title: Renin-angiotensin system inhibition is not associated with increased sudden cardiac death, cardiovascular mortality or all-cause mortality in patients with aortic stenosis.
abstract: BACKGROUND
  Renin-angiotensin system inhibition (RASI) is frequently avoided in aortic stenosis (AS) patients because of fear of hypotension. We evaluated if RASI with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) increased mortality in patients with mild to moderate AS.
  
  
  METHODS
  All patients (n=1873) from the Simvastatin and Ezetimibe in Aortic Stenosis study: asymptomatic patients with AS and preserved left ventricular (LV) ejection fraction were included. Risks of sudden cardiac death (SCD), cardiovascular death and all-cause mortality according to RASI treatment were analyzed by multivariable time-varying Cox models and propensity score matched analyses.
  
  
  RESULTS
  769 (41%) patients received RASI. During a median follow-up of 4.3 ± 0.9 years, 678 patients were categorized as having severe AS, 545 underwent aortic valve replacement, 40 SCDs, 103 cardiovascular and 205 all-cause deaths occurred. RASI was not associated with SCD (HR: 1.19 [95%CI: 0.50-2.83], p=0.694), cardiovascular (HR: 1.05 [95%CI: 0.62-1.77], p=0.854) or all-cause mortality (HR: 0.81 [95%CI: 0.55-1.20], p=0.281). This was confirmed in propensity matched analysis (all p>0.05). In separate analyses, RASI was associated with larger reduction in systolic blood pressure (p=0.001) and less progression of LV mass (p=0.040).
  
  
  CONCLUSIONS
  RASI was not associated with SCD, cardiovascular or all-cause mortality in asymptomatic AS patients. However, RASI was associated with a potentially beneficial decrease in blood pressure and reduced LV mass progression.
authors.affiliation: Department of Medicine, Weill Cornell Medical College, NY, USA; Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark. Electronic address: casperbang@hotmail.com.
authors.forename: Casper N
authors.initials: CN
authors.lastname: Bang
authors.affiliation: Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Anders M
authors.initials: AM
authors.lastname: Greve
authors.affiliation: Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Køber
authors.affiliation: Department of Cardiology, Oslo University Hospital, Norway.
authors.forename: Anne B
authors.initials: AB
authors.lastname: Rossebø
authors.affiliation: Department of Cardiology, Manchester Academic Health Sciences Centre, Manchester, United Kingdom.
authors.forename: Simon
authors.initials: S
authors.lastname: Ray
authors.affiliation: Institution of Public Health and Clinical Medicine, Umeå University, Medicine Skellefteå, Sweden.
authors.forename: Kurt
authors.initials: K
authors.lastname: Boman
authors.affiliation: Department of Cardiology, Universitätsklinikum Rostock, Germany.
authors.forename: Christoph A
authors.initials: CA
authors.lastname: Nienaber
authors.affiliation: Department of Medicine, Weill Cornell Medical College, NY, USA.
authors.forename: Richard B
authors.initials: RB
authors.lastname: Devereux
authors.affiliation: Department of Medicine, Weill Cornell Medical College, NY, USA; Department of Cardiology, Glostrup University Hospital, Copenhagen Denmark.
authors.forename: Kristian
authors.initials: K
authors.lastname: Wachtell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000494:pharmacology / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000494:pharmacology / Q000627:therapeutic use*; D001024:Aortic Valve Stenosis / Q000188:drug therapy* / Q000401:mortality*; D002318:Cardiovascular Diseases / Q000188:drug therapy; D016757:Death, Sudden, Cardiac; D004311:Double-Blind Method; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D012084:Renin-Angiotensin System / Q000187:drug effects / Q000502:physiology*
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: Angiotensin receptor blocker; Angiotensin-converting enzyme inhibitor; Aortic stenosis; Hypertension; Mortality; Renin–angiotensin system inhibition