Acute aortic regurgitation medical therapy: Difference between revisions
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In case [[cardiogenic shock]] is present in a patient with acute AR, resuscitation measures should be initiated immediately:<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref> | In case [[cardiogenic shock]] is present in a patient with acute AR, resuscitation measures should be initiated immediately:<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref> | ||
* Secure airway <ref name="pmid7681733">{{cite journal |vauthors=Pellikka PA, Tajik AJ, Khandheria BK, Seward JB, Callahan JA, Pitot HC, Kvols LK |title=Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients |journal=Circulation |volume=87 |issue=4 |pages=1188–96 |date=April 1993 |pmid=7681733 |doi=10.1161/01.cir.87.4.1188 |url=}}</ref> | * Secure airway <ref name="pmid7681733">{{cite journal |vauthors=Pellikka PA, Tajik AJ, Khandheria BK, Seward JB, Callahan JA, Pitot HC, Kvols LK |title=Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients |journal=Circulation |volume=87 |issue=4 |pages=1188–96 |date=April 1993 |pmid=7681733 |doi=10.1161/01.cir.87.4.1188 |url=}}</ref> | ||
* Administer [[oxygen]] | * Administer [[oxygen]]<ref name="pmid24661289">{{cite journal |vauthors=Gur AK, Odabasi D, Kunt AG, Kunt AS |title=Isolated tricuspid valve repair for Libman-Sacks endocarditis |journal=Echocardiography |volume=31 |issue=6 |pages=E166–8 |date=July 2014 |pmid=24661289 |doi=10.1111/echo.12558 |url=}}</ref> | ||
* Secure wide bore [[intravenous]] access | * Secure wide bore [[intravenous]] access | ||
* Perform [[ECG]] monitor | * Perform [[ECG]] monitor | ||
Revision as of 18:06, 9 April 2020
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Resident Survival Guide |
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Aortic Regurgitation Microchapters |
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Acute Aortic regurgitation |
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Chronic Aortic regurgitation |
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Acute aortic regurgitation medical therapy On the Web |
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American Roentgen Ray Society Images of Acute aortic regurgitation medical therapy |
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Risk calculators and risk factors for Acute aortic regurgitation medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S; Usama Talib, BSc, MD [2] Mohammed Salih, M.D.
Overview
Patients with acute severe aortic regurgitation (AR) are managed with emergency aortic valve replacement or repair. Medical therapy is used for the stabilization of patients prior to surgery.
Medical Therapy
In case cardiogenic shock is present in a patient with acute AR, resuscitation measures should be initiated immediately:[1]
- Secure airway [2]
- Administer oxygen[3]
- Secure wide bore intravenous access
- Perform ECG monitor
- Monitor vitals continuously
- Admit to ICU
Medical therapy to treat cardiogenic shock should be immediately initiated:
- 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 mean arterial pressure (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. [4]
Therapeutic Options
Nitroprusside
Nitroprusside lowers afterload and thereby reduces retrograde flow and left ventricular end diastolic pressure.[5]
Inotropic Agents
Inotropic agents such as dopamine and dobutamine can be used to increase the contractility of the heart resulting in improved forward flow.[6]
Beta Blockers
Beta blockers which are often used in managing aortic dissection should be used very cautiously in the presence of acute AR as beta blockers can block the compensatory tachycardia and worsen the cardiac output.[5]
Antibiotics
Patients who are hemodynamically stable with mild AR secondary to infective endocarditis can be managed with antibiotics alone.[7]
Intraaortic Balloon Pump
Insertion of an intraaortic balloon pump is contraindicated in the treatment of AR, as it may worsen the severity of the regurgitation.[8]
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)[9]
Medical Therapy
| Class I |
| "1.Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or angiotensin converting enzyme (ACE) inhibitors/angiotensin-receptor blockers (ARBs).(Level of Evidence: B)" |
| Class IIa |
| "1. Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities. (Level of Evidence: B)" |
Reference
- ↑ Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP; et al. (2009). "Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice". Eur J Echocardiogr. 10 (1): 1–25. doi:10.1093/ejechocard/jen303. PMID 19065003.
- ↑ Pellikka PA, Tajik AJ, Khandheria BK, Seward JB, Callahan JA, Pitot HC, Kvols LK (April 1993). "Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients". Circulation. 87 (4): 1188–96. doi:10.1161/01.cir.87.4.1188. PMID 7681733.
- ↑ Gur AK, Odabasi D, Kunt AG, Kunt AS (July 2014). "Isolated tricuspid valve repair for Libman-Sacks endocarditis". Echocardiography. 31 (6): E166–8. doi:10.1111/echo.12558. PMID 24661289.
- ↑ Roberts WC, Ko JM (July 2008). "Some observations on mitral and aortic valve disease". Proc (Bayl Univ Med Cent). 21 (3): 282–99. doi:10.1080/08998280.2008.11928412. PMC 2446420. PMID 18628928.
- ↑ 5.0 5.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (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". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (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): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ; et al. (2015). "Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association". Circulation. 132 (15): 1435–86. doi:10.1161/CIR.0000000000000296. PMID 26373316.
- ↑ Rius JB, Mercè AS, del Blanco BG, Aguasca GM, Mas PT, García-Dorado García D (2011). "Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump". Circulation. 124 (4): e131. doi:10.1161/CIRCULATIONAHA.111.038653. PMID 21788594.
- ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.