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* [[Rheumatic fever]]
* [[Rheumatic fever]]


==Management==
==Diagnosis==
 
Shown below is an algorithm summarizing the diagnostic approach to '''[[aortic insufficiency]] (AI)''' according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.<ref name="2014 AHA">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</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>
===Acute aortic insufficiency===
Shown below is an algorithm summarizing the approach to '''acute [[aortic insufficiency]] (AI)''' <ref name="2014 AHA">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</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>


'''Abbreviations:''' '''BP:''' [[blood pressure]]; '''CXR:''' [[chest X-ray]]; '''ECG:''' [[electrocardiogram]]; '''LV:''' [[left ventricle]]
'''Abbreviations:''' '''BP:''' [[blood pressure]]; '''CXR:''' [[chest X-ray]]; '''ECG:''' [[electrocardiogram]]; '''LV:''' [[left ventricle]]
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==Treatment==
===Acute Aortic Insufficiency===
Shown below is an algorithm summarizing the treatment approach to '''acute [[aortic insufficiency]] (AI)''' according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.<ref name="pmid9271479">{{cite journal |author=Connolly HM, Crary JL, McGoon MD, ''et al'' |title=Valvular heart disease associated with fenfluramine-phentermine |journal=N. Engl. J. Med. |volume=337 |issue=9 |pages=581–8 |year=1997 |pmid=9271479 |doi=10.1056/NEJM199708283370901|url=http://content.nejm.org/cgi/content/full/337/9/581}}</ref><ref name="pmid11307869">{{cite journal |author=Weissman NJ |title=Appetite suppressants and valvular heart disease |journal=Am. J. Med. Sci. |volume=321 |issue=4 |pages=285–91 |year=2001 |pmid=11307869|doi=10.1097/00000441-200104000-00008}}</ref><ref name="pmid17202453">{{cite journal |author=Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E |title=Dopamine agonists and the risk of cardiac-valve regurgitation |journal=N. Engl. J. Med. |volume=356 |issue=1 |pages=29–38 |year=2007 |pmid=17202453 |doi=10.1056/NEJMoa062222}}</ref><ref name="pmid17202454">{{cite journal |author=Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G |title=Valvular heart disease and the use of dopamine agonists for Parkinson's disease |journal=N. Engl. J. Med. |volume=356 |issue=1 |pages=39–46 |year=2007 |pmid=17202454 |doi=10.1056/NEJMoa054830}}</ref>


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===Chronic aortic insufficiency===
===Chronic Aortic Insufficiency===
Shown below is an algorithm summarizing the approach to '''chronic [[aortic insufficiency]]''' <ref name="2014 AHA">{{Cite web  | last = | first = | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</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>
Shown below is an algorithm summarizing the treatment approach to '''chronic [[aortic insufficiency]] (AI)''' according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.<ref name="pmid9271479">{{cite journal |author=Connolly HM, Crary JL, McGoon MD, ''et al'' |title=Valvular heart disease associated with fenfluramine-phentermine |journal=N. Engl. J. Med. |volume=337 |issue=9 |pages=581–8 |year=1997 |pmid=9271479 |doi=10.1056/NEJM199708283370901|url=http://content.nejm.org/cgi/content/full/337/9/581}}</ref><ref name="pmid11307869">{{cite journal |author=Weissman NJ |title=Appetite suppressants and valvular heart disease |journal=Am. J. Med. Sci. |volume=321 |issue=4 |pages=285–91 |year=2001 |pmid=11307869|doi=10.1097/00000441-200104000-00008}}</ref><ref name="pmid17202453">{{cite journal |author=Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E |title=Dopamine agonists and the risk of cardiac-valve regurgitation |journal=N. Engl. J. Med. |volume=356 |issue=1 |pages=29–38 |year=2007 |pmid=17202453 |doi=10.1056/NEJMoa062222}}</ref><ref name="pmid17202454">{{cite journal |author=Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G |title=Valvular heart disease and the use of dopamine agonists for Parkinson's disease |journal=N. Engl. J. Med. |volume=356 |issue=1 |pages=39–46 |year=2007 |pmid=17202454 |doi=10.1056/NEJMoa054830}}</ref>


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==Do's==
==Do's==

Revision as of 18:30, 1 April 2014


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

Overview

Aortic insufficiency refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole.[1][2][3][4]

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

Diagnosis

Shown below is an algorithm summarizing the diagnostic approach to aortic insufficiency (AI) according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.[6][7]

Abbreviations: BP: blood pressure; CXR: chest X-ray; ECG: electrocardiogram; LV: left ventricle

