Acute aortic regurgitation medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S; Usama Talib, BSc, MD [2]

Overview

Patients with acute severe aortic regurgitation (AR) are managed with emergency aortic valve replacement or repair. Medical therapy is used for the stabilization of patients prior to surgery.

Medical Therapy

In case cardiogenic shock is present in a patient with acute AR, resuscitation measures should be initiated immediately:

  • Secure airway
  • Administer oxygen
  • Secure wide bore IV access
  • Perform ECG monitor
  • Monitor vitals continuously
  • Admit to ICU

Medical therapy to treat cardiogenic shock should be immediately initiated:

  • Administer nitroprusside 0.3-0.5 υg/kg/min IV (max 10 υg/kg/min), AND
  • Administer dobutamine 0.5 υg/kg/min IV (max 20 υg/kg/min)
  • Titrate to maintain mean arterial pressure (MAP) > 60 mmHg
  • Administer beta blockers in high suspicion of aortic dissection. Do not use beta blockers for other causes as they will block the compensatory tachycardia.

Therapeutic Options

Nitroprusside

Nitroprusside lowers afterload and thereby reduces retrograde flow and left ventricular end diastolic pressure.[1]

Inotropic Agents

Inotropic agents such as dopamine and dobutamine can be used to increase the contractility of the heart resulting in improved forward flow.[2]

Beta Blockers

Beta blockers which are often used in managing aortic dissection should be used very cautiously in the presence of acute AR as beta blockers can block the compensatory tachycardia and worsen the cardiac output.[1]

Antibiotics

Patients who are hemodynamically stable with mild AR secondary to infective endocarditis can be managed with antibiotics alone.[3]

Intraaortic Balloon Pump

Insertion of an intraaortic balloon pump is contraindicated in the treatment of AR, as it may worsen the severity of the regurgitation.[4]

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)[5]

Medical Therapy

Class I
"1.Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or angiotensin converting enzyme (ACE) inhibitors/angiotensin-receptor blockers (ARBs).(Level of Evidence: B)"
Class IIa
"1. Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities. (Level of Evidence: B)"

Reference

  1. 1.0 1.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.". J Am Coll Cardiol. 63 (22): e57–185. PMID 24603191. doi:10.1016/j.jacc.2014.02.536. 
  2. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. PMID 18820172. doi:10.1161/CIRCULATIONAHA.108.190748. Retrieved 2011-04-07.  Unknown parameter |month= ignored (help)
  3. Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ; et al. (2015). "Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.". Circulation. 132 (15): 1435–86. PMID 26373316. doi:10.1161/CIR.0000000000000296. 
  4. Rius JB, Mercè AS, del Blanco BG, Aguasca GM, Mas PT, García-Dorado García D (2011). "Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump.". Circulation. 124 (4): e131. PMID 21788594. doi:10.1161/CIRCULATIONAHA.111.038653. 
  5. "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary" (PDF). Retrieved 4 March 2014. 


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