Aortic regurgitation resident survival guide: Difference between revisions

Aortic Regurgitation Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis Acute Chronic
Treatment Acute Chronic Type of Valve and Anticoagulation
Do's
Don'ts

VisualWikitext

Latest revision as of 22:58, 14 March 2016

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Aortic regurgitation (AR) refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole. The clinical presentation depends on the response and adaptability of the left ventricle to the increased left ventricular diastolic volume. In chronic AR, the left ventricle has adapted by dilatation of its walls; however, in acute AR a rapid increase in the diastolic volume is not tolerated by a normal-size ventricle which could lead to cardiogenic shock. Acute AR can be caused by either aortic dissection or infective endocarditis, and it requires immediate surgical intervention. The most common causes of chronic AR are bicuspid aortic valve and calcific valve disease. The treatment of chronic AR depends on the stage of the disease. Acute AR is a life-threatening condition and must be recognized and treated promptly.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Bicuspid aortic valve
Senile or degenerative calcific aortic valve disease^[1]
Dilatation of the aorta due to primary diseases
Rheumatic fever

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The algorithm below is based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.^[2]^[3]

Boxes in red signify that an urgent management is needed.

Abbreviations: ECG: Electrocardiogram; ICU: Intensive care unit; MAP: Mean arterial pressure ; P2: Second heart sound, pulmonary component; S1: First heart sound; S3: Third heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography

Identify cardinal findings that increase the pretest probability of aortic regurgitation

Acute aortic regurgitation
❑ Low pitched early diastolic murmur

❑ Best heard at the right 2nd intercostal space

❑ Decreased or absent S1
❑ Increased P2
❑ Sudden onset of dyspnea

Chronic aortic regurgitation
❑ High pitched holodiastolic decrescendo murmur

❑ Best heard at the upper left sternal border

❑ Increases with sitting forward, expiration and handgrip

❑ Wide pulse pressure (≥ 60 mmHg)
❑ Presence of S3
❑ Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse

Does the patient have any findings of cardiogenic shock that require urgent management?
❑ Tachycardia
❑ Hypotension
❑ Altered mental status
❑ Tachypnea
❑ Oliguria
❑ Cold extremities

YES

NO

Proceed to the complete diagnostic approach below

Initiate resuscitation measures:
❑ Secure airway
❑ Administer oxygen
❑ Secure wide bore IV access
❑ Perform ECG monitor
❑ Monitor vitals continuously
❑ Admit to ICU

Initiate medical therapy to treat cardiogenic shock:
❑ 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 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

Order urgent TTE:
❑ Confirm aortic regurgitation
❑ Look for additional findings according to etiology:

❑ Vegetations on the leaflets

❑ Aortic root dissection

❑ In high suspicion of aortic dissection or when TTE is nondiagnostic, perform a TEE

Do not perform percutaneous aortic balloon counterpulsation (it will increase the diastolic pressure and the regurgitant volume)

Click here for cardiogenic shock resident survival guide

What is the etiology of aortic regurgitation based on clinical findings and echocardiography?

Type A aortic dissection

Diagnostic clues:
❑ Chest pain of the following characteristics:

❑ Sudden onset

❑ Intense

❑ Tearing and sharp

❑ Worsened by deep breathing or cough

❑ Relieved by sitting upright

❑ Unexplained syncope
❑ Low pitched early diastolic murmur

❑ Best heard at the right 2nd intercostal space

❑ Aortic root dissection found on TTE
❑ Previous history of:

❑ Marfan syndrome

❑ Connective tissue disorder

Infective endocarditis

Diagnostic clues:
❑ Persistent fever
❑ New valvular regurgitation murmur
❑ Previous blood culture positive
❑ Vegetations found on TTE
❑ High risk factors:

❑ Pre-existing cardiac abnormality

❑ Prosthetic valve

❑ Recent surgical or medical procedures

❑ Intravenous drug use

❑ Recent bacterial infection

❑ History of previous endocarditis

❑ Order blood cultures (if they have not been previously ordered)
❑ Evaluate the modified Duke criteria (click here to see)

Symptomatic severe chronic AR

Diagnostic clues:
❑ No TTE findings of aortic dissection or leaflet vegetations
❑ Previous history of aortic valve disease
❑ High pitched holodiastolic decrescendo murmur

❑ Best heard at the upper left sternal border

❑ Increases with sitting forward, expiration and handgrip

❑ Wide pulse pressure (≥ 60 mmHg)
❑ S3
❑ Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse

❑ Immediate surgical intervention

Proceed to the complete diagnostic approach below

Click here for aortic dissection resident survival guide

Click here for infective endocarditis resident survival guide

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.^[2]^[3]

Abbreviations: AVR: Aortic valve replacement; BP: Blood pressure; CBC: Complete blood count; CXR: Chest X-ray; ECG: Electrocardiogram; ESR: Erythrocyte sedimentation rate; HF: Heart failure; LV: Left ventricle; LVEF: Left ventricle ejection fraction; MI: Myocardial infarction; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; S4: Fourth heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography; TAVR: Transcatheter aortic valve replacement

Acute Aortic Regurgitation

Shown below is a complete diagnostic approach for acute aortic regurgitation based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.^[2]

Characterize the symptoms:

❑ Sudden and severe dyspnea
❑ Palpitations
❑ Altered mental status
❑ Cold extremities
❑ Oliguria

Symptoms suggestive of aortic dissection
❑ Chest pain

❑ Sudden onset

❑ Intense

❑ Tearing and sharp

❑ Interscapular

❑ Worsened by deep breathing or cough

❑ Relieved by sitting upright

❑ Unexplained syncope

Symptoms suggestive of infective endocarditis
❑ Fever
❑ Sweats
❑ Fatigue
❑ Pleuritic chest pain
❑ Back pain
❑ Weakness
❑ Myalgias

Inquire about past medical history:
Suggestive of infective endocarditis

❑ Bicuspid aortic valve
❑ Rheumatic fever
❑ Prosthetic valves
❑ Intravenous drug use

❑ Substances used in the mixture

❑ Sharing the equipment

❑ The process of cleaning the equipment

❑ Previous infective endocarditis
Suggestive of aortic dissection
❑ Hypertension
❑ Marfan syndrome
❑ Connective tissue disorder

Examine the patient:

Vitals
❑ Temperature

❑ Fever (suggestive of infective endocarditis)

❑ Heart rate

❑ Tachycardia

❑ Blood pressure

❑ Asymmetric blood pressure in the upper extremities

❑ Hypertension (suggestive of aortic dissection)

❑ Hypotension (suggestive of severe regurgitation or aortic dissection)

❑ Respiratory rate

❑ Tachypnea

Cardiovascular examination
❑ Weak pulses
❑ Jugular venous distension
❑ Cardiac auscultation

❑ Murmur

❑ Low pitched early diastolic murmur (may be absent)

❑ Best heard at the right 2nd intercostal space in aortic dissection

❑ Heart sounds

❑ Decreased or absent S1

❑ Increased P2 (suggestive of pulmonary hypertension)

❑ S3 and S4 may be present

❑ Apical diastolic rumble
Respiratory examination
❑ Rales (suggestive of pulmonary congestion)

❑ Wheeze

Order labs and tests:

❑ TTE (most important test) (Class I; Level of Evidence: B)

❑ In high suspicion of aortic dissection, perform a TEE

❑ Chest X-ray

❑ Increased cardiac silhouette (suggestive of aortic dissection)

❑ Widened mediastinum (suggestive of aortic root dilation)

❑ Pulmonary congestion (suggestive of pulmonary edema or pulmonary hypertension)

❑ ECG

❑ Nonspecific changes of ST and T wave (due to LV enlargement)

❑ Right coronary artery ischemic changes (suggestive of aortic dissection)

❑ ST elevation in II, III, aVF (inferior MI)

❑ ST elevation in V3R and V4R (right ventricle MI)

❑ ST depression in V1-V3 (posterior MI)

❑ Blood culture (if suspected infective endocarditis)
❑ CBC
❑ ESR

❑ Cardiac enzymes (Troponin, CK-MB)

Determine the etiology of the acute aortic regurgitation

Aortic dissection

Diagnostic clues:
❑ Chest pain of the following characteristics:

❑ Sudden onset

❑ Intense

❑ Tearing and sharp

❑ Worsened by deep breathing or cough

❑ Relieved by sitting upright

❑ Syncope
❑ Low pitched early diastolic murmur

❑ Best heard at the right 2nd intercostal space

❑ Previous history of:

❑ Marfan syndrome

❑ Connective tissue disorder

Click here for aortic dissection resident survival guide

Infective endocarditis

Diagnostic clues:
❑ Persistent fever
❑ New valvular regurgitation murmur
❑ Positive blood culture
❑ Vegetations found on TTE
❑ High risk factors:

❑ Pre-existing cardiac abnormality

❑ Prosthetic valve

❑ Recent surgical or medical procedures

❑ Intravenous drug use

❑ Recent bacterial infection

❑ History of previous endocarditis

❑ Evaluate the modified Duke criteria (click here to see)

Click here for infective endocarditis resident survival guide

Other causes

❑ Complication of:

❑ TAVR

❑ Percutaneous aortic balloon dilation

❑ Prosthetic valve dysfunction
❑ Blunt chest trauma

Chronic Aortic Regurgitation

Shown below is a complete diagnostic approach for chronic aortic regurgitation based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.^[2]

Characterize the symptoms:
❑ Asymptomatic
❑ Dyspnea on exertion
❑ Orthopnea
❑ Paroxysmal nocturnal dyspnea
❑ Palpitations
❑ Chest pain
❑ Shortness of breath
❑ Cough
❑ Altered mental status
❑ Syncope
❑ Fatigue

Inquire about past medical history:
❑ Cardiac disease:

❑ Hypertension

❑ Bicuspid aortic valve

❑ Rheumatic fever
❑ Pulmonary disease
❑ Trauma
❑ Syphilis
❑ Ankylosing spondylitis
❑ Acromegaly
❑ Marfan syndrome
❑ Ehlers-Danlos syndrome
❑ Giant cell arteritis
❑ Takayasu's arteritis
❑ Previous cardiac surgery

Examine the patient:

Vitals
❑ Heart rate:

❑ Tachycardia (suggestive of reduced stroke volume)

❑ Blood pressure:

❑ Wide pulse pressure (≥ 60 mmHg)

