356Effect of renin-angiotensin system blockade in long term outcomes following transcatheter aortic valve implantation

Abstract

Introduction: Several studies have demonstrated the benefits of transcatheter aortic valve implantation (TAVI) in high‐risk and intermediate‐risk patients, but there is still a gap in the evidence of pharmacological therapies with potential impact in long‐term outcomes. In particular, the presence of fibrosis and myocardial hypertrophy in patients with aortic stenosis has been related to worse prognosis. Therefore, better outcomes may be achieved with the use of strategies improving cardiac remodelling by reversing fibrosis and hypertrophy. In this regard, reninangiotensin system (RAS) blockade has been shown to have a positive impact in remodelling and in major clinical outcomes in alternative scenarios. We aimed to determine the effects of this therapy following successful TAVI procedures. Methods: Patients from 9 institutions with severe aortic stenosis who underwent TAVI between August/2007 and August/2017 were included. All baseline clinical, echocardiographic and procedural data were prospectively recorded in a dedicated database, and pre‐specified follow up was performed. Dose and type of RAS blockade therapy was also recorded. Patients were compared according to the prescription of RAS blockade or not. Only those patients surviving the inhospital period and under continuous RAS blockade therapy for at least 1 month after TAVI were included in the treatment group. Also, a matched comparison was performed according to baseline characteristics, use of other medications, procedural approach, left ventricular ejection fraction, and residual aortic regurgitation degree. Results: A total of 1980 patiens were included. Mean age of the study population was 81.3±9.1 years and 65.3% were males. STS and EuroSCORE‐II mean values were 7.2±1.3 and 6.5±2.4%, respectively, with 35.5% of diabetes mellitus, 13.9% of prior myocardial infarction, and left ventricular ejection fraction <40% in 32.6%of the patients. Of them, 706 (59.5%) received RAS blockade therapy after the procedure. At a median follow up of 3 years post‐TAVI, the RAS blockade group had significantly lower cumulative mortality than the no‐RAS blockade group (9.5% vs 16.5%; log‐rank test, p=0.001). After matching, RAS blockade therapy was still associated with significantly lower mortality (HR, 0.581; 95% CI 0.310 to 0.893; p=0.002). In addition, the rates of myocardial infarction, new‐onset atrial fibrillation, stroke, and re‐admission due to heart failure remained lower in the RAS blockade group for the entire cohort and the matched one. Conclusions: Post‐TAVI RAS blockade therapy is associated to lower all‐cause mortality at 3‐year follow up and presents a global cardiovascular protective effect irrespective of the left ventricular ejection fraction and the residual aortic regurgitation. An ongoing randomised controlled trial (RASTAVI Study, NCT03201185) will help to determine the accuracy of these findings.