Management of Hypertension in Patients With Mild to Moderate Aortic Stenosis
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Article, see p 455
The treatment of hypertension has been the subject of intense interest and debate over the last several years.1–5 Although a “lower is better strategy” has been adopted in clinical practice for many but not all patient cohorts, the boundary conditions for blood pressure treatment have not been established rigorously by clinical trials involving middle-aged and older adults with hypertension and other prespecified cardiovascular disorders such as acute coronary syndromes, heart failure, and valvular heart disease. Concern remains that a J- or U-curve association between blood pressure and outcomes exists in vulnerable patients with impaired coronary flow reserve or myocardial dysfunction.6 Excessive lowering of the diastolic blood pressure (DBP) may result in critical reductions in coronary perfusion pressure below the autoregulatory limit and render the heart ischemic, especially when myocardial oxygen demand is increased. Nevertheless, the evidence base is not uniformly consistent, and issues such as confounding and reverse causality have been invoked to explain the observations made in some but not all trials.5 The deleterious effects of significantly elevated systolic blood pressure (SBP) or DBP, however, across essentially all patient populations are not in question.
The prevalence of hypertension and significant valvular heart disease, especially calcific aortic valve stenosis, increases with age,7,8 and their combined treatment can prove quite challenging. Older patients not uncommonly have coexistent coronary or cerebrovascular disease, chronic kidney disease, atrial fibrillation, and diabetes mellitus, comorbidities that further complicate management decisions and argue for an individualized approach. Polypharmacy, …