Cardiovascular examination
❑ Pulses

❑ Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse

❑ Cardiac auscultation

❑ Murmur

❑ High pitched holodiastolic decrescendo murmur

❑ Best heard at the upper left sternal border

❑ Murmur increases with sitting forward, expiration and handgrip

❑ Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex (suggestive of severe regurgitation)

❑ Heart sounds

❑ S2: decreased or absent A2; normal P2

❑ S3 may be present (suggestive of left ventricular dysfunction)

❑ S4 may also be present

❑ Search for other characteristic signs suggestive of aortic regurgitation

❑ Traube's sign: 'pistol shot' pulse heard over the femoral artery

❑ Müller's sign: systolic pulsations of uvula ^[4]
❑ de Musset's sign: head bobbing with each heart beat

❑ Hill's sign: ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures (suggestive of chronic severe AR)
❑ Quincke's sign: pulsation of the capillary bed in the nail

Respiratory examination

❑ Rales (seen when congestive heart failure has developed)

Order imaging studies:

❑ TTE (most important evaluation test) (Class I; Level of Evidence: B)
❑ CMR in cases of moderate or severe AR and suboptimal echocardiographic images for the evaluation of the severity of AR (Class I; Level of Evidence: B)
❑ Chest X-ray

❑ Increased cardiac silhouette (suggestive of LV dilatation)

❑ Widened mediastinum (suggestive of aortic root dilation)

❑ Pulmonary congestion (suggestive of HF)

❑ ECG

❑ Nonspecific changes of ST and T wave (due to LV dilatation)

Classify aortic regurgitation based on the following findings on TTE:

❑ Vena contracta
❑ Jet/LVOT
❑ Regurgitant volume
❑ Regurgitant fraction
❑ Effective regurgitant orifice

Risk of aortic regurgitation (Stage A)

❑ No regurgitation

Mild (Stage B)

❑ Vena contracta <0.3 cm
❑ Jet/LVOT <25%
❑ Regurgitant volume <30 mL/beat
❑ Regurgitant fraction <30%
❑ Effective regurgitant orifice <0.10 cm²

Moderate (Stage B)

❑ Vena contracta 0.3-0.6 cm
❑ Jet/LVOT 25-64%
❑ Regurgitant volume 30-59 mL/beat
❑ Regurgitant fraction 30-49%
❑ Effective regurgitant orifice 0.10-0.29 cm²

Severe

❑ Vena contracta >0.6 cm
❑ Jet/LVOT ≥ 65%
❑ Regurgitant volume ≥60 mL/beat
❑ Regurgitant fraction ≥50%
❑ Effective regurgitant orifice ≥ 0.30 cm²
❑ Holodiastolic flow reversal in the proximal abdominal aorta

Is the patient symptomatic?

No

Yes

Asses the LV and LVEF

Stage C1

❑ Normal LVEF
❑ Mild to moderate dilatation of LV

Stage C2

❑ LV systolic dysfunction
❑ Decreased LVEF or severe LV dilatation

Stage D
❑ Normal or decreased LV systolic function
❑ Moderate to severe LV dilatation

Treatment

Abbreviations: AVR: Aortic valve replacement; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CCB: Calcium channel blocker; LVEF: Left ventricle ejection fraction; TTE: Transthoracic echocardiography

Treatment of Acute Aortic Regurgitation

Shown below is an algorithm for the treatment of acute aortic regurgitation.^[2]

What is the cause of acute AR?

Infective endocarditis

Aortic dissection

Does the patient have AR related heart failure symptoms?

❑ Schedule for an emergent surgery^[5]
❑ Administer beta blockers with caution (beta blockers inhibit compensatory tachycardia)

Yes

No

❑ Schedule for early aortic valve replacement (Class I, level of evidence B)^[6]
Click here for more details

❑ Administer antibiotics^[6]
❑ Follow up the patient
Click here for more details

Treatment of Chronic Aortic Regurgitation

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the blood pressure is more than 140 mmHg. Patients with stage A AR do not require any treatment.^[2]^[3]

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter

What is the severity of the aortic regurgitation?

Severe regurgitation

❑ Vena contracta >0.6 cm
❑ Doppler jet width ≥ 65% of LVOT
❑ Regurgitant volume ≥60 mL/beat
❑ Regurgitant fraction ≥50%
❑ Effective regurgitant orifice ≥ 0.30 cm²
❑ Holodiastolic flow reversal in the proximal abdominal aorta
❑ Left ventricle dilatation

Progressive regurgitation (Stage B)

❑ Vena contracta <0.6 cm
❑ Regurgitant volume <60 mL/beat
❑ Regurgitant fraction <50%
❑ Effective regurgitant orifice <0.30 cm²

Is the patient symptomatic?

Is the patient undergoing
another surgery?

Yes
(Stage D)

No
(Stage C)

No

Yes

❑ LVEF<50%
(Stage C2)

❑ The patient is undergoing another surgery

❑ LVEF ≥ 50%
AND
❑ LVESD > 50mm
(Stage C2)

❑ LVEF ≥ 50%
AND
❑ LVEDD > 65mm
AND
❑ Low surgical risk

❑ LVEF ≥ 50%
AND
❑ LVESD ≤ 50mm
AND
❑ LVEDD ≤ 65mm

AVR (Class I)

AVR (Class IIa)

AVR (Class IIb)

AVR (Class IIa)

❑ Perform a periodic echocardiogram every 6 - 12 months (Class I, Level of Evidence C)
❑ Control hypertension preferably with

❑ Dihydropyridine CCB, or

❑ ACE inhibitors or ARBs (Class I; Level of Evidence: B)

❑ Perform a periodic echocardiogram (Class I; Level of Evidence:B)

❑ Every 3 -5 years for mild regurgitation

❑ Every 1 - 2 years for moderate regurgitation

❑ Control hypertension preferably with

❑ Dihydropyridine CCB, or

❑ ACE inhibitors or ARBs (Class I; Level of Evidence: B)

Type of Valve and Discharge Anticoagulation Therapy

Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.^[2]

Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement

Determine:
❑ Age
❑ Contraindications for anticoagulation

❑ Major bleeding diathesis or coagulopathy

❑ Uncontrolled severe hypertension (systolic blood pressure >200 mmHg)

❑ Recent head trauma

❑ Platelet count < 100 000

❑ Pregnancy

❑ Hypersensitivity to warfarin

❑ Hemorrhagic stroke

❑ Patients ≤ 60 years old
AND
❑ No contraindication for anticoagulation (Class IIa; Level of Evidence: B)

❑ Patients 60 - 70 years old
AND
❑ No contraindication for anticoagulation

❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B)
OR
❑ Patients at any age AND contraindications for anticoagulation therapy (Class I; Level of Evidence: C)

Bioprosthesic
OR
Mechanical prosthesis (Class IIa; Level of Evidence: B)

Mechanical prosthesis

Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis (Class III; Level of Evidence: B)

Bioprosthesis

Does the patient have risk factors for thromboembolism†?

Surgical AVR
OR
TAVR

Yes

No

Surgical AVR

TAVR

Administer for long term:
❑ Warfarin to achieve INR of 3.0 (Class I; Level of Evidence: B)
AND
❑ Aspirin 75-100 mg/d (Class I; Level of Evidence: A)

Administer for long term:
❑ Warfarin to achieve INR of 2.5 (Class I; Level of Evidence: B)
AND
❑ Aspirin 75-100 mg/d (Class I; Level of Evidence: A)

Administer
❑ Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B)
AND
❑ Aspirin 75-100 mg/d long term (Class IIa; Level of Evidence: B)

Administer:

❑ Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B), OR

❑ Clopidogrel 75 mg/d (first 6 months) (Class IIb; Level of Evidence: C)
AND
❑ Aspirin 75-100 mg/d (for life) (Class IIa; Level of Evidence: B)

†Risk factors for thromboembolism include atrial fibrillation, hypercoagulable conditions, left ventricle dysfunction, and previous thromboembolism.

Do's

Order a cardiac MRI in patients with moderate or severe AR with an inconclusive TTE to assess the left ventricular systolic function and the systolic and diastolic volumes, as well as to evaluate the severity of AR (Class I; Level of Evidence: B).^[2]

Schedule for a transthoracic echocardiography (TTE) after aortic valve replacement to evaluate the valve hemodynamics (Class I; Level of Evidence: B).^[2]

Order a TTE when clinical symptoms or signs suggest prosthetic valve dysfunction (Class I; Level of Evidence: C).^[2]

Don'ts

Avoid beta blockers in aortic regurgitation that is not caused by aortic dissection as it will block the compensatory tachycardia.^[2]

Do not use intra-aortic balloon counterpulsation in severe acute aortic regurgitation as it will increase the aortic diastolic pressure and the regurgitant volume.^[2]

Do not administer antibiotics to patients with known aortic regurgitation before blood cultures are obtained for unexplained fever (Class III; Level of Evidence: C).^[2]

Do not prescribe ACE inhibitors to pregnant patients with aortic regurgitation (Class III; Level of Evidence: B).^[2]

References

↑ Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter |month= ignored (help)
↑ ^2.00 ^2.01 ^2.02 ^2.03 ^2.04 ^2.05 ^2.06 ^2.07 ^2.08 ^2.09 ^2.10 ^2.11 ^2.12 ^2.13 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
↑ ^3.0 ^3.1 ^3.2 Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (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–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.
↑ Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. doi:10.1056/NEJMicm050642. PMID 16855259. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)
↑ "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)
↑ ^6.0 ^6.1 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)

Template:WikiDoc Sources

CME Category::Cardiology

[Nishimura-2002-1] Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter |month= ignored (help)

[NishimuraOtto2014-2] 2.00 ^2.01 ^2.02 ^2.03 ^2.04 ^2.05 ^2.06 ^2.07 ^2.08 ^2.09 ^2.10 ^2.11 ^2.12 ^2.13 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.

[BonowCarabello2008-3] 3.0 ^3.1 ^3.2 Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (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–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.

