AORTIC REGURGITATION   14A

A 64-year-old man presents to the clinic with a 3-month history of worsening shortness of breath. He becomes short of breath after walking one block or up one flight of stairs. He awakens at night gasping for breath and has to prop himself up with pillows to sleep. On physical examination, his blood pressure is 190/60 mm Hg, and his pulses are hyperdynamic. His apical impulse is displaced to the left and downward. There are rales over both lower lung fields. There are two distinct cardiac murmurs: a high-pitched, early diastolic murmur loudest at the left lower sternal border and a diastolic rumble heard at the apex. Chest radiography shows cardiomegaly and pulmonary edema. Echocardiography shows severe aortic regurgitation (AR) with left ventricular hypertrophy (LVH) and dilatation.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Progressive shortness of breath on exertion, paroxysmal nocturnal dyspnea, orthopnea; pulmonary edema and cardiomegaly indicating heart failure (HF); wide pulse pressure; hyperdynamic pulses; early diastolic murmur at the left sternal border; diastolic rumble at the apex (Austin-Flint murmur); echocardiogram diagnostic of AR with LVH and dilatation

How to think through: This patient has symptoms (dyspnea on exertion, paroxysmal nocturnal dyspnea, and orthopnea) and signs (rales) of HF. Can a clinician generally distinguish between systolic, diastolic, and valvular cause based on symptoms? (Not reliably.) The murmurs suggest a valvular cause. The diastolic murmur at the left upper sternal border and the apical diastolic rumble suggest AR. What other data help in the diagnosis of AR? (The wide pulse pressure, high systolic blood pressure, and hyperdynamic carotid pulse are also characteristic of AR.) What underlying processes cause AR? (Rheumatic heart disease, congenitally bicuspid valve, infective endocarditis, hypertension, cystic medial necrosis, Marfan syndrome, aortic dissection, ankylosing spondylitis, and reactive arthritis.) Echocardiography is key to diagnosis and to monitoring progression of AR. Imaging by contrast computed tomography (CT) may be indicated to assess aortic root diameter or ascending aneurysm. How should this patient be managed? (Blood pressure control with afterload reduction can decrease regurgitation. This patient is symptomatic, and elective valve replacement is indicated.)

AORTIC REGURGITATION   14B

What are the essentials of diagnosis and general considerations regarding aortic regurgitation?

Essentials of Diagnosis

Usually asymptomatic until middle age; then presents with left-sided failure or chest pain

Wide pulse pressure; diastolic murmur along the left sternal border

ECG shows left ventricular hypertrophy; radiograph shows left ventricular (LV) dilatation

Echocardiography with Doppler is diagnostic

General Considerations

Rheumatic heart disease is less common since the advent of antibiotics.

Nonrheumatic causes include congenitally bicuspid valve, infective endocarditis, hypertension, cystic medial necrosis, Marfan syndrome, aortic dissection, ankylosing spondylitis, and reactive arthritis.

LVH occurs from both increased preload and afterload.

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