Impact of TAVR on GDMT in patients with severe aortic stenosis and HFrEF

Abstract Background Transcatheter Aortic Valve Replacement (TAVR) is the standard of care in patients with severe aortic stenosis (AS), including those with heart failure with reduced ejection fraction (HFrEF). Guideline-directed medical therapy (GDMT) optimization in severe AS may be limited due to poor tolerability. While TAVR improves hemodynamics and clinical outcomes, its impact on the utilization of guideline-directed medical therapy (GDMT) remains unclear. Purpose This study aimed to assess trends in GDMT use, the extent of optimal dosing, and associated echocardiographic changes over time among patients with HFrEF undergoing TAVR. Methods HFrEF patients (LVEF 40%) that underwent TAVR for severe AS were retrospectively identified. GDMT use, including beta blockers (BB), renin-angiotensin-aldosterone system inhibitors (RAASi), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT2i), was compared between pre and post TAVR periods (discharge, 30 days, and 1 year). The maximum prescribed dose for each drug class and the proportion of patients receiving optimal doses (50% max recommended dose) were examined. Left ventricular ejection fraction (LVEF), left ventricular internal dimensions in diastole and in systole (LVIDd, LVIDs), and relative wall thickness (RWT) were also analyzed over time. Results Across the cohort (n=162), beta blocker use declined immediately post-TAVR before increasing at later follow-up (Figure 1). RAASi and MRA doses modestly increased post TAVR, whereas SGLT2i use remained low across all time points (Figure 1). The proportion of patients receiving optimal GDMT doses (50% max dose) was consistently low across all drug classes, with the lowest rates seen for SGLT2i therapy (Figure 1). Echocardiographic trends revealed a transient improvement in LVEF post-TAVR, followed by a decline at 1 year (Figure 2). LVIDd and LVIDs gradually decreased, and RWT increased over time, consistent with reverse remodeling (Figure 2). Conclusion GDMT in patients with HFrEF who are undergoing TAVR remains inadequate, partly explaining the lack of improvement in LVEF. These patients may require tight surveillance on their GDMT to continue to improve their outcomes.Figure 1 Figure 2