[pmid16855259-4] Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. doi:10.1056/NEJMicm050642. PMID 16855259. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)

[circ.ahajournals.org-5] "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)

[Baddour-2005-6] 6.0 ^6.1 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)

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@@ Line 28: / Line 28: @@
 ==Overview==
-[[Aortic regurgitation]] (AR) refers to the retrograde or backward flow of [[blood]] from the [[aorta]] into the [[left ventricle]] during [[diastole]].  The presentation depends on the response and adaptability of the left ventricle to the increased [[diastolic volume]], in chronic [[AR]] the left ventricle has adapted by dilatation of its walls. However, in acute [[AR]], a rapid increase in the diastolic volume is not tolerated by a normal size ventricle and this could lead to [[cardiogenic shock]].  The most common causes of acute [[aortic regurgitation]] are [[aortic dissection]] and [[infective endocarditis]] and the preferred treatment in both cases is surgical intervention. The most common cause of chronic [[AR]] is [[bicuspid aortic valve]] and the treatment will depend on the [[Aortic insufficiency stages|stage]] of the disease.  Acute [[AR]] is a life-threatening condition and must be recognized and treated promptly.
+[[Aortic regurgitation]] (AR) refers to the retrograde or backward flow of [[blood]] from the [[aorta]] into the [[left ventricle]] during [[diastole]].  The clinical presentation depends on the response and adaptability of the [[left ventricle]] to the increased [[left ventricular]] diastolic volume.  In chronic [[AR]], the [[left ventricle]] has adapted by dilatation of its walls; however, in acute [[AR]] a rapid increase in the [[diastolic]] volume is not tolerated by a normal-size ventricle which could lead to [[cardiogenic shock]].  Acute [[AR]] can be caused by either [[aortic dissection]] or [[infective endocarditis]], and it requires immediate surgical intervention.  The most common causes of chronic [[AR]] are [[bicuspid aortic valve]] and [[Calcific aortic valve disease|calcific valve disease]].  The treatment of chronic AR depends on the [[Aortic insufficiency stages|stage]] of the disease.  Acute [[AR]] is a life-threatening condition and must be recognized and treated promptly.
 ==Causes==
@@ Line 39: / Line 39: @@
 * [[Bicuspid aortic valve]]
 * [[Calcific aortic valve disease|Senile or degenerative calcific aortic valve disease]]<ref name="Nishimura-2002">{{Cite journal  | last1 = Nishimura | first1 = RA. | title = Cardiology patient pages. Aortic valve disease. | journal = Circulation | volume = 106 | issue = 7 | pages = 770-2 | month = Aug | year = 2002 | doi =  | PMID = 12176943 }}</ref>
-* [[Hypertension]]
+*  Dilatation of the aorta due to primary diseases
-* Idiopathic dilatation of the aorta
-* [[Myxomatous degeneration]]
 * [[Rheumatic fever]]
@@ Line 49: / Line 47: @@
 A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The algorithm below is based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|title=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|journal=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref>
-<span style="font-size:85%">Boxes in salmon color signify that an urgent management is needed.</span>
+<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>
-<span style="font-size:85%">'''Abbreviations:''' '''ECG:''' [[electrocardiogram]]; '''TTE:''' [[transthoracic echocardiography]]; '''TEE:''' [[transesophageal echocardiography]]; '''S1:''' first heart sound; '''P2:''' second heart sound, pulmonary component; '''S3:''' third heart sound  </span>
+<span style="font-size:85%">'''Abbreviations:''' '''ECG:''' [[Electrocardiogram]]; '''ICU:''' [[Intensive care unit]]; '''MAP:''' [[Mean arterial pressure]] ; '''P2:''' [[Second heart sound]], pulmonary component; '''S1:''' [[First heart sound]]; '''S3:''' [[Third heart sound]]; '''TTE:''' [[Transthoracic echocardiography]]; '''TEE:''' [[Transesophageal echocardiography]]</span>
 {{Family tree/start}}
 {{familytree  | | | | | | | D01 | | | | | | | | | D01=<div style="width:24em">'''Identify cardinal findings that increase the pretest probability of [[aortic regurgitation]]'''</div><br><div style="width:30em; text-align:left"> '''Acute [[aortic regurgitation]]''' <br> ❑ Low pitched early diastolic murmur
 : ❑ Best heard at the right 2nd intercostal space
-❑ Decreased or absent [[S1]] <br> ❑ Increased P2 <br> ❑ Sudden onset of [[dyspnea]]
+❑ Decreased or absent [[S1]] <br> ❑ Increased [[P2]] <br> ❑ Sudden onset of [[dyspnea]]
 ----
 <br> '''Chronic [[aortic regurgitation]]''' <br> ❑ High pitched holodiastolic decrescendo murmur
 : ❑ Best heard at the upper left sternal border
 : ❑ Increases with sitting forward, [[expiration]] and handgrip
-❑  [[Wide pulse pressure]] (≥ 60 mmHg) <br> ❑ [[S3]] <br> ❑ [[Corrigan's pulse]]: a rapid upstroke and collapse of the [[carotid artery]] pulse </div>}}
+❑  [[Wide pulse pressure]] (≥ 60 mmHg) <br> ❑ Presence of [[S3]] <br> ❑ [[Corrigan's pulse]]: a rapid upstroke and collapse of the [[carotid artery]] pulse </div>}}
-{{familytree  | | | | | | | |!| | | | | | | | | | }}
+{{familytree  | | | | | | | |!| | | | | | | }}
-{{familytree  | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''Does the patient have any of the following findings that require urgent management?'''<br>
+{{familytree  | | | | | | | A01 | | | | | |  A01= <div style="float: left; text-align: left; width: 24em; padding:1em;">'''Does the patient have any  findings of cardiogenic shock that require urgent management?'''<br>
 ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ [[Altered mental status]]<br>❑ [[Tachypnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</div>}}
 {{family tree | | | | |,|-|-|^|-|-|-|.| }}
-{{family tree | | | | B01 | | | | | B02 | |B01=<div style="width:20em;background: #FA8072">{{fontcolor|#F8F8FF|'''YES'''}}</div>| B02='''NO'''}}
+{{family tree | | | | B01 | | | | | B02 | |B01=<div style="width:21em;background: #FA8072">{{fontcolor|#F8F8FF|'''YES'''}}</div>| B02=<div style="width:12em">'''NO'''</div>}}
-{{family tree | | | | |!| | | | | | |!| | | | }}
+{{family tree | | | | |!| | | | | | |!| | | }}
-{{family tree | | | | C01 | | | | | C02 | | | |C01=<div style="float: left; text-align: left; width: 20em ;background: #FA8072">{{fontcolor|#F8F8FF| '''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen <br> ❑ 2 wide bore IV access <br> ❑ ECG monitor <br> ❑ Monitor vitals continuously <br> ❑ ICU admission <br><br> '''Initiate medical therapy''' <br> ❑ Administer [[nitroprusside|<span style="color:white;">nitroprusside</span>]] 0.3-0.5 υg/kg/min IV (max 10 υg/kg/min), AND <br> ❑ Administer [[dobutamine|<span style="color:white;">dobutamine</span>]] 0.5  υg/kg/min IV (max 20 υg/kg/min) <br>
+{{family tree | | | | |!| | | | | | C02| | | |C02=<div style="width:12em"> '''Proceed to the [[Aortic regurgitation resident survival guide#Complete Diagnostic Approach|complete diagnostic approach]] below''' </div>}}
-❑  Administer [[Beta blockers|<span style="color:white;">beta blockers</span>]] in high suspicion of [[Aortic dissection|<span style="color:white;">aortic dissection</span>]]<br> '''''Do not use [[Beta blockers|<span style="color:white;">beta blockers</span>]] for other causes as they will block the compensatory tachycardia''''' <br><br>
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; width: 21em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen <br> ❑ Secure wide bore IV access <br> ❑ Perform ECG monitor <br> ❑ Monitor vitals continuously <br> ❑ Admit to [[ICU|<span style="color:white;">ICU </span>]] <br><br> '''Initiate medical therapy to treat cardiogenic shock:''' <br> ❑ Administer [[nitroprusside|<span style="color:white;">nitroprusside</span>]] 0.3-0.5 υg/kg/min IV (max 10 υg/kg/min), AND <br> ❑ Administer [[dobutamine|<span style="color:white;">dobutamine</span>]] 0.5  υg/kg/min IV (max 20 υg/kg/min) <br> ❑  Titrate to maintain [[MAP|<span style="color:white;">MAP</span>]] > 60 mmHg <br> ❑  Administer [[Beta blockers|<span style="color:white;">beta blockers</span>]] in high suspicion of [[Aortic dissection|<span style="color:white;">aortic dissection</span>]]<br> '''''Do not use [[Beta blockers|<span style="color:white;">beta blockers</span>]] for other causes as they will block the compensatory tachycardia''''' <br><br>
-'''Order urgent [[TTE|<span style="color:white;">TTE</span>]]''' <br> ❑ Confirm [[aortic regurgitation|<span style="color:white;">aortic regurgitation</span>]] <br> ❑ Additional findings according to etiology:
+'''Order urgent [[TTE|<span style="color:white;">TTE</span>]]:''' <br> ❑ Confirm [[aortic regurgitation|<span style="color:white;">aortic regurgitation</span>]] <br> ❑ Look for additional findings according to etiology:
 : ❑ [[Vegetation|<span style="color:white;">Vegetations</span>]] on the leaflets
-: ❑ Aortic root dissection}}
+: ❑ [[Aortic dissection|<span style="color:white;">Aortic root dissection</span>]]
-'''In high suspicion of [[Aortic dissection|<span style="color:white;">aortic dissection</span>]] or when [[TTE|<span style="color:white;">TTE</span>]] is nondiagnostic, perform a [[TEE|<span style="color:white;">TEE</span>]]'''  <br> '''Do not perform [[Percutaneous Aortic Balloon Valvotomy|<span style="color:white;">Percutaneous Aortic Balloon Valvotomy</span>]]''' (it will increase the diastolic pressure and the regurgitant volume)</div>
+❑ '''In high suspicion of [[Aortic dissection|<span style="color:white;">aortic dissection</span>]] or when [[TTE|<span style="color:white;">TTE</span>]] is nondiagnostic, perform a [[TEE|<span style="color:white;">TEE</span>]]'''  <br><br> '''Do not perform [[Intra-aortic balloon pump|<span style="color:white;">percutaneous aortic balloon counterpulsation</span>]]''' (it will increase the diastolic pressure and the regurgitant volume)</div>}}
