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| ==Diagnosis==
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| 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>
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| <span style="font-size:85%">'''Abbreviations:''' '''BP:''' [[blood pressure]]; '''CXR:''' [[chest X-ray]]; '''ECG:''' [[electrocardiogram]]; '''LV:''' [[left ventricle]] </span>
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| {{family tree | | | | | | V01 | | | | | | | | |V01= <div style="float: left; text-align: left; width:30em; line-height: 150%; width:30em ">'''Characterize the symptoms:''' <br>
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| '''Acute'''<br>❑ Sudden and severe [[dyspnea]] <br> ❑ [[Chest pain]] <br> ❑ [[Palpitations]]<br>
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| '''Chronic'''<br> ❑ [[Dyspnea on exertion]] <br> ❑ [[Orthopnea]]<br> ❑ [[Paroxysmal nocturnal dyspnea]] <br> ❑ [[Palpitations]]<br> ❑ [[Chest pain]] <br> </div> }}
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| {{Family tree | | | | | | Y01 | | | | | | | | Y01=<div style="float: left; text-align: Left; width:30em ">'''Inquire about past medical history:''' <br> ❑ Previously healthy <br> ❑ [[Cardiac disease]]: <br>
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| : ❑ [[Hypertension]]
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| : ❑ [[Bicuspid aortic valve]]
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| ❑ [[Rheumatic fever]] <br> ❑ [[Pulmonary disease]] </div> }}
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| {{family tree | | | | | | |!| | | | | | | | |}}
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| {{Family tree | | | | | | A01 | | | | | | | | A01=<div style="float: left; text-align: left; width:30em; line-height: 150% ">'''Examine the patient:''' <br>
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| '''Vitals''' <br>
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| ❑ [[Heart rate]]:
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| : ❑ [[Tachycardia]] (suggestive of reduced [[stroke volume]]) <br>
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| ❑ [[Blood pressure]]:
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| : ❑ [[Wide pulse pressure]] (≥ 60 mmHg) <br>
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| '''Cardiovascular examination'''<br>
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| ❑ Pulses<br>
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| : ❑ [[Corrigan's pulse]]: a rapid upstroke and collapse of the [[carotid artery pulse]]
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| ❑ [[Cardiac auscultation]]<br>
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| : ❑ [[Murmur]]
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| :: ❑ Early diastolic decrescendo murmur
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| :: ❑ Best heard at the upper left sternal border
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| :: ❑ Murmur increases with sitting forward, [[expiration]] and handgrip
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| :: ❑ [[Austin Flint murmur]]: a soft mid-diastolic rumble, best heard at the cardiac apex
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| : ❑ [[Heart sounds]]
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| :: ❑ [[S3]] may be present (suggestive of [[left ventricular dysfunction]])
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| ❑ Search for other signs suggestive of [[aortic regurgitation]]<br>
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| : ❑ [[Traube's sign]]: systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed
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| : ❑ [[Müller's sign]]: systolic pulsations of uvula <ref name="pmid16855259">{{cite journal |author=Williams BR, Steinberg JP |title=Images in clinical medicine. Müller's sign |journal=[[The New England Journal of Medicine]] |volume=355 |issue=3 |pages=e3 |year=2006 |month=July |pmid=16855259 |doi=10.1056/NEJMicm050642 |url=http://dx.doi.org/10.1056/NEJMicm050642 |accessdate=2012-04-15}}</ref> <br> ❑ [[de Musset's sign]]: head bobbing with each heart beat <br>
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| : ❑ [[Hill's sign]]: ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures (suggestive of chronic severe AR) <br> ❑ [[Quincke's sign]]: pulsation of the [[capillary]] bed in the nail<br>
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| '''Respiratory examination''' <br>
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| ❑ [[Rales]] (seen when [[congestive heart failure]] has developed)</div> }}
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| {{Family tree | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: Left; width:30em "> '''Order imaging studies:''' <br>
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| ❑ [[Chest X-ray]]
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| : ❑ Increase cardiac silhouette (suggestive of [[aortic dissection]])
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| : ❑ [[Widened mediastinum]] (suggestive of [[aortic root dilation]])
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| [[Image:Wide mediastinum.jpg|200px|center|border]]
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| : ❑ Pulmonary congestion (suggestive of [[HF]])
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| ❑ [[ECG]]
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| : ❑ Nonspecific changes of [[ST]] and [[T wave]] (due to [[LV]] enlargement)
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| : ❑ [[Right coronary artery]] ischemic changes (suggestive of [[aortic dissection]])
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| ❑ [[TTE]] (most important evaluation test) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])
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| : ''Assess the following:''
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| : ❑ Valve morphology
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| : ❑ Pressure gradient
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| : ❑ Aortic valve area
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| : ❑ Ejection fraction
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| : ❑ LV wall thickness and motility </div>}}
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| {{family tree | | | M01 | | | | | | M02 | | | | | |M01=<div style="text-align:center">'''Acute''' </div><div style="text-align:left"> <br> ❑ <br> ❑ </div>| M02=<div style="text-align:center">'''Chronic'''</div><div style="text-align:left"> <br> ❑ <br> ❑</div>}}
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| {{family tree | C01 | | C02 | | | | C03 | | | | C01= | C02= | C03=<div style="width:30em;text-align:left">'''Interpret the results from TTE'''
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| ----
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| '''Risk of [[AI]]''' ([[Aortic regurgitation stages|Stage A]]) <br> ❑ No regurgitation <br><br> '''Mild''' ([[Aortic regurgitation stages|Stage B]])<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><br>'''Moderate''' ([[Aortic regurgitation stages|Stage B]]) <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 <br><br>'''Severe''' <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>}}
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| {{family tree | | | | | | | | | D01 | | D02 | | | | | |D01=<div style="text-align:center; width:15em">'''Asymptomatic''' ([[Aortic regurgitation stages|Stage C]]) </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:15em">'''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>}}
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