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After transcatheter aortic valve replacement (TAVR), about half of patients experience a sustained increase in systolic blood pressure (BP), which is associated with improved cardiac function, according to a study published online April 17, 2013, ahead of print in JACC: Cardiovascular Interventions. Somewhat paradoxically, the increased BP predicts a better clinical outcome.

Haim D. Danenberg, MD, and colleagues, all of Hadassah Hebrew University Medical Center (Jerusalem, Israel), monitored the BP of 105 consecutive inoperative patients with severe aortic stenosis who underwent TAVR at their institution and measured cardiac parameters with clinical follow-up out to 1 year. At baseline, 85 patients had prior diagnoses of hypertension and 16 were already receiving antihypertensive drugs for other diagnoses.

For the entire cohort, systolic BP rose 15 ± 31 mmHg immediately after TAVR and remained 8 mmHg above baseline at 5 days despite medical treatment (P < 0.01 for both). By contrast, diastolic BP was reduced just after TAVR and remained 7 mmHg lower at 5 days (P < 0.001 for both). 

Post-TAVR Hypertension in Half of Patients

Overall, 53 patients (51%) had increased BP after TAVR, including 9 individuals (17%) who were not previously diagnosed. In the elevated BP group, the number of antihypertensive agents prescribed rose by 0.83 ± 1.03, while in the stable BP group the number of drugs declined by 1.02 ± 1.30 (P < 0.01 for both).

Cardiac output, cardiac index, and stroke volume were increased after TAVR in patients with increased BP compared with patients with stable BP. By contrast, stroke volume and cardiac output declined slightly in the stable BP group (table 1).

Table 1. Postprocedural Hemodynamic, Echocardiographic Parameters

Rates of procedural complications with possible hemodynamic consequences, such as bleeding, vascular complications, and infections, did not differ between the groups.

No mortality differences were seen between the increased BP and stable BP groups in-hospital, at 30 days, or at 12 months. But patients with increased BP had a better overall prognosis than those with stable BP at all time points, experiencing fewer serious adverse events, in particular worsening of heart failure (table 2).

Table 2. Clinical Outcomes

 
Interestingly, adverse events possibly related to increased hypertension, such as stroke or TIA, MI, and acute kidney injury, were rare and similar between the groups.

Severity of post-TAVR aortic regurgitation was also similar between the groups, with low rates of moderate or severe regurgitation.

“The association between good prognosis and increased BP, a potentially harmful response, is unexpected and its underlying mechanism has yet to be defined,” the authors write. “The rise in BP may represent myocardial contractile reserve even in patients with reduced LV function.” 

Dr. Danenberg and colleagues acknowledge that longer follow-up is needed to be sure that there is no clinical price to be paid for chronic hypertension. 

Clinical Import of Observation Unclear 

A post-TAVR surge in BP is a phenomenon that operators see regularly, Josep Rodés-Cabau, MD, of Laval University (Quebec City, Canada), told TCTMD in a telephone interview. Moreover, it is well known that increasing cardiac output increases BP.

But the real importance of a BP rise in predicting clinical outcome is difficult to know, he commented, since the small size of the study cohort did not permit multivariable analysis, which could help weed out possible confounders.

Another clinical limitation, Dr. Rodés-Cabau noted, is that the study offers no cutoff for increase in systolic pressure that would predict significant hemodynamic improvement.

Despite the findings, clinicians must treat any procedural and postprocedural hypertension aggressively, Dr. Rodés-Cabau said. But, he added, the good news is that what would normally be viewed as a potentially dangerous complication in fact has a positive side—it signals that the patient has had a good left ventricular response and shows contractile reserve.

On the other hand, he cautioned, patients whose BP does not rise at all may need to be monitored more closely because they are at higher risk for heart failure. 

Study Details

Increased BP after TAVR was defined as the presence of 1 of the following:

• Sustained (> 48 h) systolic pressure > 140 mmHg or diastolic pressure > 90 mmHg that was not present at baseline
• Need to more than double the dosage of an antihypertensive drug to achieve control of systemic BP
• Need to add another antihypertensive drug to the preprocedural regimen to achieve control of systemic BP

Patients’ mean age was 80.7 ± 6.6 years and logistic EuroScore was 23.3 ± 15.1. Most baseline and procedural parameters were similar between the 2 groups; however, patients with increased BP had a lower mean BMI than those with stable BP (26.5 vs. 28.6; P < 0.05) and were using fewer antihypertensive medications to achieve a similarly well-controlled BP at baseline before TAVR.

• Dr. Rodés-Cabau reports serving as a consultant to Edwards Lifesciences and St. Jude Medical.

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