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Clinical Reference
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Aortic Regurgitation
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Aortic Regurgitation
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Acute vs chronic determination
▶
Acute severe AR is a surgical emergency
▶
Endocarditis, dissection, or trauma etiology
Sudden dyspnea with hemodynamic collapse
LV and aortic diastolic pressures equilibrate rapidly
Chronic AR is insidious
▶
Compensated phase may last years
Decompensation signals irreversible remodeling
If acute severe AR suspected, emergent cardiac surgery activation
▶
Class I recommendation
Do not delay for further workup
Airway and breathing threats
▶
Acute pulmonary edema
▶
SpO2 < 90% on room air
Flash edema from sudden volume overload
Ventilation support
▶
NIV when not hypotensive
Early intubation if cardiogenic shock
Circulation threats
▶
Cardiogenic shock physiology
▶
SBP < 90 mmHg
Cool extremities and tachycardia
Forward flow failure
▶
Low diastolic pressure with coronary hypoperfusion
Narrow effective stroke volume despite wide pulse pressure in chronic AR
Hemodynamic goals and devices
Afterload and rate targets
▶
Afterload reduction priority
▶
IV nitroprusside first-line in acute decompensation
Augment forward flow and reduce regurgitant fraction
Heart rate preservation
▶
Avoid bradycardia which prolongs diastole and worsens regurgitation
Compensatory tachycardia is protective in acute AR
Contraindicated mechanical support
▶
Intra-aortic balloon pump
▶
Absolutely contraindicated
Diastolic augmentation worsens regurgitation
Peripheral VA-ECMO and Impella
▶
Worsen AR hemodynamics
Avoid as bridge in isolated severe AR
Monitoring and escalation
Monitoring bundle
▶
Continuous pulse oximetry
▶
SpO2 target 92% to 96%
Trend during diuresis and afterload reduction
Arterial line
▶
Accurate diastolic pressure tracking
Titration of vasodilators
Escalation triggers
▶
Refractory hypotension after vasodilator
▶
Add inotrope such as dobutamine
ICU level care
Rising lactate or worsening edema
▶
Emergent surgical consultation
Operating room readiness
Immediate consults
Consultation triggers
▶
Acute severe AR
▶
Cardiothoracic surgery emergently
Cardiology and cardiac anesthesia
Suspected etiology
▶
Infectious disease if endocarditis
Vascular or CT surgery if dissection
History
Onset and tempo
Time course
▶
Acute presentation
▶
Sudden dyspnea and collapse
Endocarditis, dissection, or trauma trigger
Chronic presentation
▶
Insidious decline over years
Duration of known murmur and prior echocardiograms
Symptom progression
▶
Rate of decline
▶
NYHA functional class change
Exercise tolerance trend
Prior imaging
▶
Serial LV dimensions
Documented valve morphology
Classic symptoms
Exertional dyspnea
▶
Most common symptom of chronic decompensated AR
▶
Exercise tolerance limitation
NYHA class quantification
Orthopnea and PND
▶
Elevated LV filling pressures
Decompensation marker
Chest pain
▶
Reduced coronary perfusion from low diastolic BP
▶
May occur without coronary disease
Worse with tachycardia
Differentiate from dissection pain
▶
Tearing quality argues for dissection
Pleuritic features
Palpitations
▶
Awareness of forceful heartbeat
▶
Worse lying on left side
Hyperdynamic circulation
Syncope or presyncope
▶
Less common than in aortic stenosis
May indicate severe disease
Risk factors
Valve and root pathology
▶
Bicuspid aortic valve
▶
Most common congenital cause in high-income countries
Heritable
Aortic root dilation or ascending aneurysm
▶
Secondary functional AR
Murmur louder at right sternal border
Chronic hypertension
▶
Leading cause of secondary AR
Connective tissue and inflammatory
▶
Connective tissue disorders
▶
Marfan syndrome FBN1
Ehlers-Danlos and osteogenesis imperfecta
Inflammatory aortitis
▶
Ankylosing spondylitis and reactive arthritis
Giant cell arteritis and syphilitic aortitis
Acquired and acute causes
▶
Rheumatic heart disease
▶
Leading cause in low- to middle-income countries
