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Vasodilators Tested in Asymptomatic Aortic Regurgitation

In patients with asymptomatic, chronic, severe aortic regurgitation, vasodilator treatment neither reduced nor delayed the need for aortic valve replacement.

ACC/AHA guidelines on valvular heart disease strongly recommend vasodilator therapy for patients with symptomatic or asymptomatic severe aortic regurgitation, left-ventricular dilation, and normal LV systolic function. However, the evidence in asymptomatic patients is not solid. Researchers in Spain conducted a randomized, open-label trial comparing nifedipine (20 mg every 12 hours), enalapril (20 mg daily), or no treatment in 95 patients with asymptomatic, chronic, severe aortic regurgitation (mean age, 43; 78% men; mean LV ejection fraction, 59%; mean LV end-diastolic dimension, about 6.6 cm).

Aortic valve replacement (AVR) was performed, according to an explicit protocol, only for symptoms or for LV dysfunction or enlargement. During a mean follow-up of 7 years, the need for AVR did not differ significantly among the groups (41% of the nifedipine group, 50% of the enalapril group, and 39% of the no-treatment group), nor did the mean time elapsed until AVR (5.4, 4.2, and 5.4 years, respectively). Changes in echocardiographic measures also were similar among the groups. No patients died from surgery.

Comment: In patients with asymptomatic, chronic, severe aortic regurgitation, vasodilator treatment (with nifedipine or enalapril) neither reduced nor delayed the need for aortic valve replacement. Although the study was small, its findings nonetheless cast doubt upon the current guideline recommendation. What’s clear, as an editorialist notes, is the paucity of trial findings to guide the care of patients with significant valvular disease.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology October 21, 2005

Citation(s):

Evangelista A et al. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med 2005 Sep 29; 353:1342-9.

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Carabello BA. Vasodilators in aortic regurgitation — Where is the evidence of their effectiveness? N Engl J Med 2005 Sep 29; 353:1400-2.

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• Medline abstract (Free)