Vasodilator therapy in severe chronic aortic regurgitation in adults
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Asymptomatic patients with chronic aortic regurgitation (AR, also called aortic insufficiency) are generally managed in a conservative fashion and surgery is postponed until the patient develops symptoms, left ventricular (LV) systolic dysfunction, and/or severe LV dilatation. (See "Natural history and management of chronic aortic regurgitation in adults".)
Vasodilator therapy in patients with severe chronic AR is aimed at reducing the hemodynamic burden by reducing regurgitant volume. However, the efficacy of vasodilator therapy has not been established in asymptomatic AR as a means of mitigating changes in LV size and function and delaying the onset of symptoms and thus the need for corrective surgery.
The role of vasodilator therapy in chronic severe AR in adults will be reviewed here. Issues related to the pathophysiology, clinical features, and course and management of chronic AR and to acute AR are discussed separately. (See "Clinical manifestations and diagnosis of chronic aortic regurgitation in adults" and "Natural history and management of chronic aortic regurgitation in adults" and "Acute aortic regurgitation in adults".)
DETERMINANTS OF PROGNOSIS
Among asymptomatic patients with chronic AR and normal LV systolic function (ie, normal left ventricular ejection fraction [LVEF]), the likelihood of progressing to symptoms and/or LV dysfunction ranges from 0 to 19 percent per year according to the absence or presence of LV dysfunction and/or enlargement as determined in part from the LV end-systolic dimension (table 1) [1,2]. Values above 55-60 mm are considered to reflect a decompensated state (table 2) .
As will be described below, vasodilator therapy should be considered only in patients with severe chronic AR and LV dilation . There is no evidence of benefit in patients with mild to moderate AR.
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- DETERMINANTS OF PROGNOSIS
- DETERMINANTS OF REGURGITANT VOLUME
- CLINICAL TRIALS AND STUDIES
- - Outcome after AVR
- ACE inhibitors
- Comparative trial
- Possible explanations for conflicting data
- Clinical trial and study summary
- THERAPEUTIC DECISIONS
- Major society guidelines
- Our approach
- Choice of drug
- Other antihypertensive drugs
- SUMMARY AND RECOMMENDATIONS