Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

Brian R. Lindman; Kashish Goel; Javier Bermejo; Joshua Beckman; Jared O'Leary; Colin M. Barker; Clayton Kaiser; João L. Cavalcante; Sammy Elmariah; Jian Huang; Graeme L. Hickey; David H. Adams; Jeffrey J. Popma; Michael J. Reardon

doi:10.1161/JAHA.119.014020

Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

Brian R. Lindman, Kashish Goel, Javier Bermejo, Joshua Beckman, Jared O'Leary, Colin M. Barker, Clayton Kaiser, João L. Cavalcante, Sammy Elmariah, Jian Huang, Graeme L. Hickey, David H. Adams, Jeffrey J. Popma, Michael J. Reardon

Research output: Contribution to journal › Article › peer-review

10 Scopus citations

Abstract

Background: Blood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted. Methods and Results: Among patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post-AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all-cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate-to-severe aortic regurgitation post-AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.62, 95% CI 1.23–2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52–3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.63, 95% CI 1.21–2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25–2.61), but SBP 150 to <180 mm Hg was not. Conclusions: Lower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes. Clinical Trial Registration Information: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.

Original language	English (US)
Article number	e014020
Journal	Journal of the American Heart Association
Volume	8
Issue number	21
DOIs	https://doi.org/10.1161/JAHA.119.014020
State	Published - Nov 5 2019
Externally published	Yes

Keywords

aortic valve stenosis
blood pressure
mortality
transcatheter aortic valve implantation

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

Access to Document

10.1161/JAHA.119.014020

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Lindman, B. R., Goel, K., Bermejo, J., Beckman, J., O'Leary, J., Barker, C. M., Kaiser, C., Cavalcante, J. L., Elmariah, S., Huang, J., Hickey, G. L., Adams, D. H., Popma, J. J., & Reardon, M. J. (2019). Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality. Journal of the American Heart Association, 8(21), [e014020]. https://doi.org/10.1161/JAHA.119.014020

Lindman, BR, Goel, K, Bermejo, J, Beckman, J, O'Leary, J, Barker, CM, Kaiser, C, Cavalcante, JL, Elmariah, S, Huang, J, Hickey, GL, Adams, DH, Popma, JJ & Reardon, MJ 2019, 'Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality', Journal of the American Heart Association, vol. 8, no. 21, e014020. https://doi.org/10.1161/JAHA.119.014020

@article{4aa52c62c90f4741b9a5d04d7bc9cfc8,

title = "Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality",

abstract = "Background: Blood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted. Methods and Results: Among patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post-AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all-cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate-to-severe aortic regurgitation post-AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.62, 95% CI 1.23–2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52–3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.63, 95% CI 1.21–2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25–2.61), but SBP 150 to <180 mm Hg was not. Conclusions: Lower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes. Clinical Trial Registration Information: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.",

keywords = "aortic valve stenosis, blood pressure, mortality, transcatheter aortic valve implantation",

author = "Lindman, {Brian R.} and Kashish Goel and Javier Bermejo and Joshua Beckman and Jared O'Leary and Barker, {Colin M.} and Clayton Kaiser and Cavalcante, {Jo{\~a}o L.} and Sammy Elmariah and Jian Huang and Hickey, {Graeme L.} and Adams, {David H.} and Popma, {Jeffrey J.} and Reardon, {Michael J.}",

note = "Funding Information: Dr. Lindman has served on the scientific advisory board for Roche Diagnostics, has received research grants from Edwards Lifesciences and Roche Diagnostics, and has consulted for Medtronic. Dr. Beckman has consulted for Astra Zeneca, Bristol Myers Squibb, Boehringer Ingelheim, Merck, Novo Nordisk, and Sanofi, and has served on the Data Safety and Monitoring Board for Bayer and Novartis. Dr. Barker has served on the advisory board for Medtronic and Boston Scientific. Dr. Cavalcante has consulted for Siemens, Medtronic, and Circle Cardiovascular Imaging, and received research grants from Abbott and Medtronic. Dr. Elmariah has received institutional grant support from Edwards Lifesciences and received consulting fees from Astra Zeneca and Medtronic. Drs. Huang and Hickey are employees of Medtronic. Dr. Adams has received grant support from Medtronic and has royalty agreements through Mount Sinai School of Medicine with Medtronic and Edwards Lifesciences. Dr. Popma has received institutional grant support from Boston Scientific, Direct Flow Medical, and Medtronic; has received consultant fees from Boston Scientific and Direct Flow Medical; and owns equity in Direct Flow Medical. Dr. Reardon has received consultant fees from Medtronic paid to his department. The remaining authors have no disclosures to report. Publisher Copyright: {\textcopyright} 2019 The Authors and Medtronic Inc. Published on behalf of the American Heart Association, Inc., by Wiley.",

year = "2019",

month = nov,

day = "5",

doi = "10.1161/JAHA.119.014020",

language = "English (US)",

volume = "8",

journal = "Journal of the American Heart Association",

issn = "2047-9980",

publisher = "Wiley-Blackwell",

number = "21",

}

TY - JOUR

T1 - Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

AU - Lindman, Brian R.