-|C02=<div style="width:15em"> '''Proceed to [[Aortic regurgitation resident survival guide#Complete Diagnostic Approach|Complete Diagnostic Approach]]''' </div>}}
 {{family tree | | | | |!| | | | | | | | | | }}
-{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | X01 | | | | | | | |X01='''What is the etiology based on clinical findings and [[echocardiography|<span style="color:white;">echo</span>]]?''' }}
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | Y01 | | | | | | | |Y01= <div style="float: left; text-align: Left;"> '''Click here for [[cardiogenic shock resident survival guide|<span style="color:white;">cardiogenic shock resident survival guide</span>]]''' </div>}}
-{{family tree | |,|-|-|+|-|-|.| | | | | | | }}
+{{family tree | | | | |!| | | | | | | | | | }}
-{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| D01 | | D02 | | D03 | | | D01=<div style="float: left; text-align: center; width:21em "> '''[[Aortic dissection|<span style="color:white;">Type A aortic dissection</span>]]'''</div><br>
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | | | X01 | | | | | | | |X01='''What is the etiology of aortic regurgitation based on clinical findings and [[echocardiography|<span style="color:white;">echocardiography</span>]]?''' }}
+{{family tree | |,|-|-|+|-|-|-|.| | | | | | | }}
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| D01 | | D02 | |D03| | D01=<div style="float: left; text-align: center; width:20em "> '''[[Aortic dissection|<span style="color:white;">Type A aortic dissection</span>]]'''</div><br>
 ----
 <div style="float: left; text-align: left"> '''Diagnostic clues:''' <br> ❑ [[Chest pain|<span style="color:white;">Chest pain</span>]] of the following characteristics:
@@ Line 86: / Line 85: @@
 : ❑ Worsened by deep breathing or [[cough|<span style="color:white;">cough</span>]]
 : ❑ Relieved by sitting upright <br>
-❑ [[Syncope|<span style="color:white;">Syncope</span>]] <br> ❑ Low pitched early [[diastolic murmur|<span style="color:white;">diastolic murmur</span>]]
+❑ Unexplained [[syncope|<span style="color:white;">syncope</span>]] <br> ❑ Low pitched early [[diastolic murmur|<span style="color:white;">diastolic murmur</span>]]
 : ❑ Best heard at the right 2nd intercostal space
 ❑ Aortic root dissection  found on [[TTE|<span style="color:white;">TTE</span>]]<br> ❑ Previous history of:
 : ❑ [[Marfan syndrome|<span style="color:white;">Marfan syndrome</span>]]
 : ❑ [[The heart in mixed connective tissue disorder|<span style="color:white;">Connective tissue disorder</span>]]  </div>
-|D02=<div style="float: left; text-align: center; width:21em"> '''[[Infective endocarditis|<span style="color:white;">Infective endocarditis</span>]]'''</div><br>
+|D02=<div style="float: left; text-align: center; width:19em"> '''[[Infective endocarditis|<span style="color:white;">Infective endocarditis</span>]]'''</div><br>
 ----
 <div style="float: left; text-align: left">'''Diagnostic clues:''' <br> ❑ Persistent [[fever|<span style="color:white;">fever</span>]] <br> ❑ New valvular regurgitation murmur <br> ❑  Previous [[blood culture|<span style="color:white;">blood culture</span>]] positive <br> ❑ [[Vegetation|<span style="color:white;">Vegetations</span>]] found on [[TTE|<span style="color:white;">TTE</span>]] <br> ❑ High risk factors:
@@ Line 101: / Line 100: @@
 : ❑ History of previous [[endocarditis|<span style="color:white;">endocarditis</span>]]
 <br>
-❑ Evaluate the [[Infective endocarditis resident survival guide#Modified Duke Criteria|<span style="color:white;">modified Duke criteria</span>]] (click '''[[Infective endocarditis resident survival guide#Modified Duke Criteria|<span style="color:white;">here</span>]]''' to see the [[Infective endocarditis resident survival guide#Modified Duke Criteria|<span style="color:white;">modified Duke criteria</span>]] )<br>
+❑ Order [[blood culture|<span style="color:white;">blood cultures</span>]] (if they have not been previously ordered) <br> ❑ Evaluate the [[Infective endocarditis resident survival guide#Modified Duke Criteria|<span style="color:white;">modified Duke criteria</span>]] (click '''[[Infective endocarditis resident survival guide#Modified Duke Criteria|<span style="color:white;">here</span>]]''' to see) </div>| D03 =<div style="float: left; text-align: center; width:20em "> '''Symptomatic severe chronic AR''' </div><br>
-❑ Order [[blood culture|<span style="color:white;">blood cultures</span>]] (if they have not been previously ordered) <br> </div>| D03 =<div style="float: left; text-align: center; width:21em "> '''Chronic AR'''</div><br>
+----
-----}}
+<div style="float: left; text-align: left; width:19em "><br> '''Diagnostic clues:''' <br>❑ No [[TTE|<span style="color:white;">TTE</span>]] findings of [[Aortic dissection|<span style="color:white;">aortic dissection</span>]] or leaflet [[Vegetation|<span style="color:white;">vegetations</span>]] <br> ❑ Previous history of [[aortic valve disease|<span style="color:white;">aortic valve disease</span>]] <br> ❑ High pitched holodiastolic decrescendo murmur
-{{family tree | |!| | | |!| | | | | | | | }}
+: ❑ Best heard at the upper left sternal border
-{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | | | | | | E01=<div style="float: left; text-align: Left; width:23em ">❑ '''Immediate surgical intervention''' </div> |E02=<div style="float: left; text-align: Left;"> ❑ '''Immediate surgical intervention'''  </div> }}
+: ❑ Increases with sitting forward, [[expiration|<span style="color:white;">expiration</span>]] and handgrip
-{{family tree | |!| | | |!| | | | | | | | }}
+❑  [[Wide pulse pressure|<span style="color:white;">Wide pulse pressure</span>]] (≥ 60 mmHg) <br> ❑ [[S3|<span style="color:white;">S3</span>]] <br> ❑ [[Corrigan's pulse|<span style="color:white;">Corrigan's pulse</span>]]: a rapid upstroke and collapse of the [[carotid artery|<span style="color:white;">carotid artery</span>]] pulse <br> <br> </div>}}
-{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| F01 | | F02 | | | | | | | F01=<div style="float: left; text-align: Left; width:23em ">  '''Click here for [[aortic dissection resident survival guide|<span style="color:white;">aortic dissection resident survival guide </span>]]'''</div> |F02=<div style="float: left; text-align: Left;"> '''Click here for [[infective endocarditis resident survival guide|<span style="color:white;">infective endocarditis resident survival guide</span>]]''' </div> }}
+{{family tree | |!| | | |!| | | |!| | | | }}
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| E01 | | E02 | | |!| | | | E01=<div style="float: left; text-align: Left; width:20em ">❑ '''Immediate surgical intervention''' </div> |E02=<div style="float: left; text-align: Left;"> ❑ '''Immediate surgical intervention'''  </div> }}
+{{family tree | |!| | | |!| | | Z01 | | | |Z01=<div style="width:12em"> '''Proceed to the [[Aortic regurgitation resident survival guide#Chronic Aortic Regurgitation|complete diagnostic approach]] below''' </div>}}
+{{family tree |boxstyle=background: #FA8072; color: #F8F8FF;| F01 | | F02 | | | | | | | F01=<div style="float: left; text-align: Left; width:20em ">  '''[[aortic dissection resident survival guide|<span style="color:white;">Click here for aortic dissection resident survival guide </span>]]'''</div> |F02=<div style="float: left; text-align: Left;"> '''[[infective endocarditis resident survival guide|<span style="color:white;">Click here for infective endocarditis resident survival guide</span>]]''' </div> }}
 {{Family tree/end}}
@@ Line 113: / Line 115: @@
 A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|title=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|journal=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref>
-<span style="font-size:85%">'''Abbreviations:''' '''BP:''' [[blood pressure]]; '''CXR:''' [[chest X-ray]]; '''ECG:''' [[electrocardiogram]]; '''LV:''' [[left ventricle]]; '''MI:''' [[myocardial infarction]]; '''TTE:''' [[transthoracic echocardiography]]; '''TEE:''' [[transesophageal echocardiography]]; '''TAVR:''' [[transcatheter aortic valve replacement]]; '''S1:''' first heart sound; '''S2:''' second heart sound; '''S3:''' third heart sound; </span>
+<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' Aortic valve replacement; '''BP:''' [[Blood pressure]]; '''CBC:''' [[Complete blood count]]; '''CXR:''' [[Chest X-ray]]; '''ECG:''' [[Electrocardiogram]]; '''ESR:''' [[Erythrocyte sedimentation rate]]; '''HF:''' [[Heart failure]]; '''LV:''' [[Left ventricle]]; '''LVEF:''' [[Ejection fraction|Left ventricle ejection fraction]]; '''MI:''' [[Myocardial infarction]]; '''S1:''' [[First heart sound]]; '''S2:''' [[Second heart sound]]; '''S3:''' [[Third heart sound]]; '''S4:''' [[Fourth heart sound]]; '''TTE:''' [[Transthoracic echocardiography]]; '''TEE:''' [[Transesophageal echocardiography]]; '''TAVR:''' [[Transcatheter aortic valve replacement]] </span>
 ===Acute Aortic Regurgitation===
+Shown below is a complete diagnostic approach for acute [[aortic regurgitation]] based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 {{Family tree/start}}
 {{family tree | | | | | V01 | | | | | | | | | | | | | | | |V01= <div style="float: left; text-align: left; width:30em; line-height: 150%;">'''Characterize the symptoms:''' <br>
-❑ Sudden and severe [[dyspnea]]  <br> ❑ [[Palpitations]]<br> ❑ [[Altered mental status]] <br> ❑ Cold extremities <br> ❑  [[Oliguria]] <br> <br> '''Symptoms suggestive of [[aortic dissection]]''' <br> ❑ [[Chest pain]]
