Time to Treat Hypertension in Patients With Aortic Stenosis

Historically, patients with aortic stenosis (AS) rarely had concurrent systemic hypertension (HTN). Now, echocardiography allows early diagnosis, calcific remodeling has replaced rheumatic heart disease as the most prevalent cause of AS in the developed world, and the population of adults with AS is older, paralleling the demographic shift in the age of our population.1,2 In combination, these trends mean that HTN is a more common comorbidity in patients with AS and is coexistent for a longer period of time before aortic valve replacement. In studies involving younger patients with AS, the prevalence of HTN is 30% to 40%,3 whereas in recent series involving older patients at high risk for aortic valve replacement, the prevalence of HTN is 75% or higher.4,5Article see p 1349In patients with AS, increased systemic vascular load, resulting from increased vascular stiffness, resistance, pressure, or a combination of these factors, adds to the load on the left ventricle (LV) from the stenotic valve and is associated with increased hypertrophic remodeling, impaired LV function, and worse clinical outcomes.6–8 As Carabello2 pointed out, the resistance of the valve and the resistance of the systemic vasculature—in effect, 2 resistors in series—both contribute to pressure overload on the LV. In comparison with decades ago, patients managed with AS today tend to have lower valvular resistance and higher peripheral resistance. Whether aggressive treatment of increased systemic vascular load will improve outcomes and whether specific targeting of stiffness or resistance matters is an area of active investigation.Despite the recognition that HTN is an important …