Department of Internal Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 57, Glostrup 2600, Denmark
Department of Internal Medicine, Section of Cardiology, Glostrup Hospital, University of Copenhagen, Nordre Ringvej 57, Glostrup 2600, Denmark.
Eur Heart J Cardiovasc Pharmacother. 2017 Jan;3(1):21-27. doi: 10.1093/ehjcvp/pvw027. Epub 2016 Sep 11.
Aortic valve stenosis (AVS) is associated with significant morbidity and mortality, especially in the presence of symptoms and echocardiographic signs of left ventricular remodelling (i.e. increase in left ventricular mass, left ventricular dilation, and systolic dysfunction). Renin-angiotensin system inhibitors (RASi) attenuate cardiac remodelling in various conditions, but the safety and efficacy of RASi in AVS is unsure. We performed a systematic review and meta-analysis to address these issues. We identified three smaller randomized clinical trials and five observational studies eligible for inclusion (PubMed, EMBASE, and Cochrane library search criteria: aortic stenosis, aortic valve, angiotensin-converting enzyme inhibitor in different combinations, published in English at any time up to 1 April 2016). Our analyses suggested that use of RASi was safe, with no observed increase in mortality risk [576/3389 patients receiving RASi vs. 1118/4384 controls died; relative risk 0.93 (95% confidence interval 0.78-1.11), P = 0.44]. Use of RASi was also observed to lower the risk of aortic valve replacement (AVR) surgery [67/2913 patients with RASi vs. 154/3666 controls underwent AVR; relative risk 0.68 (95% confidence interval 0.51-0.91), P = 0.01]. In current clinical practice (based on published literature; mainly observational studies), use of RASi appears to be safe in patients with AVS and may reduce the need for AVR, but the evidence is overall weak. Large-scale randomized clinical trials are warranted to address whether prescription of RASi to treatment-naïve patients may prevent disease progression, delay AVR surgery need, and lower the risk of mortality.
主动脉瓣狭窄（AVS）与显著的发病率和死亡率相关，特别是在存在左心室重构的症状和超声心动图征象（即左心室质量增加、左心室扩张和收缩功能障碍）的情况下。肾素-血管紧张素系统抑制剂（RASi）在各种情况下可减轻心脏重构，但 RASi 在 AVS 中的安全性和疗效尚不确定。我们进行了一项系统评价和荟萃分析来解决这些问题。我们确定了三项较小的随机临床试验和五项符合纳入标准的观察性研究（检索PubMed、EMBASE 和 Cochrane 图书馆的标准：主动脉瓣狭窄、主动脉瓣、不同组合的血管紧张素转换酶抑制剂，发表时间为 2016 年 4 月 1 日之前的任何时间的英文文献）。我们的分析表明，RASi 的使用是安全的，未观察到死亡率风险增加[接受 RASi 的 3389 例患者中有 576 例/对照组 4384 例中有 1118 例死亡；相对风险 0.93（95%置信区间 0.78-1.11），P=0.44]。也观察到 RASi 的使用可降低主动脉瓣置换（AVR）手术的风险[接受 RASi 的 2913 例患者中有 67 例/对照组 3666 例中有 154 例接受 AVR；相对风险 0.68（95%置信区间 0.51-0.91），P=0.01]。在当前的临床实践中（基于已发表的文献；主要为观察性研究），RASi 在 AVS 患者中似乎是安全的，并且可能减少 AVR 的需要，但总体证据较弱。需要进行大规模的随机临床试验来确定是否向未经治疗的患者开具 RASi 处方是否可以预防疾病进展、延迟 AVR 手术需求并降低死亡率。
