title: Hemodynamic effects of the angiotensin-converting enzyme inhibitor, ramipril, in patients with mild to moderate aortic stenosis and preserved left ventricular function.
abstract: BACKGROUND
  Angiotensin-converting enzyme (ACE) inhibitor use is presumed to be contraindicated in patients with aortic stenosis (AS). We determined the hemodynamic effects of ACE inhibitors in patients with mild to moderate aortic stenosis (AS) and preserved left ventricular function.
  
  
  METHODS
  Thirteen elderly patients (mean [SD] age = 65 [17] years), with mild to moderate AS (aortic jet velocity 2.5-4.0 m/s), normal left ventricular and renal function, and no clinical coronary artery disease, were enrolled in a single-center, open-label trial comparing the hemodynamic effects at baseline and following titration of ramipril to a maximum dose of 7.5 mg twice daily. Patients were identified from echocardiography laboratory logs. Despite a presumed contraindication to ACE inhibitor use in AS patients, 30% (71 of 235) of patients otherwise meeting inclusion or exclusion criteria were excluded owing to current ACE inhibitor use. Patients were monitored with weekly clinic visits, biweekly laboratory tests, and monthly echocardiograms.
  
  
  RESULTS
  There were no significant changes from baseline to week 8 in echocardiographic parameters, including mean (SD) aortic jet velocity [2.9 (0.4) vs 2.9 (0.4) m/s], calculated aortic transvalvular gradient [18 (6) vs 18 (6) mm Hg], or cardiac output [5.5 (1.2) vs 6.0 (2.1) L/min], or significant changes in blood pressure or heart rate. Early discontinuations were for asymptomatic low blood pressure (one patient) or a reversible creatinine increase of 0.3 mg/dL (one patient).
  
  
  CONCLUSIONS
  Short-term treatment with up to 7.5 mg twice daily of ramipril was well tolerated in patients with mild to moderate AS and preserved left ventricular function. A surprisingly high proportion of patients with documented AS were already receiving ACE inhibitors.
authors.affiliation: Division of Cardiology, University of Washington, Seattle, WA 98195-6422, USA. cardiac@u.washington.edu
authors.forename: Kevin D
authors.initials: KD
authors.lastname: O'Brien
authors.forename: Xue-Qiao
authors.initials: XQ
authors.lastname: Zhao
authors.forename: David M
authors.initials: DM
authors.lastname: Shavelle
authors.forename: Michael T
authors.initials: MT
authors.lastname: Caulfield
authors.forename: Rebecca A
authors.initials: RA
authors.lastname: Letterer
authors.forename: Samir R
authors.initials: SR
authors.lastname: Kapadia
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Probstfield
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Otto
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000494:pharmacology / Q000627:therapeutic use*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D000075202:Contraindications; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D017257:Ramipril / Q000494:pharmacology / Q000627:therapeutic use*; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D017257:Ramipril