts with severe AS are scarce. We aimed at testing whether there is a further influence of the severity of HTN on clinical status and echocardiographic parameters of LV function, including rotational parameters, in pts with severe AS. Methods: We prospectively studied 127 consecutive pts (65±11 years, 76 men) with severe AS (indexed aortic valve area: AVAi <0.6 cm2 /m2 , 0.39±0.11 cm2 /m2 ) and preserved LVEF (>50%), without coronary artery disease or significant aortic or mitral regurgitation. A detailed history regarding hypertensive status (according to ESC guidelines) was available in all patients. A comprehensive echocardiogram was performed in all, including the assessment of global LV longitudinal strain and torsional deformation parameters by speckle tracking echocardiography. Results: Systemic HTN was found in 76% of pts with severe AS (56% grade 3 HTN). Symptoms were present in most of the included pts (82.7%). Hypertensive pts were older (67 ± 9 vs 58 ± 13 years, p < 0.001), had a larger body mass index and more frequently diabetes mellitus (p = 0.02). Echocardiographic parameters of LV diastolic function (septal e’ and EDT) were more impaired in HTN pts. Despite similar values of AVAi (p = 0.3) transvalvular mean gradients were lower in HTN pts (52 ± 20 vs 66 ± 26 mm Hg, p = 0.002). Compared to pts with grade 1 and 2 HTN, pts with severe HTN had higher NYHA class, larger left atria and more delayed LV untwisting, although AS severity, LV geometry and systolic function parameters were not significantly different between groups (p > 0.1 for all). Conclusions: The prevalence of coexistent HTN in pts with severe AS is high. Patients with severe AS and severe systemic HTN had worse functional status and worse LV diastolic function compared to those with mild/moderate HTN. Further studies are needed to clarify if effective HTN treatment may add prognostic benefit beyond AVR in this setting.

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