+❑ Sudden and severe [[dyspnea]]  <br> ❑ [[Palpitations]]<br> ❑ [[Altered mental status]] <br> ❑ [[Cold extremities]] <br> ❑  [[Oliguria]] <br> <br> '''Symptoms suggestive of [[aortic dissection]]''' <br> ❑ [[Chest pain]]
 : ❑ Sudden onset
 : ❑ Intense
@@ Line 126: / Line 130: @@
 : ❑ Worsened by deep breathing or [[cough]]
 : ❑ Relieved by sitting upright <br>
-❑ [[Syncope]] <br> <br>
+❑ Unexplained [[syncope]] <br> <br>
 '''Symptoms suggestive of [[infective endocarditis]]'''<br> ❑ [[Fever]] <br> ❑ [[Sweat]]s <BR> ❑ [[Fatigue]] <BR> ❑ [[Pleuritic chest pain]] <BR> ❑ [[Back pain]] <br> ❑ [[Weakness]] <BR> ❑ [[Myalgia]]s <BR></div> }}
 {{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
-{{Family tree | | | | | Y01 | | | | | | | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:30em ">'''Inquire about past medical history:''' <br> ❑ [[Cardiac disease]]: <br>
+{{Family tree | | | | | Y01 | | | | | | | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:30em ">'''Inquire about past medical history:''' <br>'''Suggestive of [[infective endocarditis]]''' <br>
-: ❑ [[Hypertension]]
+❑ [[Bicuspid aortic valve]] <br> ❑ [[Rheumatic fever]] <br> ❑  [[Prosthetic valves]] <BR> ❑ [[Intravenous drug use]]<BR>
-: ❑ [[Bicuspid aortic valve]]
-❑ [[Rheumatic fever]]  <br> ❑ [[Marfan syndrome]] <br> ❑ [[The heart in mixed connective tissue disorder|Connective tissue disorder]] <br> ❑  [[Prosthetic valves]]<BR> ❑ [[Intravenous drug use]]<BR>
 :❑ Substances used in the mixture
 :❑ Sharing the equipment
 :❑ The process of cleaning the equipment
-❑ Previous [[infective endocarditis]]</div> }}
+❑ Previous [[infective endocarditis]]<br> '''Suggestive of [[aortic dissection]]'''<br> ❑ [[Hypertension]] <br> ❑ [[Marfan syndrome]] <br> ❑ [[The heart in mixed connective tissue disorder|Connective tissue disorder]] </div> }}
 {{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
 {{Family tree | | | | | A01 | | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; width:30em; line-height: 150% ">'''Examine the patient:''' <br>
@@ Line 145: / Line 147: @@
 : ❑ [[Tachycardia]] <br>
 ❑ [[Blood pressure]]
-: ❑ Systolic [[BP]] differential > 20 mmHg <br>
+: ❑ Asymmetric [[blood pressure]] in the [[upper extremities]]<br>
 : ❑ [[Hypertension]] (suggestive of [[aortic dissection]])
-: ❑ [[Hypotension]] (suggestive of severe regurgitation)
+: ❑ [[Hypotension]] (suggestive of severe regurgitation or [[aortic dissection]])
 ❑ [[Respiratory rate]]
 : ❑ [[Tachypnea]]
@@ Line 170: / Line 172: @@
 {{Family tree | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: Left; width:30em "> '''Order labs and tests:''' <br>
 ❑ [[TTE]] (most important test) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])
-: ''In high suspicion of [[aortic dissection]], perform a [[TEE]]'' <br>
+: ❑ ''In high suspicion of [[aortic dissection]], perform a [[TEE]]'' <br>
 ❑ [[Chest X-ray]] <br>
-: ❑ Increase cardiac silhouette (suggestive of [[aortic dissection]])
+: ❑ Increased cardiac silhouette (suggestive of [[aortic dissection]])
 : ❑ [[Widened mediastinum]] (suggestive of aortic root dilation)
 : ❑ Pulmonary congestion (suggestive of [[pulmonary edema]] or [[pulmonary hypertension]])
@@ Line 178: / Line 180: @@
 : ❑ Nonspecific changes of [[ST]] and [[T wave]] (due to [[LV]] enlargement)
 : ❑ [[Right coronary artery]] ischemic changes (suggestive of [[aortic dissection]])
-:: ❑ [[ST elevation]] in II, III, aVF ([[Inferior MI]])
+:: ❑ [[ST elevation]] in II, III, aVF ([[inferior MI]])
-:: ❑ [[ST elevation]] in V3R and V4R ([[Right ventricle MI]])
+:: ❑ [[ST elevation]] in V3R and V4R ([[right ventricle MI]])
-:: ❑ [[ST depression]] in V1-V3 ([[Posterior MI]])
+:: ❑ [[ST depression]] in V1-V3 ([[posterior MI]])
-❑ [[Blood culture]] (if suspected [[infective endocarditis]])
+❑ [[Blood culture]] (if suspected [[infective endocarditis]])<br>
+❑ [[CBC]] <br>
+❑ [[Erythrocyte sedimentation rate|ESR]] <br>
 ❑ [[Cardiac enzymes]] ([[Troponin]], [[CK-MB]])</div>}}
 {{family tree | | | | | |!| | | | | | | | | | | }}
@@ Line 198: / Line 202: @@
 ❑ Previous history of:
 : ❑ [[Marfan syndrome]]
-: ❑ [[The heart in mixed connective tissue disorder|Connective tissue disorder]]  </div>
+: ❑ [[The heart in mixed connective tissue disorder|Connective tissue disorder]] <br><br>[[aortic dissection resident survival guide|Click here for aortic dissection resident survival guide]] </div>
 |D02=<div style="float: left; text-align: center; width:30em"> '''[[Infective endocarditis]]'''</div><br><br>
 ----
@@ Line 208: / Line 212: @@
 : ❑ Recent [[bacterial infection]]
 : ❑ History of previous [[endocarditis]]
-❑ Evaluate the [[Infective endocarditis resident survival guide#Modified Duke Criteria|modified Duke criteria]] (click '''[[Infective endocarditis resident survival guide#Modified Duke Criteria|here]]''' to see)<br><br><br> </div>
+❑ Evaluate the [[Infective endocarditis resident survival guide#Modified Duke Criteria|modified Duke criteria]] (click '''[[Infective endocarditis resident survival guide#Modified Duke Criteria|here]]''' to see)<br><br>[[infective endocarditis resident survival guide| Click here for infective endocarditis resident survival guide]]<br> </div>
 |D03=<div style="float: left; text-align: center; width:22em "> '''Other causes'''</div><br><br>
 ----
@@ Line 215: / Line 219: @@
 : ❑ [[Percutaneous aortic balloon dilation]]
 ❑ [[Prosthetic valve|Prosthetic valve dysfunction]] <br> ❑ Blunt [[chest trauma]] <br><br><br><br><br><br><br><br><br><br><br></div> }}
-{{family tree | |!| | | |!| | | | | | | | | | | }}
-{{family tree | E01 | | E02 | | | | | | | E01=<div style="float: left; text-align: Left; width:18em ">  Click here for [[aortic dissection resident survival guide]]</div> |E02=<div style="float: left; text-align: Left;">  Click here for [[infective endocarditis resident survival guide]] </div> }}
 {{family tree/end}}
 <br>
 ===Chronic Aortic Regurgitation===
+Shown below is a complete diagnostic approach for chronic [[aortic regurgitation]] based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 {{Family tree/start}}
@@ Line 243: / Line 246: @@
 ❑ [[Cardiac auscultation]]<br>
 : ❑ [[Murmur]]
-:: ❑ High pitched holodiastolic decrescendo murmur
+:: ❑ High pitched holodiastolic decrescendo [[murmur]]
 :: ❑ Best heard at the upper left sternal border
-:: ❑ Murmur increases with sitting forward, [[expiration]] and handgrip
+:: ❑ [[Murmur]] increases with sitting forward, [[expiration]] and handgrip
-:: ❑ [[Austin Flint murmur]]: a soft mid-diastolic rumble, best heard at the cardiac apex (suggestive of severe regurgitation)
+:: ❑ [[Austin Flint murmur]]: a soft mid-diastolic rumble, best heard at the cardiac apex (suggestive of [[Aortic regurgitation|severe regurgitation]])
 : ❑ [[Heart sounds]]
 :: ❑ [[S2]]: decreased or absent A2;  normal P2
@@ Line 260: / Line 263: @@
 {{family tree | | | | | | | |!| | | | | | | | |}}
 {{Family tree | | | | | | | B01 | | | | | | | | |B01=<div style="float: left; text-align: Left; width:30em "> '''Order imaging studies:''' <br>
 ❑ [[TTE]] (most important evaluation test) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br>
+❑ CMR in cases of moderate or severe AR and suboptimal echocardiographic images for the evaluation of the severity of AR ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br>
 ❑ [[Chest X-ray]]
-: ❑ Increase cardiac silhouette (suggestive of [[Dilated cardiomyopathy|LV dilatation]])
+: ❑ Increased cardiac silhouette (suggestive of [[Dilated cardiomyopathy|LV dilatation]])
 : ❑ [[Widened mediastinum]] (suggestive of [[aortic root dilation]])
 [[Image:Wide mediastinum.jpg|200px|center|border]]
@@ Line 272: / Line 276: @@
 {{family tree | | | | | | | N01 | | | | | N01= '''Classify [[aortic regurgitation]] based on the following findings on [[TTE]]:'''<br><div style="text-align:left"> ❑ [[Vena contracta]] <br> ❑ Jet/LVOT <br> ❑ Regurgitant volume <br> ❑ Regurgitant fraction <br> ❑ Effective regurgitant orifice </div>}}
 {{family tree | |,|-|-|-|v|-|^|-|v|-|-|-|.| | |}}
-{{family tree | C01 | | C02 | | C03 | | C04 | | C01=<div style="width: 10em;text-align:center">'''Risk of [[AI]]''' ([[Aortic regurgitation stages|Stage A]]) </div><div style="text-align:left;width:10em"> <br> ❑ No regurgitation  </div>| C02=<div style="width: 12em">  '''Mild''' ([[Aortic regurgitation stages|Stage B]])</div><div style="text-align:left"> <br> ❑ [[Vena contracta]] <0.3 cm <br> ❑ Jet/LVOT <25% <br> ❑ Regurgitant volume <30 mL/beat <br> ❑ Regurgitant fraction <30% <br> ❑ Effective regurgitant orifice <0.10 cm² </div>| C03=<div style="width: 12em">'''Moderate''' ([[Aortic regurgitation stages|Stage B]]) </div><div style="text-align:left"><br> ❑ [[Vena contracta]] 0.3-0.6 cm <br> ❑ Jet/LVOT 25-64% <br> ❑ Regurgitant volume 30-59 mL/beat <br> ❑ Regurgitant fraction 30-49% <br> ❑ Effective regurgitant orifice 0.10-0.29 cm² </div>| C04=<div style="width: 20em">'''Severe''' </div><div style="text-align:left"><br> ❑ [[Vena contracta]] >0.6 cm <br> ❑ Jet/LVOT ≥ 65% <br> ❑ Regurgitant volume ≥60 mL/beat <br> ❑ Regurgitant fraction ≥50% <br> ❑ Effective regurgitant orifice ≥ 0.30 cm² <br> ❑  Holodiastolic flow reversal in the proximal abdominal aorta </div>}}
+{{family tree | C01 | | C02 | | C03 | | C04 | | C01=<div style="width: 10em;text-align:center">'''Risk of [[aortic regurgitation]]''' '''([[Aortic regurgitation stages|Stage A]])''' </div><div style="text-align:left;width:10em"> <br> ❑ No regurgitation  </div>| C02=<div style="width: 12em">  '''Mild''' '''([[Aortic regurgitation stages|Stage B]])'''</div><div style="text-align:left"> <br> ❑ [[Vena contracta]] <0.3 cm <br> ❑ Jet/LVOT <25% <br> ❑ Regurgitant volume <30 mL/beat <br> ❑ Regurgitant fraction <30% <br> ❑ Effective regurgitant orifice <0.10 cm² </div>| C03=<div style="width: 12em">'''Moderate''' '''([[Aortic regurgitation stages|Stage B]])''' </div><div style="text-align:left"><br> ❑ [[Vena contracta]] 0.3-0.6 cm <br> ❑ Jet/LVOT 25-64% <br> ❑ Regurgitant volume 30-59 mL/beat <br> ❑ Regurgitant fraction 30-49% <br> ❑ Effective regurgitant orifice 0.10-0.29 cm² </div>| C04=<div style="width: 20em">'''Severe''' </div><div style="text-align:left"><br> ❑ [[Vena contracta]] >0.6 cm <br> ❑ Jet/LVOT ≥ 65% <br> ❑ Regurgitant volume ≥60 mL/beat <br> ❑ Regurgitant fraction ≥50% <br> ❑ Effective regurgitant orifice ≥ 0.30 cm² <br> ❑  Holodiastolic flow reversal in the proximal abdominal aorta </div>}}