Prior rheumatic fever
Infective endocarditis
▶
IV drug use
Recent dental or invasive procedures
Blunt chest trauma
Family and collateral history
Heritable conditions
▶
Bicuspid aortic valve in relatives
▶
Familial clustering
Associated root disease
Familial thoracic aortic aneurysm and dissection
▶
Loeys-Dietz syndrome
Marfan and Ehlers-Danlos
Important negatives
▶
Absence of fever or chills
▶
Argues against endocarditis
No tearing chest or back pain
▶
Argues against dissection
Physical Exam
Vital signs
Pulse pressure
▶
Wide pulse pressure hallmark
▶
Elevated systolic and low diastolic BP
Reflects large regurgitant stroke volume
Decreasing diastolic BP
▶
Independent mortality risk factor
Coronary hypoperfusion marker
Hill's sign
▶
Leg SBP >= 30 mmHg higher than arm SBP
Suggests severe AR
Acute AR vitals
▶
Pulse pressure may not be wide
▶
LV has not dilated
Subtle peripheral signs
Tachycardia and low output predominate
Cardiac auscultation
Diastolic murmur
▶
High-pitched blowing early diastolic decrescendo murmur
▶
Best at left sternal border
Patient sitting up, leaning forward, end-expiration
Right sternal border accentuation
▶
Suggests aortic root dilation etiology
Soft and short murmur in acute AR
▶
Rapid pressure equilibration
Easily missed
Additional findings
▶
Austin Flint murmur
▶
Low-pitched diastolic rumble at apex
Specific for severe AR
S3 gallop
▶
Volume overload in severe AR
Not necessarily heart failure
Systolic flow murmur
▶
From increased stroke volume
May be louder than diastolic murmur
Peripheral signs
Hyperdynamic circulation signs
▶
Corrigan water-hammer pulse
▶
Bounding carotid with rapid upstroke and collapse
Quincke pulse
▶
Nail bed capillary pulsation
de Musset sign
▶
Head bobbing with each heartbeat
Apex findings
▶
Displaced hyperdynamic PMI
▶
Laterally and inferiorly displaced
Reflects LV dilation
Signs of decompensation
▶
Pulmonary crackles
Peripheral edema
PITFALLS
Acute AR underrecognition
▶
Subtle physical findings
▶
Pulse pressure not wide
Soft short diastolic murmur
Misattribution to pneumonia or sepsis
▶
Pulmonary edema dominates
Low threshold for echocardiography
Severity misjudgment
▶
Loud murmur does not equal severe AR
▶
Murmur intensity unreliable
Austin Flint and S3 better indicators
Preserved LVEF can mask dysfunction
▶
Reduced global longitudinal strain
Subclinical decompensation
Differential Diagnosis
Life-threatening causes of acute AR
Aortic dissection
▶
Type A dissection
▶
Tearing chest or back pain
Asymmetric blood pressures
New AR murmur with malperfusion
ICD-10 I71.00 dissection of unspecified site
Infective endocarditis
▶
New murmur with fever
▶
Janeway lesions and Osler nodes
Splinter hemorrhages
ICD-10 I33.0 acute and subacute infective endocarditis
Traumatic valve injury
▶
Blunt chest trauma
▶
Deceleration mechanism
Acute regurgitation onset
Murmur and syndrome mimics
Diastolic murmur mimics
▶
Pulmonary regurgitation
▶
Graham Steell murmur in pulmonary hypertension
Diastolic murmur at left sternal border
Mitral stenosis
▶
Low-pitched apical diastolic rumble
Opening snap
Continuous or systolic mimics
▶
Patent ductus arteriosus
▶
Continuous machinery murmur
Ruptured sinus of Valsalva aneurysm
▶
Acute continuous murmur with compromise
Wide pulse pressure mimics
▶
High-output states
▶
Thyrotoxicosis and severe anemia
Arteriovenous fistula
No diastolic murmur
Mixed valve disease
▶
Concomitant aortic stenosis in ~20% of severe AR
ICD-10 I35.1 aortic insufficiency
Laboratory Tests
Cardiac and heart failure markers
BNP / NT-proBNP
▶
Elevated in decompensated AR with heart failure
▶
Useful for monitoring
Correlates with filling pressures
Serial trending
▶
Response to diuresis
Baseline for surveillance
Troponin
▶
Acute coronary syndrome in differential
▶
Acute AR with hemodynamic compromise
Demand ischemia from low diastolic pressure
Infection and inflammation
Endocarditis workup
▶
Blood cultures
▶
Two sets from separate sites
Prior to antibiotics when feasible
ESR and CRP
▶
