Cardiovascular Management After Transcatheter Aortic Valve Replacement

Introduction to Beta-Blocker Titration

The European Society of Cardiology and the American Heart Association recommend beta-blocker titration after transcatheter aortic valve replacement, with a target heart rate of 50-70 beats per minute and a systolic blood pressure of 100-120 mmHg 1, 2, 3
The titration schedule should increase the dose in steps of 1.25 or 2.5mg every 2-4 weeks, as recommended by the European Society of Cardiology 1

The maximum dose of beta-blockers should not exceed 10mg once daily, as recommended by the American College of Cardiology and the European Society of Cardiology 1, 2
The starting dose for geriatric patients should be 2.5mg once daily, with careful monitoring of heart rate and blood pressure, and may be titrated up to 5 mg once daily based on response 4, 1

Resting heart rate should be evaluated on a daily basis during dose adjustments, and the dose should not be increased if signs of worsening heart failure, symptomatic hypotension, or excessive bradycardia occur, as recommended by the American Heart Association and the European Society of Cardiology 1, 2
If symptomatic hypotension occurs during titration, consider reducing doses of other antihypertensive medications, as recommended by the European Society of Cardiology 1

Avoid abrupt discontinuation of beta-blockers, as it has been associated with increased risk of adverse cardiac events, as recommended by the American Heart Association and reported in Circulation 4, 2
Bisoprolol can be safely titrated from lower doses to higher doses (up to 10mg) with careful monitoring, reducing perioperative cardiac death and nonfatal MI, as demonstrated by the DECREASE trials and reported by the American College of Cardiology and the Journal of the American College of Cardiology 4, 5, 6, 7
Aspirin 75-100 mg daily is recommended for lifelong use, and clopidogrel 75 mg daily may be considered for 3-6 months post-procedure, according to the American Heart Association 8
For bioprosthetic valves, warfarin may be considered for the first 3 months if high-risk features are present, as suggested by the American College of Cardiology 8
Beta-blockers are beneficial after valve replacement to reduce the force of left ventricular ejection (dP/dt) and control heart rate and blood pressure, according to the European Heart Journal and the American College of Cardiology 4, 3