 
 
 
 
 
 
 
Characterize the symptoms:

Acute
❑ Sudden and severe dyspnea
❑ Chest pain
❑ Palpitations

Chronic
❑ Dyspnea on exertion
❑ Orthopnea
❑ Paroxysmal nocturnal dyspnea
❑ Palpitations
❑ Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
❑ Previously healthy
❑ Cardiac disease:
❑ Hypertension
❑ Bicuspid aortic valve
❑ Rheumatic fever
❑ Pulmonary disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
❑ Heart rate: tachycardia may be present to compensate for a reduced stroke volume
❑ Blood pressure: wide pulse pressure (systolic BP - diastolic BP ≥ 60 mmHg)

Cardiovascular
❑ Pulses

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

❑ Cardiac auscultation

❑ Early diastolic decrescendo murmur
❑ Best heard at the upper left sternal border
❑ Murmur increases with: sitting forward, expiration, handgrip
❑ An S3 gallop may be present (suggestive of left ventricular dysfunction)
❑ Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex
❑ Traube's sign: Systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed

❑ Search for other signs suggestive of aortic insufficiency

❑ Müller's sign: systolic pulsations of uvula
❑ de Musset's sign: head bobbing with each heart beat [8]
❑ Hill's sign: A ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AR. Considered to be an artifact of sphygmomanometric lower limb pressure measurement
❑ Quincke's sign: Pulsation of the capillary bed in the nail

Respiratory

❑ Pulmonary auscultation: search for rales (seen when congestive heart failure has developed)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies:
❑ Order an echocardiography, assess:
❑ Valve morphology
❑ Pressure gradient
❑ Aortic valve area
❑ Ejection fraction
❑ LV wall thickness and motility

❑ Order a CXR

❑ For acute AI, a CXR might be normal
❑ Increase cardiac silhouette (if the etiology is aortic dissection)
❑ Widened mediastinum (if the etiology is aortic root dilation)
❑ Pulmonary congestion (suggestive of HF)

❑ Order a ECG

❑ Might see nonspecific changes of ST and T wave (due to LV enlargement)
❑ If aortic dissection is the cause, the right coronary artery may be compromised and you may see ischemic changes in the territory of the right coronary artery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute AI
 
 
 
 
 
Chronic AI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Treatment

Acute Aortic Insufficiency

Shown below is an algorithm summarizing the treatment approach to acute aortic insufficiency (AI) according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.[1][2][3][4]

 
 
 
 
 
 
 
Treatment

❑ The use of nitroprusside and inotropic agents (such as: dopamine and dobutamine) help reduce the LV end-diastolic pressure before surgery
❑ Avoid the use of beta blockers because may block compensating tachycardia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild or moderate
 
 
 
Severe
 
 
 
 
 
Urgent surgical intervention

❑ Aortic valve replacement

❑ Intra-aortic balloon counterpulsation is contraindicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotic treatment
A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available here
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chronic Aortic Insufficiency

Shown below is an algorithm summarizing the treatment approach to chronic aortic insufficiency (AI) according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.[1][2][3][4]


Do's

❑


Don'ts

❑ Do not use beta blockers in AI of causes other than AD as it will block the compensation tachycardia. ❑ Do not use intra-aortic baloon counterpulsation in severe acute AI as it will increase the aortic diastolic pressure and the regurgitant volume.

References

  1. ↑ 1.0 1.1 1.2 Connolly HM, Crary JL, McGoon MD; et al. (1997). "Valvular heart disease associated with fenfluramine-phentermine". N. Engl. J. Med. 337 (9): 581–8. doi:10.1056/NEJM199708283370901. PMID 9271479.
  2. ↑ 2.0 2.1 2.2 Weissman NJ (2001). "Appetite suppressants and valvular heart disease". Am. J. Med. Sci. 321 (4): 285–91. doi:10.1097/00000441-200104000-00008. PMID 11307869.
  3. ↑ 3.0 3.1 3.2 Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E (2007). "Dopamine agonists and the risk of cardiac-valve regurgitation". N. Engl. J. Med. 356 (1): 29–38. doi:10.1056/NEJMoa062222. PMID 17202453.
  4. ↑ 4.0 4.1 4.2 Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G (2007). "Valvular heart disease and the use of dopamine agonists for Parkinson's disease". N. Engl. J. Med. 356 (1): 39–46. doi:10.1056/NEJMoa054830. PMID 17202454.
  5. ↑ Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter |month= ignored (help)
  6. ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  7. ↑ 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.
  8. ↑ 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)


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