Updated: 3/7/2021

Aortic Regurgitation

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Snapshot
  • A 65-year-old man presents to his cardiologist for a check-up. His last appointment was 2 years ago.  Since then, he reports that he has developed significant shortness of breath with exertion and easy fatigability. He has a past medical history of hypertension and coronary artery disease. On cardiac exam, there is a diastolic decrescendo murmur and bounding peripheral pulses. The physician also notices head bobbing. He is scheduled for an echocardiogram.
Introduction
  • Clinical definition
    • a valvular disorder characterized by regurgitation of blood through the aortic valve into the left ventricle during diastole
      • can be chronic or acute
  • Etiology
    • endocarditis
    • rheumatic heart disease
      • most common cause in developing nations
    • bicuspid aortic valve  
      • most common cause in the U.S.
    • hypertension
    • syphilis
    • aortic dissection
    • birth defects
  • Pathogenesis
    • chronic aortic regurgitation causes volume overload in the left ventricle (LV)
      • LV will overstretch, leading to decreased contractility
        • overload in LV → hypertrophy
  • Associated conditions
    • Marfan syndrome
    • reactive arthritis
Presentation
  • Symptoms
    • shortness of breath
    • fatigue
  • Physical exam
    • three distinct murmurs
      • early diastolic decrescendo murmur
        • best at the lower left sternal border
      • Austin Flint murmur
        • apical diastolic rumbling
      • mid-systolic murmur at the apex
    • maneuvers
      • ↑ with hand grip, leg raise, and squatting
      • ↓ with standing and Valsalva 
    • severe cases
      • wide-pulse pressure
      • bounding pulse
      • head bobbing
      • arterial pulsations in fingernails
      • thrill or murmur over femoral arteries
Imaging
  • Chest radiography
    • indication
      • initial evaluation
    • findings
      • LV and aortic dilation
  • Echocardiograph
    • indication
      • gold standard diagnostic test
    • findings
      • aortic regurgitation
      • dilated LV and aorta
Studies
  • Electrocardiogram
    • findings
      • left ventricular hypertrophy
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Mitral stenosis
    • distinguishing factor
      • diastolic murmur with opening snap
      • also a sequela of rheumatic fever
Treatment
  • Management approach
    • endocarditis prophylaxis is not required
    • treat heart failure
  • Conservative
    • salt restriction
      • indication
        • for all patients
  • Medical
    • vasodilating agents
      • indications
        • patients with AR and hypertension
        • bridge to surgery
      • drugs
        • angiotensin-converting enzyme (ACE) inhibitors
        • angiotensin-II receptor blockers (ARBs)
        • nifedipine
    • β-blockers
      • indication
        • patients with AR and heart failure
    • mineralocorticoid antagonists
      • indication
        • patients with AR and heart failure
    • loop diuretics
      • indication
        • patients with AR and heart failure
    • digoxin
      • indication
        • patients with AR and heart failure
  • Operative
    • aortic valve surgery
      • indication
        • symptomatic patients regardless of LV function
        • asymptomatic patients with ejection fraction < 50%
Complications
  • Heart failure and pulmonary congestion
  • Left ventricular hypertrophy

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