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  • Review Article
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Aortic regurgitation: disease progression and management

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 269–279 (2008)Cite this article

Abstract

Aortic regurgitation (AR) is a common valvular heart disease that unless appropriately managed is associated with morbidity and mortality. Left ventricular (LV) mechanics and aortic impedance are the main determinants of outcome in patients with AR and govern clinical management. Mild and moderate AR in individuals with normal LV dimensions are both generally benign. In the absence of symptoms and before LV dimensions increase, even severe AR is not generally associated with increased morbidity or mortality. Once LV enlargement occurs, however, symptoms and/or a decline in ejection fraction can develop, and both represent an indication for surgical intervention. Disease progression occurs at a variable rate, and is often insidious. Hence, symptoms do not correlate with objective evidence of ventricular dysfunction. Exercise testing can help highlight symptoms related to valve dysfunction. Asymptomatic patients with severe AR and preserved LV function can benefit from vasodilator drug therapy. Several agents from this class can reduce AR severity, but results are inconsistent. In this Review, we examine the epidemiology of AR in terms of the interplay between arterial and ventricular forces marking progression of disease over time, and analyze the practice guidelines regarding diagnosis and treatment.

Key Points

  • Aortic regurgitation (AR) is a common valvular pathology that when severe often requires valve replacement

  • Evaluation and risk stratification of patients with severe AR requires echocardiography

  • Complex interaction between ventricular and vascular forces governs progression from compensated AR to permanent left ventricular dysfunction

  • Ventricular dysfunction as a result of chronic AR is reversible when treatment is initiated early, but advanced adverse myocardial remodeling can be irreversible

  • Vasodilator drugs such as renin–angiotensin inhibitors can produce favorable myocardial remodeling and benefit patients with AR, but cannot replace definitive surgical treatment when regurgitation is severe

  • Early surgical intervention is generally indicated when AR is associated with expansion of the ascending aorta

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Figure 1: Severe aortic regurgitation increases the volume load on the left ventricle, which along with decreasing aortic distensibility over time, leads to increased stroke work and wall stress.
Figure 2: Survival of patients with severe aortic regurgitation based on left ventricular systolic dimension adjusted for body surface area.
Figure 3: A management algorithm for chronic severe aortic regurgitation.
Figure 4: Cumulative rates of progression to valve replacement surgery for aortic regurgitation in patients treated with nifedipine or digoxin.
Figure 5: The rate of valve replacement surgery in patients receiving nifedipine, enalapril or no treatment.

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Authors and Affiliations

  1. SH Goldbarg is a Fellow in Cardiology at the Mount Sinai Medical Center, and JL Halperin is the Robert and Harriet Heilbrunn Professor of Medicine at the Mount Sinai School of Medicine, and Director of Clinical Cardiology Services in the Zena and Michael A Wiener Cardiovascular Institute at Mount Sinai Medical Center, New York, NY, USA.,

    Seth H Goldbarg & Jonathan L Halperin

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Correspondence to Seth H Goldbarg.

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Goldbarg, S., Halperin, J. Aortic regurgitation: disease progression and management. Nat Rev Cardiol 5, 269–279 (2008). https://doi.org/10.1038/ncpcardio1179

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