Elevated in endocarditis or aortitis
Nonspecific markers
Complete blood count
▶
Anemia worsens AR hemodynamics
▶
Increases regurgitant fraction
High-output contribution
Leukocytosis
▶
Supports infective endocarditis
Etiologic and pre-surgical labs
Specialized serology
▶
Syphilis serology RPR or VDRL
▶
Syphilitic aortitis suspicion
Inflammatory markers for aortitis
▶
Giant cell arteritis screen
Pre-operative panel
▶
Basic metabolic panel
▶
Renal function for surgical risk
Diuretic monitoring
Coagulation studies
▶
Pre-surgical baseline
Anticoagulation planning
Diagnostic Tests
Scoring Systems
ACC/AHA staging (2020)
▶
Stage A at risk
▶
Bicuspid valve or aortic root disease
No regurgitation
Stage B progressive
▶
Mild to moderate AR
Normal LV function
Stage C asymptomatic severe
▶
C1 normal LVEF > 55% and LVESD < 50 mm
C2 LVEF <= 55% or LVESD > 50 mm
Stage D symptomatic severe
▶
Exertional dyspnea, angina, or heart failure
TTE severity criteria for severe AR
▶
Jet width >= 65% of LVOT
Vena contracta > 0.6 cm
Regurgitant volume >= 60 ml per beat
Regurgitant fraction >= 50%
Effective regurgitant orifice >= 0.3 cm2
Pressure half-time < 200 ms
Holodiastolic flow reversal in proximal abdominal aorta
Functional and prognostic measures
▶
Global longitudinal strain
▶
GLS worse than -18% to -19% detects subclinical dysfunction
Predicts adverse outcomes with preserved LVEF
Exercise stress testing
▶
Unmask symptoms in asymptomatic severe AR
Abnormal hemodynamic response
MRI
Cardiac MRI role
▶
Gold standard for AR quantification
▶
When echo discordant or suboptimal
Direct regurgitant fraction measurement
Myocardial tissue characterization
▶
Late gadolinium enhancement for fibrosis
T1 mapping predicts adverse outcomes
Limitations
▶
Limited acute utility in unstable patient
Non-compatible implants
Indications and avoidance
▶
Problem solving indications
▶
Discordant echo severity grading
Borderline surgical thresholds
When unnecessary
▶
Mild AR with adequate TTE windows
Stable clinical status
CT
CT angiography
▶
Primary modality for acute aortic dissection
▶
Dissection as cause of acute AR
Rapid availability
Aortic root and ascending aorta
▶
Aneurysm sizing
Surgical planning
Contrast considerations
▶
Renal function assessment
Contrast allergy history
Adjunct chest imaging
▶
Chest X-ray
▶
Cardiomegaly and aortic root dilation
Pulmonary congestion
When CT unnecessary
▶
Mild AR with stable status and adequate TTE
No dissection suspicion
Ultrasound
Transthoracic echocardiography
▶
Cornerstone of diagnosis
▶
Valve morphology and AR severity
LV dimensions, LVEF, aortic root size
Serial surveillance
▶
Compare LVESD and LVEF over time
Detect progression before symptoms
Transesophageal echocardiography
▶
Detailed leaflet morphology
▶
Surgical planning
When TTE inadequate
Dissection assessment
▶
Sensitivity 98% to 100% for Type A dissection
Intraoperative guidance
Point-of-care ultrasound
▶
Bedside LV function estimate
▶
Gross systolic function
Pericardial effusion screen
Volume and shock assessment
▶
IVC assessment
Lung B-lines for pulmonary edema
Disposition
Level of care
ICU and emergent admission
▶
Acute severe AR
▶
Surgical emergency
Operating room readiness
Decompensated chronic AR
▶
Pulmonary edema or hypotension
Cardiogenic shock
New AR with acute etiology
▶
Suspected endocarditis
Suspected aortic dissection
Observation
▶
Borderline new moderate to severe AR
▶
LV parameters near surgical thresholds
Borderline symptoms
Discharge and consultation
Copy
Discharge criteria
▶
Stable chronic AR
▶
Stages A to C1
Established follow-up plan
Hemodynamic stability
▶
No acute etiology identified
Adequate oral intake
Specialist consultation triggers
▶
Cardiology
▶
All new moderate or greater AR for surveillance planning
Cardiothoracic surgery
▶
LVEF <= 55%, LVESD > 50 mm, or symptomatic severe AR
Infectious disease or genetics
▶
Endocarditis suspicion
Connective tissue disorder suspicion
Treatment
Acute severe AR stabilization
Emergent surgery
▶
Emergent surgical aortic valve replacement
