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Updated: Nov 15 2022

Aortic Regurgitation

4.8

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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
    • Associated conditions
      • Marfan syndrome
      • reactive arthritis
  • 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
  • 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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