Acute aortic regurgitation medical therapy: Difference between revisions

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Revision as of 12:57, 8 December 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S; Usama Talib, BSc, MD [3]

Overview

In patients with acute severe AR resulting from infectious endocarditis or aortic dissection, reduction LV afterload by medications may be a temporary stabilization, but surgery should not be delayed, especially in the presence of hypotension, pulmonary edema, or evidence of low flow. Intra-aortic balloon counterpulsation is contraindicated in patients with acute severe AR. Beta blockers are often used in treating aortic dissection. However, these agents should be used very cautiously because of block the compensatory tachycardia and reduction in blood pressure.

Medical Therapy

In patients with acute severe AR resulting from infectious endocarditis or aortic dissection, reduction LV afterload by medications may be a temporary stabilization, but surgery should not be delayed, especially in the presence of hypotension, pulmonary edema, or evidence of low flow.
Intra-aortic balloon counterpulsation is contraindicated in patients with acute severe AR.
Beta blockers are often used in treating aortic dissection. However, these agents should be used very cautiously because of block the compensatory tachycardia and reduction in blood pressure.^[1]

Therapeutic Options

Nitroprusside

Nitroprusside lowers afterload and thereby reduces retrograde flow and left ventricular end diastolic pressure.^[2]

Inotropic Agents

Inotropic agents such as dopamine and dobutamine can be used to increase the contractility of the heart resulting in improved forward flow.^[3]

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.

Intraaortic Balloon Pump

Insertion of an intraaortic balloon pump is contraindicated in acute AR, as it may worsen the severity of the regurgitation.^[4]

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines^[5]

Medical treatment to lower LV afterload may temporarily stabilize patients with acute severe AR brought on by IE or aortic dissection, but surgery should not be postponed, especially if there is hypotension, pulmonary edema, or indications of low flow.

Aortic dissection is frequently treated with beta-blockers. However, these medications should only be used very sparingly, if at all, for other acute AR reasons because they will prevent compensatory tachycardia and may induce a significant drop in blood pressure.

Reference

↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).
↑ Miller RR, Vismara LA, DeMaria AN, Salel AF, Mason DT (November 1976). "Afterload reduction therapy with nitroprusside in severe aortic regurgitation: improved cardiac performance and reduced regurgitant volume". Am J Cardiol. 38 (5): 564–7. doi:10.1016/s0002-9149(76)80003-3. PMID 983953.
↑ Dubin A, Lattanzio B, Gatti L (2017). "The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients". Rev Bras Ter Intensiva (in Portuguese). 29 (4): 490–498. doi:10.5935/0103-507X.20170068. PMC 5764562. PMID 29340539.
↑ 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.
↑ Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW; et al. (2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).

Template:WH Template:WS CME Category::Cardiology

[pmid33332149-1] Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35–e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help).

[pmid983953-2] Miller RR, Vismara LA, DeMaria AN, Salel AF, Mason DT (November 1976). "Afterload reduction therapy with nitroprusside in severe aortic regurgitation: improved cardiac performance and reduced regurgitant volume". Am J Cardiol. 38 (5): 564–7. doi:10.1016/s0002-9149(76)80003-3. PMID 983953.

[pmid29340539-3] Dubin A, Lattanzio B, Gatti L (2017). "The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients". Rev Bras Ter Intensiva (in Portuguese). 29 (4): 490–498. doi:10.5935/0103-507X.20170068. PMC 5764562. PMID 29340539.

[pmid21788594-4] 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.

[pmid36334952-5] Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW; et al. (2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).

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@@ Line 29: / Line 29: @@
 ===Intraaortic Balloon Pump===
 Insertion of an [[intraaortic balloon pump]] is contraindicated in acute [[AR]], as it may worsen the severity of the regurgitation.<ref name="pmid21788594">{{cite journal| author=Rius JB, Mercè AS, del Blanco BG, Aguasca GM, Mas PT, García-Dorado García D| title=Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= e131 | pmid=21788594 | doi=10.1161/CIRCULATIONAHA.111.038653 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21788594  }} </ref>
+== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid36334952">{{cite journal| author=Writing Committee Members. Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW | display-authors=etal| title=2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. | journal=J Am Coll Cardiol | year= 2022 | volume=  | issue=  | pages=  | pmid=36334952 | doi=10.1016/j.jacc.2022.08.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=36334952  }}</ref> ==
+Medical treatment to lower LV afterload may temporarily stabilize patients with acute severe AR brought on by IE or aortic dissection, but surgery should not be postponed, especially if there is hypotension, pulmonary edema, or indications of low flow.
+Aortic dissection is frequently treated with beta-blockers. However, these medications should only be used very sparingly, if at all, for other acute AR reasons because they will prevent compensatory tachycardia and may induce a significant drop in blood pressure.
 ==Reference==