▶
Do not delay
Class I recommendation
Operating room activation
▶
Cardiac anesthesia and perfusion
Cross-match blood products
Pharmacologic bridge
▶
Nitroprusside infusion
▶
Start 0.3 mcg/kg/min IV
Titrate by 0.5 mcg/kg/min every 5 minutes to afterload reduction
Maximum 10 mcg/kg/min and limit duration for cyanide risk
Inotropic support if hypotensive
▶
Dobutamine 2 to 20 mcg/kg/min IV
Dopamine alternative to augment forward flow
Heart rate management
▶
Preserve compensatory tachycardia
Avoid agents that slow rate in isolated acute AR
Contraindicated interventions
▶
Intra-aortic balloon pump
▶
Augments diastolic pressure
Worsens regurgitation
Pure vasoconstrictors
▶
Phenylephrine and vasopressin increase afterload
Worsen AR
Beta-blockers in isolated acute AR
▶
Block protective tachycardia
Exception is concurrent aortic dissection
Chronic AR medical therapy
Hypertension control
▶
First-line agents
▶
ACE inhibitors or ARBs for SBP > 140 mmHg
Dihydropyridine CCBs such as amlodipine or nifedipine
Treatment rationale
▶
Reduce wall stress
No proven delay of surgery in normotensive normal LV
Reduced LVEF and prohibitive surgical risk
▶
Guideline-directed medical therapy
▶
ACE inhibitors or ARBs
Sacubitril/valsartan for severe AR with reduced LVEF
Volume management
▶
Diuretics for symptomatic heart failure
Sodium restriction <= 2 g/day
When vasodilators not indicated
▶
Asymptomatic mild to moderate AR with normal LV function
▶
No disease-modifying benefit
Surveillance instead
Surgical intervention indications
Class I indications (ACC/AHA 2020)
▶
Symptomatic severe AR Stage D
▶
Regardless of LVEF
Asymptomatic severe AR with LVEF <= 55% Stage C2
▶
Reduced systolic function
Severe AR undergoing other cardiac surgery
Class IIa indications
▶
Asymptomatic severe AR with LVESD > 50 mm
▶
Or LVESDi > 25 mm/m2
Moderate AR undergoing other cardiac surgery
Class IIb and emerging thresholds
▶
Progressive LVEF decline to 55% to 60% on >= 3 serial studies
▶
Or LVEDD > 65 mm
ESC 2025 earlier intervention in low-risk patients
▶
LVESDi > 22 mm/m2
LVESVi >= 45 ml/m2
GLS worse than -18% to -19%
Surgical options
Replacement and repair
▶
Surgical aortic valve replacement
▶
Mechanical or bioprosthetic
Standard of care
Valve-sparing root replacement (David procedure)
▶
Secondary AR with normal cusps
Especially patients < 65 years
Aortic valve repair
▶
For cusp prolapse at experienced centers
Freedom from reoperation ~88% at 5 years and ~73% at 10 years
Transcatheter therapy
▶
TAVI not recommended for isolated severe AR with surgical indications
▶
Class III harm
Off-label use ~10% need second valve in high-risk patients
Special Populations
Pregnancy
Hemodynamic considerations
▶
Physiologic adaptation often tolerated
▶
Decreased systemic vascular resistance reduces regurgitation
Tachycardia of pregnancy is protective
Decompensation risk
▶
Severe symptomatic AR before pregnancy
Pre-conception counseling and repair
Management adjustments
▶
Medication safety
▶
ACE inhibitors and ARBs contraindicated
Hydralazine and nifedipine for afterload and BP control
Delivery planning
▶
Multidisciplinary cardio-obstetric team
Avoid prolonged Valsalva in severe AR
Geriatric
Etiology and presentation
▶
Common causes
▶
Age-related calcific degeneration
Aortic root dilation and hypertension
Atypical presentation
▶
Fatigue and reduced exertion masking symptoms
Comorbidity overlap
Management adjustments
▶
Surgical risk assessment
▶
Frailty and comorbidity weighting
Consider prohibitive-risk GDMT pathway
Medication considerations
▶
Renal dosing of ACE inhibitors and diuretics
Orthostatic hypotension risk
Pediatrics
Etiology differences
▶
Congenital and acquired causes
▶
Bicuspid aortic valve
Rheumatic heart disease where endemic
Connective tissue disorders
▶
Marfan and Loeys-Dietz syndromes
Progressive root dilation
Management considerations
▶
Surveillance
▶
Serial echocardiography for valve and root
Growth-indexed dimensions
Timing of intervention
▶
Preserve native valve when feasible
