Beta Blockers in Aortic Stenosis

Primary Guideline Recommendations

The American College of Cardiology recommends beta blockers for patients with aortic stenosis and heart failure with reduced ejection fraction, as they provide mortality benefit even in the presence of severe aortic stenosis 1
The American College of Cardiology recommends continuing standard post-myocardial infarction beta blocker therapy despite severe aortic stenosis 1
Beta blockers are appropriate for rate control and arrhythmia management in patients with aortic stenosis 1
Beta blockers reduce myocardial oxygen consumption and valve gradients in patients with angina pectoris and aortic stenosis 1

The American College of Cardiology recommends avoiding beta blockers in patients with chronic aortic insufficiency/regurgitation, as they can worsen regurgitation (Class IIa recommendation, Level C evidence) 2, 3, 1
Beta blockers should be avoided in patients with severe aortic stenosis and moderate aortic regurgitation without compelling indications 3

The American College of Cardiology recommends RAS inhibitors (ACE inhibitors or ARBs) over beta blockers for treating hypertension in aortic stenosis without compelling indications 3, 1
RAS inhibitors have beneficial effects on left ventricular fibrosis 2, 1
RAS inhibitors improve blood pressure control 3, 1
RAS inhibitors reduce dyspnea 2, 3
RAS inhibitors improve effort tolerance 2, 3

The American College of Cardiology recommends assessing for compelling indications, such as heart failure with reduced ejection fraction, recent myocardial infarction, arrhythmias, or angina pectoris, before initiating beta blockers 2, 1, 3
If compelling indications are present, beta blockers are appropriate 1
If no compelling indications are present, assess for concurrent aortic regurgitation and use RAS inhibitors instead of beta blockers if moderate or greater AR is present 3

The SEAS study demonstrated a 50% reduction in all-cause mortality (HR 0.5, 95% CI 0.3-0.7) and 23% reduction in cardiovascular events in patients with severe aortic stenosis already receiving beta blockers 1
Metoprolol reduces valve gradients and myocardial oxygen consumption in asymptomatic moderate-severe aortic stenosis 1

Diuretics should be used sparingly in patients with small LV chamber dimensions and LV hypertrophy 2
The combination of hypertension and aortic stenosis creates "2 resistors in series" and increases complications 2

High blood pressure significantly worsens the underlying mechanisms that produce angina by increasing left ventricular afterload, exacerbating left ventricular hypertrophy, and intensifying coronary microvascular dysfunction in patients with severe aortic stenosis, according to the American College of Cardiology 4
Coronary microvascular dysfunction is the most common cause of chest pain in patients with severe aortic stenosis, resulting from very elevated left ventricular pressure caused by high left ventricular afterload, combined with associated left ventricular hypertrophy, as stated by the American College of Cardiology 4
Coexisting obstructive epicardial coronary artery disease may also contribute to angina in patients with severe aortic stenosis, as noted by the American College of Cardiology 4