Heart failure therapy in severe aortic stenosis after surgical or transcatheter aortic valve replacement (The HF-STAR cohort study)

Background

In the setting of aortic stenosis (AS), long-standing pressure overload leads to myocardial damage and subjects patients to an increased risk of heart failure (HF) and death even after successful aortic valve replacement (AVR). Conventional HF medications may have the potential to target this residual HF component, but current evidence on the efficacy in severe AS after AVR is limited.

Aims

The aims of this study were to assess HF medication prescription patterns and their association with outcomes in severe AS after AVR.

Methods

Consecutive patients with severe AS undergoing successful AVR between 2013 and 2024 were included. Treatment status with HF medications (Renin-angiotensin-system inhibitors [RASi], Mineralocorticoid receptor antagonists [MRA], beta-blockers [BB], Sodium glucose co-transporter 2 inhibitors [SGLT2i]) at discharge after AVR was recorded.

Nearest neighbor propensity score (PS) matching for age, sex, N-terminal pro-B-type natriuretic peptide [NT-proBNP], estimated glomerular filtration rate [eGFR], glycated hemoglobin [HbA1c], hypertension and coronary artery disease was performed.

All-cause and cardiovascular (CV) mortality at month 60 were assessed in the overall population and prespecified subgroups: a) surgical (SAVR) vs. transcatheter aortic valve replacement (TAVR) b) left ventricular ejection fraction (LVEF) ≥50% vs. <50%.

Results

In total, 4,882 patients (75.9 years, 56.4% male, 51.8% TAVR, 48.2% SAVR) were included. RASi were prescribed in 35.1%, MRA in 30.5%, SGLT2i in 14.3%, and BB in 10.4%.

Patients receiving RASi (LVEF <50%: 17.2% vs. 10.1%; NT-proBNP: 1,238 pg/ml vs. 971 pg/ml), MRA (LVEF <50%: 18.7% vs. 9.8%; NT-proBNP: 1,372 pg/ml vs. 962 pg/ml) and SGLT2i (LVEF <50%: 20.6 vs. 11.1; NT-proBNP: 1,450 pg/ml vs. 1,037 pg/ml) were at a more advanced stage of cardiac disease compared to patients not receiving respective medications.

Treatment with RASi (HR: 0.68; 95%CI: 0.59-0.78; HR: 0.68; 95%CI: 0.56-0.82), MRA (HR: 0.74; 95%CI: 0.63-0.86; HR: 0.70; 95%CI: 0.57-0.85), and SGLT2i (HR: 0.69; 95%CI: 0.53-0.91; HR: 0.56; 95%CI: 0.38-0.80) was independently associated with a reduced hazard for all-cause and CV mortality, respectively. Treatment benefits were confirmed across evaluated subgroups. Conversely, no outcome signals for BB treatment were found.

Conclusions

Prescription of HF medications in AS undergoing AVR is impacted by the stage of cardiac disease. Treatment with RASi, MRA and SGLT2i, but not BB, is associated with favourable clinical outcomes, including subgroups of TAVR/SAVR and reduced/preserved LVEF.All-cause mortality in severe AS after AVRAll-cause mortality in investigated subgroups