Ross procedure consideration in select cases
Background
Epidemiology
Disease burden and causes
▶
Etiologic distribution
▶
Bicuspid aortic valve leading congenital cause in high-income countries
Rheumatic disease leading cause in low- to middle-income countries
Secondary AR
▶
Chronic hypertension and root dilation
Functional aortic regurgitation
Prognosis
▶
Mortality with LV dysfunction
▶
Annual mortality exceeds 20% when LVEF < 30%
Decreasing diastolic BP independent mortality risk
Mixed disease frequency
▶
~20% of severe AR have concomitant aortic stenosis
Pathophysiology
Mechanism of regurgitation
▶
Primary valve pathology
▶
Intrinsic leaflet disease
Endocarditis or rheumatic destruction
Secondary root pathology
▶
Annular and aortic root dilation
Incomplete leaflet coaptation
Hemodynamic progression
▶
Chronic compensation
▶
Eccentric LV hypertrophy and dilation
Maintained stroke volume for years
Decompensation
▶
Maladaptive remodeling and myocardial fibrosis
Often irreversible once established
Acute AR physiology
▶
Non-dilated LV cannot accommodate regurgitant volume
Rapid rise in LV diastolic pressure and pulmonary edema
Therapeutic Considerations
Timing principles
▶
Intervene before irreversible damage
▶
Outcomes best when LVEF preserved above 50%
Serial imaging detects threshold crossing
Acute versus chronic pathways
▶
Acute severe AR is emergent surgery
Chronic AR follows staged surveillance
Medical therapy limits
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No disease-modifying benefit in asymptomatic normal LV
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Vasodilators reserved for hypertension
GDMT for prohibitive surgical risk
Device contraindications
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IABP and Impella worsen regurgitation
Avoid pure vasoconstrictors
Patient Discharge Instructions
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Aortic regurgitation home care
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Take all heart and blood pressure medicines exactly as prescribed
Keep all cardiology and echocardiogram follow-up appointments
Weigh yourself daily and report rapid weight gain
Limit salt in your diet
Activity guidance
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Mild to moderate leak: usually no activity restriction
Severe leak: avoid heavy weightlifting and competitive sports
Resume activity gradually after any procedure
Warning signs to return to ER
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New or worsening shortness of breath, especially at rest or lying flat
Chest pain or fainting
Sudden severe shortness of breath
Fever with a new or changing heart murmur
Sudden tearing chest or back pain
Follow up
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Cardiology follow-up as scheduled
Repeat echocardiogram on the recommended interval
Dental hygiene and tell providers about your valve condition
References
Guidelines and key sources
Valvular heart disease guidelines
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2020 ACC/AHA Guideline for Management of Valvular Heart Disease
2014 AHA/ACC Valvular Heart Disease Guideline
ESC/EACTS valvular heart disease guidelines and 2025 thresholds
Aortic disease and acute care sources
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2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease
Acute Decompensated Valvular Disease in the Intensive Care Unit (JACC Advances 2024)
State-of-the-art reviews
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Contemporary Diagnosis and Treatment of Aortic Regurgitation (JACC 2026)
Imaging Methods for Evaluation of Chronic Aortic Regurgitation (JACC 2023)
Valvular Heart Disease From Mechanisms to Management (Lancet 2024)
Coding standards
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ICD-10 I35.1 aortic insufficiency
ICD-10 I06.1 rheumatic aortic insufficiency
SNOMED CT aortic valve regurgitation disorder concept
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Aortic Regurgitation