Chronic aortic regurgitation medical therapy
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Aortic Regurgitation Microchapters |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Cafer Zorkun, M.D., Ph.D. [2], Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S., Mohammed A. Sbeih, M.D. [3]
Overview
In the management of chronic aortic insufficiency; the left ventricular size and function should be monitored closely along with the exercise tolerance of the patient. If the patient develops heart failure symptoms and the disease starts to be symptomatic; then aortic valve replacement or valve repair is indicated. Annual echocardiographic studies are indicated in all patients with significant aortic insufficiency.
Vasodilators such as ACE inhibitors, nifedipine, sodium nitroprusside and hydralazine may slow the rate of progression of aortic insufficiency. The greatest benefit of medical therapy is in symptomatic patients and for those with heart failure symptoms due to advanced disease, but in general; they have a limited role in aortic insufficiency because symptomatic cases should be treated with valve replacement if the patient is a good candidate for surgery.
Warfarin and long-term anticoagulation is not recommended in aortic insufficiency if there are no other indications for anticoagulation [1].
Medical Therapy
Pharmacotherapy
Medical therapy of chronic aortic insufficiency involves the use of vasodilators. Small trials have demonstrated a benefit from the administration of ACE inhibitors, nifedipine, sodium nitroprusside and hydralazine in improving left ventricular wall stress, ejection fraction, and left ventricular mass [2] [3] [4] [5]. The use of these vasodilators is indicated only in those individuals who suffer from hypertension in addition to aortic insufficiency. The goal in using these pharmacologic agents is to decrease the afterload so that the left ventricle is unloaded. This results in reduction in left ventricular end diastolic pressure thereby preserving the left ventricular systolic function and also benefits the patients in left ventricular failure secondary to aortic insufficiency.
Long term therapy with nifedipine and hydralazine have shown to increase left ventricular ejection fraction, reduce left ventricular end diastolic volume and reduction in left ventricular mass thereby delaying the need for valve surgery [6] [7] [8]. While ACE inhibitors such as enalapril and quinapril have shown to decrease left ventricular mass and end diastolic volume but with no influence on ejection fraction [9] [10]
Patients with severe aortic insufficiency with normal left ventricular function are recommended to undergo surgery though there are no sufficient evidences against medical management.
Use of drugs other than vasodilators, such as digoxin, diuretics and other positive inotropic drugs for long term treatment have no supporting data. Beta blockers are relatively contraindicated since they decrease heart rate and prolong diastolic phase. There by increasing the back flow of blood from aorta. However beta blockers can be considered in patients with bicuspid aortic valve with mild aortic insufficiency and aortic root diameter of more than 40mm [11].
ACC/AHA 2008 guidelines for the Management of Patients with Valvular heart Disease - Vasodilator Therapy in Chronic Severe Aortic Insufficiency (DO NOT EDIT) [12]
| Class I |
| "1. Vasodilator therapy is indicated for chronic therapy in patients with severe aortic insufficiency who have symptoms or left ventricular dysfunction when surgery is not recommended because of additional cardiac or noncardiac factors. (Level of Evidence: B)" |
| Class III |
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1. Vasodilator therapy is not indicated for long-term therapy in asymptomatic patients with mild to moderate aortic insufficiency and normal left ventricular systolic function. (Level of Evidence: B)" |
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2. Vasodilator therapy is not indicated for long-term therapy in asymptomatic patients with left ventricular systolic dysfunction who are otherwise candidates for aortic valve replacement. (Level of Evidence: C)" |
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3. Vasodilator therapy is not indicated for long-term therapy in symptomatic patients with either normal left ventricular function or mild to moderate left ventricular systolic dysfunction who are otherwise candidates for aortic valve replacement. (Level of Evidence: C)" |
| Class IIa |
| "1. Vasodilator therapy is reasonable for short-term therapy to improve the hemodynamic profile of patients with severe heart failure symptoms and severe left ventricular dysfunction before proceeding with aortic valve replacement. (Level of Evidence: C)" |
| Class IIb |
| "1. Vasodilator therapy may be considered for long-term therapy in asymptomatic patients with severe aortic insufficiency who have left ventricular dilatation but normal systolic function. (Level of Evidence: B)" |
Prophylactic antibiotics prior dental procedures are not recommended for all patients with aortic insufficiency as per 2007 AHA guidelines (for infective endocarditis) unless there are other indications.
Sources
- 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [12].
References
- ↑ Salem DN, O'Gara PT, Madias C, et al. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:593S
- ↑ Bolen JL, Alderman EL (1976). "Hemodynamic consequences of afterload reduction in patients with chronic aortic regurgitation". Circulation. 53 (5): 879–83. PMID 1260993. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Miller RR, Vismara LA, DeMaria AN, Salel AF, Mason DT (1976). "Afterload reduction therapy with nitroprusside in severe aortic regurgitation: improved cardiac performance and reduced regurgitant volume". The American Journal of Cardiology. 38 (5): 564–7. PMID 983953. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Greenberg BH, DeMots H, Murphy E, Rahimtoola S (1980). "Beneficial effects of hydralazine on rest and exercise hemodynamics in patients with chronic severe aortic insufficiency". Circulation. 62 (1): 49–55. PMID 7379285. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Fioretti P, Benussi B, Scardi S, Klugmann S, Brower RW, Camerini F (1982). "Afterload reduction with nifedipine in aortic insufficiency". The American Journal of Cardiology. 49 (7): 1728–32. PMID 7081058. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Scognamiglio R, Rahimtoola SH, Fasoli G, Nistri S, Dalla Volta S (1994). "Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function". The New England Journal of Medicine. 331 (11): 689–94. doi:10.1056/NEJM199409153311101. PMID 8058074. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Greenberg B, Massie B, Bristow JD, Cheitlin M, Siemienczuk D, Topic N, Wilson RA, Szlachcic J, Thomas D (1988). "Long-term vasodilator therapy of chronic aortic insufficiency. A randomized double-blinded, placebo-controlled clinical trial". Circulation. 78 (1): 92–103. PMID 3289791. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Scognamiglio R, Fasoli G, Ponchia A, Dalla-Volta S (1990). "Long-term nifedipine unloading therapy in asymptomatic patients with chronic severe aortic regurgitation". Journal of the American College of Cardiology. 16 (2): 424–9. PMID 2197314. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Lin M, Chiang HT, Lin SL, Chang MS, Chiang BN, Kuo HW, Cheitlin MD (1994). "Vasodilator therapy in chronic asymptomatic aortic regurgitation: enalapril versus hydralazine therapy". Journal of the American College of Cardiology. 24 (4): 1046–53. PMID 7930196. Retrieved 2011-03-23. Unknown parameter
|month=ignored (help) - ↑ Schön HR, Dorn R, Barthel P, Schömig A (1994). "Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation". The Journal of Heart Valve Disease. 3 (5): 500–9. PMID 8000584. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 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 2011-03-24. Unknown parameter
|month=ignored (help) - ↑ 12.0 12.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (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". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.