In the JournalsPerspective

High BP may confer elevated risk for aortic valve disease

In a cohort study of 5.4 million participants, long-term exposure to high BP was associated with increased risk for aortic valve stenosis and regurgitation, according to data published in the European Heart Journal.

“The study shows that serious valvular heart diseases that are common at old age are not simply due to aging,” Kazem Rahimi, FRCP, DM, MSc, FESC, deputy director and associate professor of cardiovascular medicine at The George Institute for Global Health, University of Oxford, said in a press release. “Long-term exposure to higher blood pressure is a strong and potentially modifiable risk factor for aortic stenosis and regurgitation at every level of typical blood pressure, not only in those who are classified as having hypertension. Blood pressure should be considered as a major risk factor for aortic valve disease, much in the same way as we think of elevated blood pressure as a risk factor for atherosclerotic disease. The study suggests that the associations are causal, but this requires further confirmation.”

Rahimi and colleagues investigated the relationship between high BP, aortic stenosis and aortic regurgitation in a U.K. cohort of 5.4 million adults without known CVD or aortic valve disease at baseline.

During 9.2 years of follow-up, 0.38% of participants were diagnosed with aortic stenosis and 0.12% were diagnosed with aortic regurgitation.

Consistent relationship

Rahimi and colleagues found that as systolic BP rose, the risk for aortic stenosis and aortic regurgitation increased, and the relationship was continuous starting at 115 mm Hg.

For each 20-mm Hg increase in systolic BP, risk for aortic stenosis rose by 41% (HR = 1.41; 95% CI, 1.38-1.45) and risk for aortic regurgitation rose by 38% (HR = 1.38; 95% CI, 1.31-1.45), according to the researchers.

The relationship was strongest in younger adults but did not vary by sex or BMI.

In addition, the researchers found that each 10-mm Hg increase in diastolic BP conferred a 24% higher risk for aortic stenosis (HR = 1.24; 95% CI, 1.19-1.29), but there was no significant relationship between diastolic BP and aortic regurgitation risk (HR = 1.04; 95% CI, 0.97-1.11).

Rahimi and colleagues also determined that for every 15-mm Hg increase in pulse pressure, risk for aortic stenosis increased by 46% (HR = 1.46; 95% CI, 1.42-1.5) and risk for aortic regurgitation increased by 53% (HR = 1.53; 95% CI, 1.45-1.62).

Prevention strategies

“The study by Rahimi et al provides the first solid evidence supporting the need for a radical shift in the approach to [aortic valve disease]. Indeed, over the last few years, the research on valvular heart disease has been focused on improving treatment rather than prevention strategies,” Alberto Giannoni, MD, PhD, from Fondazione Toscana Gabriele Monasterio, Pisa, Italy, and Stefano Masi, MD, PhD, from the department of clinical and experimental medicine at the University of Pisa, wrote in a related editorial. “The findings provided by Rahimi et al might be considered the first step towards a change in the management of [aortic valve disease] and are likely to influence future clinical trials and guidelines. Current European guidelines for the management of arterial hypertension do not consider [aortic valve disease] as manifestations of heart damage related to hypertension and, consequently, do not suggest accurate assessment of aortic valve function and structure in patients with arterial hypertension. Also, they might stimulate new lines of research, particularly imaging studies, with the scope of identifying early alterations of the aortic valve in patients with hypertension that might be highly predictive of future [aortic valve disease].” – by Erik Swain

Disclosures: The authors, Giannoni and Masi report no relevant financial disclosures.

In a cohort study of 5.4 million participants, long-term exposure to high BP was associated with increased risk for aortic valve stenosis and regurgitation, according to data published in the European Heart Journal.

“The study shows that serious valvular heart diseases that are common at old age are not simply due to aging,” Kazem Rahimi, FRCP, DM, MSc, FESC, deputy director and associate professor of cardiovascular medicine at The George Institute for Global Health, University of Oxford, said in a press release. “Long-term exposure to higher blood pressure is a strong and potentially modifiable risk factor for aortic stenosis and regurgitation at every level of typical blood pressure, not only in those who are classified as having hypertension. Blood pressure should be considered as a major risk factor for aortic valve disease, much in the same way as we think of elevated blood pressure as a risk factor for atherosclerotic disease. The study suggests that the associations are causal, but this requires further confirmation.”

Rahimi and colleagues investigated the relationship between high BP, aortic stenosis and aortic regurgitation in a U.K. cohort of 5.4 million adults without known CVD or aortic valve disease at baseline.

