ACE inhibition in aortic stenosis: dangerous medicine or golden opportunity?

Conventionally angiotensin-converting enzyme (ACE) inhibitors are contraind icated in patients with aortic stenosis. Abundant evidence is now available showing that angiotensin II has a central role in the development of left ventricular hypertrophy (LVH), myocardial contractile failure and diastolic dysfunction in response to pressure overload. In animal models, ACE inhibi tors have been shown to attenuate these pathological responses. In humans t here is no such evidence available, however uncontrolled studies have shown that these agents are not only tolerated but are associated with acute imp rovements in haemodynamics and diastolic function. Further studies are meri ted to assess the possible role of ACE inhibitors in aortic stenosis both b efore and after valve replacement. Potential benefits may include preventio n of LVH, improved diastolic function, reduction of arrhythmias and preserv ation of left ventricular function.