-{{family tree | | | | | | | | | | | | |,|-|^|-|.| | }}
+{{family tree | | | | | | | | | | | | | |!| | | | | }}
-{{family tree | | | | | | | | | | | | D01 | | D02 | | | | | |D01=<div style="text-align:center; width:11em">'''Asymptomatic'''</div><div style="text-align:left"> <br> '''[[Aortic regurgitation stages|Stage C1]]''' <br> ❑ Normal [[LVEF]] <br> ❑ Mild to moderate dilatation <br> '''[[Aortic regurgitation stages|Stage C2]]''' <br> ❑ [[LV]] systolic dysfunction <br> ❑ Decreased [[LVEF]] or severe [[LV]] dilatation </div>| D02=<div style="text-align:center; width:11em">'''Symptomatic''' ([[Aortic regurgitation stages|Stage D]])</div><div style="text-align:left"> <br> ❑ Normal or decreased [[LV]] systolic function <br> ❑ Moderate to severe [[LV]] dilatation</div>}}
+{{family tree | | | | | | | | | | | | | | C05 | | | | C05= Is the patient symptomatic?}}
+{{family tree | | | | | | | | | | | | |,|^|-|-|-|.| | }}
+{{family tree | | | | | | | | | | | | D01 | | | D02 | | | | | |D01=<div style="text-align:center; width:11em">'''No'''</div>| D02=<div style="text-align:center; width:11em">'''Yes''' </div>}}
+{{family tree | | | | | | | | | | | | |!| | | | |!|}}
+{{family tree | | | | | | | | | | | | D03 | | | |!| D03= Asses the [[LV]] and [[LVEF]]}}
+{{family tree | | | | | | | | | |,|-|-|^|-|.| | |!| | }}
+{{family tree | | | | | | | | | E01 | | E02 | | E03 |  E01= '''[[Aortic regurgitation stages|Stage C1]]''' <br> <div style="text-align:left">❑ Normal [[LVEF]] <br> ❑ Mild to moderate dilatation of [[LV]] </div> | E02= '''[[Aortic regurgitation stages|Stage C2]]''' <br> <div style="text-align:left">❑ [[LV]] systolic dysfunction <br> ❑ Decreased [[LVEF]] or severe [[LV]] dilatation </div>| E03= <div style="text-align:left"> '''[[Aortic regurgitation stages|Stage D]]'''<br> ❑ Normal or decreased [[LV]] systolic function <br> ❑ Moderate to severe [[LV]] dilatation</div>}}
 {{Family tree/end}}
 ==Treatment==
+<span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''ACE:''' [[Angiotensin converting enzyme]]; '''ARB:''' [[Angiotensin receptor blocker]]; '''CCB:''' [[Calcium channel blocker]]; '''LVEF:''' [[Ejection fraction|Left ventricle ejection fraction]]; '''TTE:''' [[Transthoracic echocardiography]] </span>
 ===Treatment of Acute Aortic Regurgitation===
-Shown below is an algorithm for the treatment of acute [[aortic regurgitation]] according to the 2014 AHA/ACC Guidelines for the Management of Valvular Heart Disease<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="HamiraniDietl2012">{{cite journal|last1=Hamirani|first1=Y. S.|last2=Dietl|first2=C. A.|last3=Voyles|first3=W.|last4=Peralta|first4=M.|last5=Begay|first5=D.|last6=Raizada|first6=V.|title=Acute Aortic Regurgitation|journal=Circulation|volume=126|issue=9|year=2012|pages=1121–1126|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.112.113993}}</ref> and the 2010 ACCF/AHA Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease<ref name="HiratzkaBakris2010">{{cite journal|last1=Hiratzka|first1=L. F.|last2=Bakris|first2=G. L.|last3=Beckman|first3=J. A.|last4=Bersin|first4=R. M.|last5=Carr|first5=V. F.|last6=Casey|first6=D. E.|last7=Eagle|first7=K. A.|last8=Hermann|first8=L. K.|last9=Isselbacher|first9=E. M.|last10=Kazerooni|first10=E. A.|last11=Kouchoukos|first11=N. T.|last12=Lytle|first12=B. W.|last13=Milewicz|first13=D. M.|last14=Reich|first14=D. L.|last15=Sen|first15=S.|last16=Shinn|first16=J. A.|last17=Svensson|first17=L. G.|last18=Williams|first18=D. M.|title=2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine|journal=Circulation|volume=121|issue=13|year=2010|pages=e266–e369|issn=0009-7322|doi=10.1161/CIR.0b013e3181d4739e}}</ref>
+Shown below is an algorithm for the treatment of acute [[aortic regurgitation]].<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
+{{Familytree/start}}
+{{Family tree | | | | | A01 | | | | A01= What is the cause of acute AR?}}
+{{Family tree | | | |,|-|^|-|.| | | | | | | }}
+{{Family tree | | | B01 | | B02 | | B01= [[Infective endocarditis]]| B02= [[Aortic dissection]]}}
+{{Family tree | | | |!| | | |!| | | | | | | }}
+{{Family tree | | | C01 | | C02 | | C01= <div style="text-align: left; width: 13em">Does the patient have AR related [[heart failure]] symptoms?</div>| C02= <div style="text-align: left; width: 13em">❑ Schedule for an emergent surgery<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher =  | date =  | accessdate = }}</ref> <br> ❑ Administer [[beta blockers]] with caution (beta blockers inhibit compensatory [[tachycardia]]) </div>}}
+{{Family tree | |,|-|^|-|.| | | | | | | | | }}
+{{Family tree | D01 | | D02 | | | | D01= Yes| D02= No}}
+{{Family tree | |!| | | |!| | | | | | | | | }}
+{{Family tree | E01 | | E02 | | | | E01= <div style="text-align: left; width: 13em">❑ Schedule for early aortic valve replacement ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>| E02= <div style="text-align: left; width: 13em">❑ Administer [[Endocarditis antimicrobial treatment|antibiotics]]<ref name="Baddour-2005">{{Cite journal  | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> <br> ❑ Follow up the patient <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>}}
+{{Familytree/end}}
-{{Family tree/start}}
+===Treatment of Chronic Aortic Regurgitation===
-{{Family tree | | | | | | | | | A01 | | | | | | | A01=<div style="float: left; text-align: center; width:18em; line-height: 150%"> '''Determine the etiology and the grade of regurgitation'''</div>}}
+Shown below is an algorithm depicting the indications for [[aortic valve replacement]] ([[AVR]]) in chronic aortic regurgitation. Patients that fulfill the indications for [[AVR]] but have existing comorbidities that do not permit [[AVR]] should be treated for hypertension if the [[blood pressure]] is more than 140 mmHg.  Patients with [[Aortic regurgitation stages|stage A]] AR do not require any treatment.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|title=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|journal=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref>
-{{Family tree | | | | | |,|-|-|-|^|-|-|-|.| | | |}}
-{{Family tree | | | | | B01 | | | | | | B02 | | | B01=<div style="float: left; text-align: center; width: 18em;"> '''[[Infective endocarditis]]''' </div> | B02=<div style="float: left; text-align: center; width: 18em"> '''[[Aortic dissection classification#Stanford Classification System|Type A aortic dissection]]''' </div>}}
-{{Family tree | | | |,|-|^|-|.| | | |,|-|^|-|.| |}}
-{{Family tree | | | C01 | | C02 | | C03 | | C04 | C01=<div style="text-align: center; width: 13em"> '''Mild or moderate regurgitation''' <br>([[Aortic regurgitation stages|Stage B]]) </div> | C02=<div style="text-align: center; width: 13em; "> '''Severe regurgitation''' <br> ([[Aortic regurgitation stages|Stage C or D]]) </div> | C03=<div style="text-align: center; width: 13em"> '''Mild or moderate regurgitation''' <br>([[Aortic regurgitation stages|Stage B]]) </div> | C04=<div style="text-align: center; width: 13em"> '''Severe regurgitation''' <br> ([[Aortic regurgitation stages|Stage C or D]]) </div>}}
-{{Family tree | | | |!| | | |!| | | |!| | | |!| |}}
-{{Family tree | | | D01 | | |!| | | D03 | | D04 | |D01=<div style="float: left; text-align: left; width: 18em; "> Does the patient has any of the following? <br> ❑ S.aureus infection <br> ❑ Fungal infection <br> ❑ Large vegetation </div> | D03=<div style="float: left; text-align: center; width: 13em"> Replacement of supra-coronary ascending aorta </div> |D04=<div style="float: left; text-align: center; width: 13em; "> Aortic root replacement, OR <br> [[Valve-sparing aortic root replacement]] </div> }}
-{{Family tree | | | |!| | | |!| | | | | | | | |}}
-{{Family tree | |,|-|^|-|.| |!| | | | | | |}}
-{{Family tree | E02 | | E03 |!| | | | | | |  E02= <div style="float: left; text-align: center; width: 8em">'''No'''</div> | E03= <div style="float: left; text-align: center; width:8em">'''Yes'''</div>}}
-{{Family tree | |!| | | |`|v|'|}}
-{{Family tree | F01 | | | F02 | | | | | | F01= <div style="float: left; text-align: left; width: 12em "> ❑ '''Initiate antibiotic treatment''' <br>
-: Click '''[[Endocarditis antimicrobial treatment|here]]''' for a complete list of pathogen specific antibiotics regimens </div>|F02=<div style="float: left; text-align: center; width: 12em "> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])  </div>}}
-{{Family tree | |:| | | | | | | | | | | | | }}
-{{Family tree | G01 | | | | | | | | | | | G01=<div style="float: left; text-align: center; width: 12em "> If the patient does not get better after 5-7 days: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])  </div>}}
-{{Family tree/end}}
-<br>
-===Treatment of Chronic Aortic Regurgitation===
+<span style="font-size:85%">'''Abbreviations:''' '''LVEF:''' left ventricular ejection fraction; '''LVEDD:''' left ventricular end diastolic diameter; '''LVESV:''' left ventricular end systolic diameter </span>