During 9.2 years of follow-up, 0.38% of participants were diagnosed with aortic stenosis and 0.12% were diagnosed with aortic regurgitation.

Consistent relationship

Rahimi and colleagues found that as systolic BP rose, the risk for aortic stenosis and aortic regurgitation increased, and the relationship was continuous starting at 115 mm Hg.

For each 20-mm Hg increase in systolic BP, risk for aortic stenosis rose by 41% (HR = 1.41; 95% CI, 1.38-1.45) and risk for aortic regurgitation rose by 38% (HR = 1.38; 95% CI, 1.31-1.45), according to the researchers.

The relationship was strongest in younger adults but did not vary by sex or BMI.

In addition, the researchers found that each 10-mm Hg increase in diastolic BP conferred a 24% higher risk for aortic stenosis (HR = 1.24; 95% CI, 1.19-1.29), but there was no significant relationship between diastolic BP and aortic regurgitation risk (HR = 1.04; 95% CI, 0.97-1.11).

Rahimi and colleagues also determined that for every 15-mm Hg increase in pulse pressure, risk for aortic stenosis increased by 46% (HR = 1.46; 95% CI, 1.42-1.5) and risk for aortic regurgitation increased by 53% (HR = 1.53; 95% CI, 1.45-1.62).

Prevention strategies

“The study by Rahimi et al provides the first solid evidence supporting the need for a radical shift in the approach to [aortic valve disease]. Indeed, over the last few years, the research on valvular heart disease has been focused on improving treatment rather than prevention strategies,” Alberto Giannoni, MD, PhD, from Fondazione Toscana Gabriele Monasterio, Pisa, Italy, and Stefano Masi, MD, PhD, from the department of clinical and experimental medicine at the University of Pisa, wrote in a related editorial. “The findings provided by Rahimi et al might be considered the first step towards a change in the management of [aortic valve disease] and are likely to influence future clinical trials and guidelines. Current European guidelines for the management of arterial hypertension do not consider [aortic valve disease] as manifestations of heart damage related to hypertension and, consequently, do not suggest accurate assessment of aortic valve function and structure in patients with arterial hypertension. Also, they might stimulate new lines of research, particularly imaging studies, with the scope of identifying early alterations of the aortic valve in patients with hypertension that might be highly predictive of future [aortic valve disease].” – by Erik Swain

Disclosures: The authors, Giannoni and Masi report no relevant financial disclosures.

    Perspective
    Randall M. Zusman

    Randall M. Zusman

    I was not aware of the tight relationship between hypertension, aortic stenosis and aortic regurgitation demonstrated in this study. Before it was published, I would have been likely to say there is a relationship between hypertension and aortic regurgitation, but maybe not between hypertension and aortic stenosis. But it makes some sense.

    The findings remind colleagues and others caring for patients with high BP that aortic stenosis and regurgitation are likely concomitants and may develop over time. The important point is that hopefully the control of BP will reverse this tendency. Effective, aggressive BP control to lower values as recommended in the 2017 American College of Cardiology/American Heart Association guidelines may interfere with this development. That better control will be rewarded with fewer clinical events related to aortic valve disease, such as need for valve replacement, is suggested but not answered by this study.

    There is no reason not to think these findings are applicable to Americans and others outside the U.K. There is nothing special about high BP in the U.K. that makes this population different from similar populations in other regions. This is something that should apply to everyone.

    High BP is not the only factor contributing to valvular heart disease, but I would not be surprised if it is an important factor, given the incidence of hypertension. The common pathway may be the inflammatory changes that accompany hypertension. To the extent that the agents we use suppress inflammation and comorbidities such as diabetes and hyperlipidemia, they may be able to work synergistically to reduce the incidence of aortic valve disease over time.

    We need to do more research. Aortic valve disease is an expensive disorder, considering valve replacements and development of HF, MI and angina. Preventing it is always going to be fiscally sound policy.

    The diagnosis of aortic stenosis and aortic regurgitation is best made with a stethoscope, so patients should make sure that doctors listen to their heart. If a diagnosis is made early, there are interventions to moderate the consequences of aortic valve obstruction or insufficiency in terms of the progression of disease.

    • Randall M. Zusman, MD
    • Director, Division of Hypertension
      Corrigan Minehan Heart Center
      Massachusetts General Hospital
      Associate Professor of Medicine
      Harvard Medical School

    Disclosures: Zusman reports no relevant financial disclosures.