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