-Shown below is an algorithm summarizing the treatment approach to chronic [[aortic regurgitation]] according to the 2014 AHA/ACC Guidelines on the Management of Valvular Heart Disease.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref><ref name="BonowCarabello2008">{{cite journal|last1=Bonow|first1=R. O.|last2=Carabello|first2=B. A.|last3=Chatterjee|first3=K.|last4=de Leon|first4=A. C.|last5=Faxon|first5=D. P.|last6=Freed|first6=M. D.|last7=Gaasch|first7=W. H.|last8=Lytle|first8=B. W.|last9=Nishimura|first9=R. A.|last10=O'Gara|first10=P. T.|last11=O'Rourke|first11=R. A.|last12=Otto|first12=C. M.|last13=Shah|first13=P. M.|last14=Shanewise|first14=J. S.|title=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|journal=Circulation|volume=118|issue=15|year=2008|pages=e523–e661|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.190748}}</ref>
-<span style="font-size:85%">'''Abbreviations:''' '''TTE:''' [[transthoracic echocardiography]]; '''AVR:''' [[aortic valve replacement]]; '''CCB:''' [[calcium channel blocker]]; '''ACE:''' [[angiotensin converting enzyme]]; '''ARB:''' [[angiotensin receptor blocker]] </span>
+{{Familytree/start}}
+{{Family tree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | A01= What is the severity of the aortic regurgitation?}}
+{{Family tree | | | | | | | |,|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
+{{Family tree | | | | | | | B01 | | | | | | | | | | | | | | | | | | B02 | B01= <div style="float: left; text-align: center; width:12em"> '''Severe regurgitation''' </div> <div style="float: left; text-align: left; width: 15em; line-height: 150%"> <br> ❑ Vena contracta >0.6 cm <br> ❑ Doppler jet width ≥ 65% of LVOT <br> ❑ Regurgitant volume ≥60 mL/beat <br> ❑ Regurgitant fraction ≥50% <br> ❑ Effective regurgitant orifice ≥ 0.30 cm² <br> ❑  Holodiastolic flow reversal in the proximal abdominal aorta <br> ❑ [[Left ventricle]] dilatation</div>| B02= <div style="float: left; text-align: center; width:12em">'''Progressive regurgitation''' ([[Aortic regurgitation stages|Stage B]]) </div> <div style="float: left; text-align: left; line-height: 150%"> <br> ❑ Vena contracta <0.6 cm <br>❑ Regurgitant volume <60 mL/beat <br> ❑ Regurgitant fraction <50% <br> ❑ Effective regurgitant orifice <0.30 cm² </div>}}
-{{Family tree/start}}
+{{Family tree | | | | | | | |!| | | | | | | | | | | | | | | | | | | |!| | }}
-{{Family tree | | | | | Z01 | | | | | | | | | | | | | | Z01=<div style="float: left; text-align: center; width:18em "> What is the stage of [[aortic regurgitation]] according to the [[TTE]]?</div>}}
+{{Family tree | | | | | | | B03 | | | | | | | | | | | | | | | | | | B04 | B03= Is the patient symptomatic?|B04=Is the patient undergoing<br> another surgery?}}
-{{Family tree | |,|-|-|-|+|-|-|-|-|-|-|-|.| | | | | | |}}
+{{Family tree | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | | | | |,|-|^|-|.| }}
-{{Family tree | C01 | | C02 | | | | | | C03 | | | | | |C01=<div style="float: left; text-align: center;> '''No regurgitation''' <br>([[Aortic regurgitation stages|Stage A]])</div>| C02=<div style="float: left; text-align: center; width:18em">'''Progressive regurgitation''' ([[Aortic regurgitation stages|Stage B]]) </div> <div style="float: left; text-align: left; line-height: 150%"> '''Mild''' <br> ❑ Vena contracta <0.3 cm <br> ❑ Jet/LVOT <25% <br> ❑ Regurgitant volume <30 mL/beat <br> ❑ Regurgitant fraction <30% <br> ❑ Effective regurgitant orifice <0.10 cm² <br>  '''Moderate''' <br> ❑ Vena contracta 0.3-0.6 cm <br> ❑ Jet/LVOT 25-64% <br> ❑ Regurgitant volume 30-59 mL/beat <br> ❑ Regurgitant fraction 30-49% <br> ❑ Effective regurgitant orifice 0.10-0.29 cm² </div>| C03= <div style="float: left; text-align: center; width:12em"> '''Severe regurgitation''' </div> <div style="float: left; text-align: left; width: 15em; line-height: 150%"> <br> ❑ Vena contracta >0.6 cm <br> ❑ Jet/LVOT ≥ 65% <br> ❑ Regurgitant volume ≥60 mL/beat <br> ❑ Regurgitant fraction ≥50% <br> ❑ Effective regurgitant orifice ≥ 0.30 cm² <br> ❑  Holodiastolic flow reversal in the proximal abdominal aorta </div>}}
+{{Family tree | C01 | | | | | | | | | | C02 | | | | | | | | | | C03 | | C04 |C01= Yes <br> ([[Aortic regurgitation stages|Stage D]])| C02=No <br> ([[Aortic regurgitation stages|Stage C]])| C03= No| C04= Yes}}
-{{family tree | |!| | | |!| | | | | | | |!| | | | | | | }}
+{{Family tree | |!| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | |!| | | |!| | }}
-{{family tree | |!| | | |!| | | | | | | U01 | | | | | U01= Is the patient symptomatic?}}
+{{Family tree | |!| | | D01 | | D02 | | D03 | | D04 | | D05 | | |!| | | |!| D01= ❑ LVEF<50% <br> ([[Aortic regurgitation stages|Stage C2]])|D02=❑ The patient is undergoing another surgery| D03= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD > 50mm <br>([[Aortic regurgitation stages|Stage C2]])| D04= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVEDD > 65mm <br>AND <br> ❑ Low surgical risk| D05= ❑ [[LVEF]] ≥ 50% <br>AND <br> ❑ LVESD ≤ 50mm <br>AND <br> ❑ LVEDD ≤ 65mm }}
-{{family tree | |!| | | |!| | | | | |,|-|^|-|-|-|.| | |}}
+{{Family tree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
-{{Family tree | D01 | | D02 | | | | D03 | | | | D04 | | |D01=<div style="float: left; text-align: left; width: 12em; line-height: 150% "> '''Asymptomatic patients''' <br> ❑ Normal valve <br> ❑ [[Bicuspid aortic valve|Bicuspid valve]] <br> ❑ [[Aortic sclerosis|Sclerotic valve]] </div>| D02=<div style="float: left; text-align: left; line-height: 150%; width:18em ">'''Asymptomatic patients''' <br> ❑ Control [[Hypertension medical therapy|hypertension]] preferably with <br>
+{{Family tree | E01 | | E02 | | E03 | | E04 | | E05 | | |!| | | |!| | | E07 | E01= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E02= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E03= [[AVR]] ([[ACC AHA guidelines classification scheme|Class I]])| E04= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])| E05= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIb]])|  E07= [[AVR]] ([[ACC AHA guidelines classification scheme|Class IIa]])}}
+{{Family tree | | | | | | | | | | | | | | | | | | | | | |!| | | |!| | }}
+{{Family tree | | | | | | | | | | | | | | | | | | | | | F01 | | F02 | F01=<div style="float: left; text-align: left; width:12em">❑ Perform a periodic [[echocardiogram]] every 6 - 12 months ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence C]])<br>❑ Control [[Hypertension medical therapy|hypertension]] preferably with <br>
 : ❑ Dihydropyridine [[calcium channel blockers|CCB]], or
-: ❑ [[ACE inhibitors]]/[[ARB]]s
+: ❑ [[ACE inhibitors]] or [[ARB]]s ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) </div>| F02= <div style="float: left; text-align: left; width:12em">
-([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])
+❑ Perform a periodic [[echocardiogram]] ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br>
-</div>| D03= '''NO''' <br> ([[Aortic regurgitation stages|Stage C]]) | D04= '''YES''' <br> ([[Aortic regurgitation stages|Stage D]]) }}
-{{family tree | |!| | | |!| | | |,|-|^|-|-|.| | |!| | |}}
-{{Family tree | E01 | | E02 | | E03 | | | E04 | |!| | | E01=<div style=" text-align:left; width: 14em"> ❑ No treatment is needed</div>| E02=<div style="float: left; text-align: left; width:18em "> ❑ '''Perform a periodic [[echocardiogram|echo]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence:B]]) <br>
 : ❑ Every 3 -5 years for mild regurgitation
-: ❑ Every 1 - 2 years for moderate regurgitation </div> |E03=<div style=" width: 14em "> '''[[Aortic regurgitation stages|Stage C1]]''' </div><div style="float: left; text-align: left"><br> ❑ Normal [[LVEF]] <br> ❑ Mild to moderate dilatation</div>| E04=<div style="float: left; text-align: center; width: 12em">  '''[[Aortic regurgitation stages|Stage C2]]''' </div><div style="float: left; text-align: left"><br> ❑ [[LV]] systolic dysfunction, and <br> ❑ Decreased [[LVEF]], or <br> ❑ Severe [[LV]] dilatation</div>}}
+: ❑ Every 1 - 2 years for moderate regurgitation
-{{family tree | | | | | |:| | | |!| | | | |`|-|v|'| | | | |}}
+❑ Control [[Hypertension medical therapy|hypertension]] preferably with <br>
-{{Family tree | | | | | F00 | | F01 | | | | | F02 | | | | | F00=<div style="float: left; text-align: left; width: 18em"> If patient undergoes another [[cardiac surgery]]: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: C]]) </div> |F01= <div style="float:left; text-align:left; width: 14em">❑ '''Perform a periodic [[echocardiogram]] every 6 - 12 months''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) <br> ❑ Perform an [[exercise stress test]] </div>| F02=<div style=" text-align:left; width: 14em">❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) <br> ❑ Initiate medical therapy with [[ACE inhibitors]]/[[ARB]]s or [[beta blockers]] if patient has contraindications for surgery </div>}}
+: ❑ Dihydropyridine [[calcium channel blockers|CCB]], or
-{{family tree | | | | | | | | | |!| | | | | | | | | | | | }}
+: ❑ [[ACE inhibitors]] or [[ARB]]s ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])</div>}}
-{{family tree | | | | | | | | | H01 | | | | | | | | | | H01=<div style="float:left; text-align:left; width: 14em"> Does the patient developed symptoms in the [[stress test]]? </div>}}
+{{Family tree/end}}
-{{family tree | | | | | | | |,|-|^|-|.| | | | | | | | | }}
-{{family tree | | | | | | | J01 | | J02 | | | | | | | | | J01=<div style=" text-align:center; width: 18em"> '''YES'''</div>| J02=<div style=" text-align:center; width: 18em">'''NO'''</div>}}
-{{family tree | | | | | | | |!| | | |!| | | | | | | | | }}
-{{family tree | | | | | | | H01 | | H02 | | | | | | | | H01=<div style=" text-align:left; width: 18em">  ❑ Initiate medical therapy with vasodilators
-: ❑ [[Nifedipine]] 30-60 mg/day
-: ❑ [[Hydralazine]] 10-25 mg/ q8hrs </div>
-| H02=<div style=" text-align:left; width: 14em"> ❑ No treatment is needed</div>}}
-{{family tree | | | | | | | |L|~|V|~|J| |}}
