UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Vasodilator therapy in severe chronic aortic regurgitation in adults

Author
William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

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) [1].

As will be described below, vasodilator therapy should be considered only in patients with severe chronic AR and LV dilation [1]. There is no evidence of benefit in patients with mild to moderate AR.

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Mar 12 00:00:00 GMT+00:00 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Bonow RO, Carabello BA, Chatterjee K, et al. 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 2008; 118:e523.
  2. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007; 28:230.
  3. Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol 1996; 28:1083.
  4. Judge TP, Kennedy JW, Bennett LJ, et al. Quantitative hemodynamic effects of heart rate in aortic regurgitation. Circulation 1971; 44:355.
  5. Firth BG, Dehmer GJ, Nicod P, et al. Effect of increasing heart rate in patients with aortic regurgitation. Effect of incremental atrial pacing on scintigraphic, hemodynamic and thermodilution measurements. Am J Cardiol 1982; 49:1860.
  6. Scognamiglio R, Fasoli G, Ponchia A, Dalla-Volta S. Long-term nifedipine unloading therapy in asymptomatic patients with chronic severe aortic regurgitation. J Am Coll Cardiol 1990; 16:424.
  7. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med 1994; 331:689.
  8. Scognamiglio R, Negut C, Palisi M, et al. Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction. J Am Coll Cardiol 2005; 45:1025.
  9. Lin M, Chiang HT, Lin SL, et al. Vasodilator therapy in chronic asymptomatic aortic regurgitation: enalapril versus hydralazine therapy. J Am Coll Cardiol 1994; 24:1046.
  10. Schön HR, Dorn R, Barthel P, Schömig A. Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation. J Heart Valve Dis 1994; 3:500.
  11. Wisenbaugh T, Sinovich V, Dullabh A, Sareli P. Six month pilot study of captopril for mildly symptomatic, severe isolated mitral and isolated aortic regurgitation. J Heart Valve Dis 1994; 3:197.
  12. Elder DH, Wei L, Szwejkowski BR, et al. The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study. J Am Coll Cardiol 2011; 58:2084.
  13. Evangelista A, Tornos P, Sambola A, et al. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med 2005; 353:1342.
  14. Greenberg B, Massie B, Bristow JD, et al. Long-term vasodilator therapy of chronic aortic insufficiency. A randomized double-blinded, placebo-controlled clinical trial. Circulation 1988; 78:92.
  15. Carabello BA. Vasodilators in aortic regurgitation--where is the evidence of their effectiveness? N Engl J Med 2005; 353:1400.
  16. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation 2005; 112:125.