Aortic stenosis Medication Classes Commonly Avoided
In patients with severe aortic stenosis, nitrates should be avoided due to risk of syncope from hypotension. [1] In patients with aortic stenosis undergoing non-cardiac surgery, arterial vasodilators should be avoided due to risk of hypotension and pulmonary congestion. [2]
Nitrates
- Long-acting nitrates (including isosorbide preparations and transdermal or other extended-release nitroglycerin formulations) should be avoided in severe aortic valvular stenosis. [1]
- Short-acting nitroglycerin should be avoided in severe aortic valvular stenosis due to risk of inducing syncope. [3]
Arterial vasodilators during non-cardiac surgery
- Intravenous arterial vasodilators should be avoided during non-cardiac surgery in patients with aortic stenosis to prevent marked hypotension and pulmonary congestion. [2]
Important clinical nuance
- Avoidance is most strongly emphasized for “severe” aortic stenosis and for settings where rapid blood pressure reduction is likely (perioperative or anesthesia-related vasodilation). [1], [2], [3]
Common Pitfalls to Avoid
- Use of nitroglycerin or other nitrates in severe aortic stenosis for symptom relief is associated with risk of syncope and should be avoided. [3]
- Use of perioperative arterial vasodilators in aortic stenosis without a strategy to prevent hypotension is discouraged. [2]
Targets and Monitoring Considerations
- Blood pressure should be managed to avoid large drops in systolic blood pressure during contexts where hypotension risk is increased. [2]
Medication Substitution Considerations
- Alternative antianginal strategies for ischemic symptoms in severe aortic stenosis should be selected from non-nitrate classes rather than nitrates. [3]