title: Dual renin-angiotensin system blockade for patients with prosthesis-patient mismatch.
abstract: BACKGROUND
  Patients with prosthesis-patient mismatch (PPM) continue to show some degrees of left ventricular hypertrophy after aortic valve replacement for aortic stenosis. The renin-angiotensin system plays a major role in promoting and sustaining hypertrophy. In a controlled, randomized study, we tested the hypothesis that the combination of angiotensin-converting enzyme inhibitors (ACEi) plus angiotensin II receptor blocker (ARB) can be more effective in decreasing hypertrophy than a largely employed association such as ACEi plus ß-blockers in PPM patients.
  
  
  METHODS
  We enrolled a total of 72 patients with aortic valve replacement and evidence of PPM (effective orifice area <0.85 cm(2)/m(2)) at postoperative echocardiography. At discharge, they were randomly assigned to ramipril plus candesartan (n = 36) or ramipril plus metoprolol (n = 36).
  
  
  RESULTS
  At baseline, age, 24-hour blood pressure, left ventricular measurements, and transprosthetic gradients were similar between the two groups. After 12 months, the extent of 24-hour systolic and diastolic blood pressure decrease was similar between the two groups (-13.3% and 16.3% versus -12.3% and 15.8%, respectively; p = 0.7 and 0.8, respectively). Left ventricular mass index significantly decreased in both groups (ACEi plus ARB 165 ± 19 g/m(2) to 117 ± 17 g/m(2); p < 0.0001; ACEi plus β-blockers 161 ± 15 g/m(2) to 128 ± 20 g/m(2); p < 0.0001). However, patients receiving ACEi plus ARB had a higher decrease of left ventricular mass (-46 ± 15 g/m(2) versus -35 ± 12 g/m(2); p = 0.001) and a lower rate of residual left ventricular hypertrophy (22% versus 47%; p = 0.04).
  
  
  CONCLUSIONS
  This study shows that in patients with PPM, the association ACEi and ARB has a greater antiremodeling effect compared with ACEi and β-blockers, and is independent of blood pressure.
authors.affiliation: Department of Cardiac Surgery, II School of Medicine, University of Rome La Sapienza, Policlinico S. Andrea, Rome, Italy. u2benedetto@libero.it
authors.forename: Umberto
authors.initials: U
authors.lastname: Benedetto
authors.forename: Giovanni
authors.initials: G
authors.lastname: Melina
authors.forename: Simone
authors.initials: S
authors.lastname: Refice
authors.forename: Roberta
authors.initials: R
authors.lastname: di Bartolomeo
authors.forename: Antonino
authors.initials: A
authors.lastname: Roscitano
authors.forename: Emiliano
authors.initials: E
authors.lastname: Angeloni
authors.forename: Riccardo
authors.initials: R
authors.lastname: Sinatra
mesh_terms: D058671:Adrenergic beta-1 Receptor Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D000368:Aged; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000601:surgery*; D001562:Benzimidazoles / Q000008:administration & dosage / Q000627:therapeutic use; D001713:Biphenyl Compounds; D001794:Blood Pressure / Q000187:drug effects; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D008297:Male; D008790:Metoprolol / Q000008:administration & dosage / Q000627:therapeutic use; D011474:Prosthesis Design; D011475:Prosthesis Failure; D017257:Ramipril / Q000008:administration & dosage / Q000627:therapeutic use; D012084:Renin-Angiotensin System / Q000187:drug effects*; D012189:Retrospective Studies; D013777:Tetrazoles / Q000008:administration & dosage / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D058671:Adrenergic beta-1 Receptor Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D001562:Benzimidazoles; D001713:Biphenyl Compounds; D013777:Tetrazoles; D008790:Metoprolol; D017257:Ramipril; C081643:candesartan