AU - Goel, Kashish

AU - Bermejo, Javier

AU - Beckman, Joshua

AU - O'Leary, Jared

AU - Barker, Colin M.

AU - Kaiser, Clayton

AU - Cavalcante, João L.

AU - Elmariah, Sammy

AU - Huang, Jian

AU - Hickey, Graeme L.

AU - Adams, David H.

AU - Popma, Jeffrey J.

AU - Reardon, Michael J.

N1 - Funding Information: Dr. Lindman has served on the scientific advisory board for Roche Diagnostics, has received research grants from Edwards Lifesciences and Roche Diagnostics, and has consulted for Medtronic. Dr. Beckman has consulted for Astra Zeneca, Bristol Myers Squibb, Boehringer Ingelheim, Merck, Novo Nordisk, and Sanofi, and has served on the Data Safety and Monitoring Board for Bayer and Novartis. Dr. Barker has served on the advisory board for Medtronic and Boston Scientific. Dr. Cavalcante has consulted for Siemens, Medtronic, and Circle Cardiovascular Imaging, and received research grants from Abbott and Medtronic. Dr. Elmariah has received institutional grant support from Edwards Lifesciences and received consulting fees from Astra Zeneca and Medtronic. Drs. Huang and Hickey are employees of Medtronic. Dr. Adams has received grant support from Medtronic and has royalty agreements through Mount Sinai School of Medicine with Medtronic and Edwards Lifesciences. Dr. Popma has received institutional grant support from Boston Scientific, Direct Flow Medical, and Medtronic; has received consultant fees from Boston Scientific and Direct Flow Medical; and owns equity in Direct Flow Medical. Dr. Reardon has received consultant fees from Medtronic paid to his department. The remaining authors have no disclosures to report. Publisher Copyright: © 2019 The Authors and Medtronic Inc. Published on behalf of the American Heart Association, Inc., by Wiley.

PY - 2019/11/5

Y1 - 2019/11/5

N2 - Background: Blood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted. Methods and Results: Among patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post-AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all-cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate-to-severe aortic regurgitation post-AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.62, 95% CI 1.23–2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52–3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.63, 95% CI 1.21–2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25–2.61), but SBP 150 to <180 mm Hg was not. Conclusions: Lower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes. Clinical Trial Registration Information: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.

AB - Background: Blood pressure (BP) guidelines for patients with aortic stenosis or a history of aortic stenosis treated with aortic valve replacement (AVR) match those in the general population, but this extrapolation may not be warranted. Methods and Results: Among patients enrolled in the Medtronic intermediate, high, and extreme risk trials, we included those with a transcatheter AVR (n=1794) or surgical AVR (n=1103) who were alive at 30 days. The associations between early (average of discharge and 30 day post-AVR) systolic BP (SBP) and diastolic BP (DBP) measurements and clinical outcomes between 30 days and 1 year were evaluated. Among 2897 patients, after adjustment, spline curves demonstrated an association between lower SBP (<120 mm Hg, representing 21% of patients) and DBP (<60 mm Hg, representing 30% of patients) and increased all-cause and cardiovascular mortality and repeat hospitalization. These relationships were unchanged when patients with moderate-to-severe aortic regurgitation post-AVR were excluded. After adjustment, compared with DBP 60 to <80 mm Hg, DBP 30 to <60 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.62, 95% CI 1.23–2.14) and cardiovascular mortality (adjusted hazard ratio 2.13, 95% CI 1.52–3.00), but DBP 80 to <100 mm Hg was not. Similarly, after adjustment, compared with SBP 120 to <150 mm Hg, SBP 90 to <120 mm Hg was associated with increased all-cause (adjusted hazard ratio 1.63, 95% CI 1.21–2.21) and cardiovascular mortality (adjusted hazard ratio 1.81, 95% CI 1.25–2.61), but SBP 150 to <180 mm Hg was not. Conclusions: Lower BP in the first month after transcatheter AVR or surgical AVR is common and associated with increased mortality and repeat hospitalization. Clarifying optimal BP targets in these patients ought to be a priority and may improve patient outcomes. Clinical Trial Registration Information: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01586910, NCT01240902.

KW - aortic valve stenosis

KW - blood pressure

KW - mortality

KW - transcatheter aortic valve implantation

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DO - 10.1161/JAHA.119.014020

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Lower Blood Pressure After Transcatheter or Surgical Aortic Valve Replacement is Associated with Increased Mortality

Abstract

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