-{{Family tree | | | | | | | | | G01 | | | | | | | | | | | G01=<div style=" text-align: left; width: 14em"> If the patient undergoes another [[cardiac surgery]]: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: C]]) </div>}}
-{{family tree/end}}
+===Type of Valve and Discharge Anticoagulation Therapy===
+Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-===Type of Valve and Discharge Anticoagulation Therapy===
 <span style="font-size:85%">'''Abbreviations:''' '''AVR:''' Aortic valve replacement; '''INR:''' International normalized ratio; '''TAVR''' Tansthoracic aortic valve replacement </span>
@@ Line 352: / Line 350: @@
 : ❑ [[Hemorrhagic stroke]]</span></div>}}
 {{Family tree | | | |,|-|-|-|+|-|-|-|.| | |}}
-{{Family tree | | | B01 | | B03 | | B02 | | |  B01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≤ 60 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]), ''AND'' <br> ❑ No contraindication for anticoagulation </div>| B03= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients 60 - 70 years old  <br> ❑ No contraindication for anticoagulation</div> | B02= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]), ''OR'' <br> ❑ Patients with contraindications for anticoagulation therapy ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) </div> }}
+{{Family tree | | | B01 | | B03 | | B02 | | |  B01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≤ 60 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| B03= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients 60 - 70 years old <br> ''AND'' <br> ❑ No contraindication for anticoagulation</div> | B02= <div style="float: left; text-align: left; width: 15em; padding:1em;"> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])<br> ''OR'' <br> ❑ Patients at any age AND contraindications for anticoagulation therapy ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) </div> }}
 {{Family tree | | | |!| | | |!| | | |!| | | }}
-{{Family tree | | | C01 | | C02 | | C03 | | | C01= '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical Prosthesis]]''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;"><span style="font-size:80%;color:red"> Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]) </span></div>|C02= Either a [[Aortic stenosis surgery procedure#Types of Valves|bioprosthesic]] or [[Aortic stenosis surgery procedure#Types of Valves|mechanical]] valve is reasonable ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]).|C03= '''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesis]]'''}}
+{{Family tree | | | |!| | | C00 | | |!| | | C00='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesic]]''' <br> OR <br> '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])}}
+{{Family tree | | | |!|,|-|-|^|-|-|.|!| | | }}
+{{Family tree | | | C01 | | | | | | C02 | | | C01= '''[[Aortic stenosis surgery procedure#Types of Valves|Mechanical prosthesis]]''' <br> <div style="float: left; text-align: left; width: 15em; padding:1em;"><span style="font-size:80%;color:red"> Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]) </span></div>|C02='''[[Aortic stenosis surgery procedure#Types of Valves|Bioprosthesis]]'''}}
+{{Family tree | | | |!| | | | | | | |!| | | }}
+{{Family tree | | | C04 | | | | | | C05 | | C04= Does the patient have risk factors for thromboembolism†?| C05= '''Surgical [[AVR]]''' <br> OR <br> '''[[Transcatheter aortic valve implantation|TAVR]]'''}}
 {{Family tree | |,|-|^|-|.| | | |,|-|^|-|.| }}
-{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= <div style="float: left; text-align: left; width: 14em; padding:1em;"> Patient with risk factors† </div> | D02=<div style="float: left; text-align: center; width: 14em; padding:1em;"> Patient without risk factors† </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''Surgical [[AVR]]''' </div> | D04=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''[[Transcatheter aortic valve implantation|TAVR]]''' </div>}}
+{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= <div style="float: left; text-align: center; width: 14em; padding:1em;"> Yes </div> | D02=<div style="float: left; text-align: center; width: 14em; padding:1em;"> No </div>| D03=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''Surgical [[AVR]]''' </div> | D04=<div style="float: left; text-align: center; width: 14em; padding:1em;"> '''[[Transcatheter aortic valve implantation|TAVR]]''' </div>}}
 {{Family tree | |!| | | |!| | | |!| | | |!| | | }}
-{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 3.0 <br> ❑ [[Aspirin]] 75-100 mg/d </div> | E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">  Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 <br> ❑ [[Aspirin]] 75-100 mg/d  </div>| E03= <div style="float: left; text-align: left; width: 15em; padding:1em;">  ❑ Administer [[warfarin]] to achieve [[INR]] of 2.5 for 3 months  <br> ❑ Then administer [[aspirin]] 75-100 mg/d long term </div>| E04=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for 6 months: <br> ❑ [[Clopidogrel]] 75 mg/d <br> ❑ [[Aspirin]] 75-100 mg/d  </div> }}
+{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 3.0 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br> ❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div> | E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">  Administer for long term: <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]])</div>| E03= <div style="float: left; text-align: left; width: 15em; padding:1em;">  Administer <br> ❑ [[Warfarin]] to achieve [[INR]] of 2.5 for 3 months ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d long term ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">
+Administer:
+:❑ [[Warfarin]] to achieve [[INR]] of 2.5 for 3 months ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]]), ''OR''<br>
+:❑ [[Clopidogrel]] 75 mg/d (first 6 months) ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]])<br> ''AND'' <br>❑ [[Aspirin]] 75-100 mg/d (for life) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div> }}
 {{Family tree/end}}
 <br>
@@ Line 366: / Line 371: @@
 ==Do's==
-* Perform a [[cardiac MRI]] in patients with moderate or severe AR with an inconclusive TTE to assess LV systolic function, systolic and diastolic volumes, and measurement of AR severity ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]). <br>
+* Order a [[cardiac MRI]] in patients with moderate or severe [[AR]] with an inconclusive [[TTE]] to assess the left ventricular systolic function and the systolic and diastolic volumes, as well as to evaluate the severity of [[AR]] ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-* Exercise stress test could be useful to assess symptomatic status and functional capacity of patents with severe [[aortic regurgitation]].<br>
+* Schedule for a [[TTE|transthoracic echocardiography (TTE)]] after [[aortic valve replacement]] to evaluate the valve hemodynamics ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-* It is reasonable to perform [[AVR]] in patients with moderate [[AR]] that will undergo [[CABG]], surgery on the [[ascending aorta]], or [[mitral valve surgery]] ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: C]]).<br>
+* Order a [[TTE]] when clinical symptoms or signs suggest prosthetic valve dysfunction ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-* Perform a [[TTE|transthoracic echocardiography (TTE)]] after [[aortic valve replacement]] fto evaluate the valve hemodynamics ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-* Perform a [[TTE]] when clinical symptoms or signs suggest prosthetic valve dysfunction ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 ==Don'ts==
-* Do not use [[beta blockers]] in [[aortic regurgitation ]] that is not caused by [[aortic dissection]] as it will block the compensatory tachycardia. <br>
+* Avoid [[beta blockers]] in [[aortic regurgitation ]] that is not caused by [[aortic dissection]] as it will block the compensatory tachycardia.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-* Do not use intra-aortic baloon counterpulsation in severe acute [[aortic regurgitation]] as it will increase the aortic diastolic pressure and the regurgitant volume.<br>
+* Do not use [[intra-aortic balloon counterpulsation]] in severe acute [[aortic regurgitation]] as it will increase the aortic diastolic pressure and the regurgitant volume.<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-*  Do not give [[antibiotics]] to patients with known [[aortic regurgitation]] before [[blood cultures]] are obtained for [[unexplained fever]].  ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: C]]) <br>
+*  Do not administer [[antibiotics]] to patients with known [[aortic regurgitation]] before [[blood cultures]] are obtained for unexplained [[fever]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: C]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
-*  Do not give [[ACE inhibitors]] to pregnant patients with [[aortic regurgitation]]. ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]])<br>
+*  Do not prescribe [[ACE inhibitors]] to pregnant patients with [[aortic regurgitation]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]).<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
 ==References==
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Aortic regurgitation resident survival guide: Difference between revisions

Latest revision as of 22:58, 14 March 2016

Overview

Causes

Life Threatening Causes

Common Causes

FIRE: Focused Initial Rapid Evaluation

Complete Diagnostic Approach

Acute Aortic Regurgitation

Chronic Aortic Regurgitation

Treatment

Treatment of Acute Aortic Regurgitation

Treatment of Chronic Aortic Regurgitation

Type of Valve and Discharge Anticoagulation Therapy

Do's

Don'ts

References

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