WEDNESDAY, April 30, 2003 (HealthDayNews) -- It's an increasingly common emergency room dilemma: An older patient with aortic stenosis, a narrowing of a heart valve that obstructs blood flow, has been rushed to the hospital in bad shape. The doctor has a tough choice: drug treatment, which may not work in the most severely ill; or surgery to replace the heart valve, which has a high risk of death. And that decision must be made very quickly.
Now a study gives doctors a new choice, for at least some patients. Nitroprusside, a drug commonly used to improve blood flow, can stabilize those patients long enough so a decision about surgery can be made after days, rather than hours, says a report in the May 1 issue of the New England Journal of Medicine.
The study included 25 patients, all with severe aortic stenosis and heart failure, a severely impaired ability of the heart to pump blood. While nitroprusside has been commonly used to treat heart failure, its use has been shunned for such patients because of fears that it would cause dangerously low blood pressure.
Not so, says the journal report. After six hours of nitroprusside treatment, the average cardiac index, a measure of the heart's ability to pump blood, improved by 50 percent. After 24 hours, the index increased another 10 percent. And "nitroprusside was well tolerated and had minimal side effects," the researchers say.
The treatment can be used on about 10 percent to 15 percent of patients with aortic stenosis, says Dr. Michael R. Zile, a professor of medicine at the Medical University of South Carolina and author of an accompanying editorial. There have been hints in the medical literature that it might help these patients, but its use "has not been tested in a group of patients large enough to understand its safety and efficacy profile," he says.
Even this successful trial is hedged about with cautions, he says. "This approach has risks and shouldn't be done by just any physician," Zile says. "It should be done by a specialist in an intensive care unit setting with a hemodynamic monitor."
That was true in the study, he notes. "The patients they studied were highly selected, were intensively monitored and were being treated in an intensive care unit," Zile writes.
"What we've tried to do here is open a window with very sophisticated medical treatment so that we can get the patient back to balance and hope to go to surgery with a lower risk," says Dr. Roger M. Mills, a staff cardiologist at the Cleveland Clinic and a member of the research team.
If a patient with aortic stenosis has also developed heart failure, "the surgical risk is quite high," Mills says. "The basic problem we are dealing with is a surgical disease. If the patient does not undergo valve replacement, the outlook is extremely poor."
For those highly endangered patients, the treatment buys some enormously valuable time, Mills says. "This is not a form of therapy that offers individual patients anything other than a short-term potential opportunity to re-stabilize briefly in hopes of getting to cardiac surgery," he says.
More information
You can learn more about heart valves from the American Heart Association, which also has a page on managing aortic valve disease.
