Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

Abstract

Background Blood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted. Methods and Results Among patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post-AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all-cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate-to-severe aortic regurgitation post-AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.62, 95% CI 1.23-2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52-3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.63, 95% CI 1.21-2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25-2.61), but SBP 150 to <180 mm Hg was not. Conclusions Lower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes. Clinical Trial Registration Information URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.

Keywords: aortic valve stenosis; blood pressure; mortality; transcatheter aortic valve implantation.

Figures

Figure 1

Post‐aortic valve replacement diastolic blood pressure and outcomes. Cox proportional hazard models were performed using restricted cubic splines technique. The association between early post‐aortic valve replacement diastolic blood pressure and all‐cause (A), cardiovascular (B), and non‐cardiovascular (C) 30‐day to 1‐year mortality are shown as well as the association with aortic valve‐related hospitalization (D) between 30 days and 1 year. Adjustment was made for: transcatheter aortic valve replacement (vs surgical aortic valve replacement), body mass index, New York Heart Association (III/IV vs I/II), peripheral vascular disease, home oxygen use, prior atrial fibrillation/flutter, liver cirrhosis, immunosuppressive therapy, 5 m gait speed, independent living, early stroke, early life threatening or disabling or major bleed, acute kidney injury, and early myocardial infarction. AVR indicates aortic valve replacement; DBP, diastolic blood pressure.

Figure 2

Post‐aortic valve replacement systolic blood pressure and outcomes. Cox proportional hazard models were performed using restricted cubic splines technique. The association between early post‐aortic valve replacement systolic blood pressure and all‐cause (A), cardiovascular (B), and non‐cardiovascular (C) 30‐day to 1‐year mortality are shown as well as the association with aortic valve‐related hospitalization (D) between 30 days and 1 year. Adjustment was made for the same variables as in Figure 1. AVR indicates aortic valve replacement; SBP, systolic blood pressure.

Figure 3

Post‐aortic valve replacement systolic and diastolic blood pressure and outcomes. Kaplan–Meier curves are shown for all‐cause (A) and cardiovascular (B) mortality between 30 days and 1 year for early post‐aortic valve replacement blood pressure groups defined by systolic blood pressure ≥120 vs <120 mm Hg and diastolic blood pressure ≥60 vs <60 mm Hg. AVR indicates aortic valve replacement; DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 4

Discharge and 30‐day diastolic blood pressure and outcomes. Kaplan–Meier curves are shown for all‐cause (A) and cardiovascular (B) mortality between 30 days and 1 year for diastolic blood pressure groups defined by discharge diastolic blood pressure ≥60 vs <60 mm Hg and 30‐day diastolic blood pressure ≥60 vs <60 mm Hg. DBP indicates diastolic blood pressure.