Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.
Heart. 2024 Jan 10;110(3):202-208. doi: 10.1136/heartjnl-2023-322922.
The optimal medical therapy after surgical aortic valve replacement (SAVR) for aortic stenosis remains unknown. Renin-angiotensin system (RAS) inhibitors could potentially improve cardiac remodelling and clinical outcomes after SAVR.
All patients undergoing SAVR due to aortic stenosis in Sweden 2006-2020 and surviving 6 months after surgery were included. The primary outcome was major adverse cardiovascular events (MACEs; all-cause mortality, stroke or myocardial infarction). Secondary endpoints included the individual components of MACE and cardiovascular mortality. Time-updated adjusted Cox regression models were used to compare patients with and without RAS inhibitors. Subgroup analyses were performed, as well as a comparison between angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs).
A total of 11 894 patients (mean age, 69.5 years, 40.4% women) were included. Median follow-up time was 5.4 (2.7-8.5) years. At baseline, 53.6% of patients were dispensed RAS inhibitors, this proportion remained stable during follow-up. RAS inhibition was associated with a lower risk of MACE (adjusted hazard ratio (aHR) 0.87 (95% CI 0.81 to 0.93), p<0.001), mainly driven by a lower risk of all-cause death (aHR 0.79 (0.73 to 0.86), p<0.001). The lower MACE risk was consistent in all subgroups except for those with mechanical prostheses (aHR 1.07 (0.84 to 1.37), p for interaction=0.040). Both treatment with ACE inhibitors (aHR 0.89 (95% CI 0.82 to 0.97)) and ARBs (0.87 (0.81 to 0.93)) were associated with lower risk of MACE.
The results of this study suggest that medical therapy with an RAS inhibitor after SAVR is associated with a 13% lower risk of MACE and a 21% lower risk of all-cause death.
主动脉瓣置换术（SAVR）后最佳的药物治疗方案仍不明确。肾素-血管紧张素系统（RAS）抑制剂可能会改善 SAVR 后的心脏重构和临床结局。
本研究纳入了 2006 年至 2020 年期间在瑞典接受 SAVR 治疗的所有主动脉瓣狭窄患者，且术后存活 6 个月以上。主要结局为主要不良心血管事件（MACE；全因死亡率、卒中和心肌梗死）。次要终点包括 MACE 的各个组成部分和心血管死亡率。使用时间更新调整后的 Cox 回归模型比较了使用和未使用 RAS 抑制剂的患者。进行了亚组分析，并比较了血管紧张素转换酶（ACE）抑制剂和血管紧张素 II 受体阻滞剂（ARB）。
共纳入 11894 例患者（平均年龄 69.5 岁，40.4%为女性）。中位随访时间为 5.4（2.7-8.5）年。基线时，53.6%的患者使用了 RAS 抑制剂，这一比例在随访期间保持稳定。RAS 抑制与 MACE 风险降低相关（调整后的危险比（aHR）0.87（95%CI 0.81 至 0.93），p<0.001），主要归因于全因死亡率降低（aHR 0.79（0.73 至 0.86），p<0.001）。除了使用机械瓣膜的患者（aHR 1.07（0.84 至 1.37），p 交互=0.040）外，这种较低的 MACE 风险在所有亚组中均一致。ACE 抑制剂（aHR 0.89（95%CI 0.82 至 0.97））和 ARB（0.87（0.81 至 0.93））治疗与 MACE 风险降低相关。
本研究结果表明，SAVR 后使用 RAS 抑制剂的药物治疗与 MACE 风险降低 13%和全因死亡率降低 21%相关。
