Sandbox/AL

Diagnosis

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

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 (suggestive of reduced stroke volume) ❑ Blood pressure: ❑ Wide pulse pressure (≥ 60 mmHg) Cardiovascular examination ❑ Pulses ❑ Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse ❑ Cardiac auscultation ❑ Murmur ❑ Early diastolic decrescendo murmur ❑ Best heard at the upper left sternal border ❑ Murmur increases with sitting forward, expiration and handgrip ❑ Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex ❑ Heart sounds ❑ S3 may be present (suggestive of left ventricular dysfunction) ❑ Search for other signs suggestive of aortic regurgitation ❑ Traube's sign: systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed ❑ Müller's sign: systolic pulsations of uvula ❑ de Musset's sign: head bobbing with each heart beat ❑ Hill's sign: ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures (suggestive of chronic severe AR) ❑ Quincke's sign: pulsation of the capillary bed in the nail Respiratory examination ❑ Rales (seen when congestive heart failure has developed)

Order imaging studies: ❑ Chest X-ray ❑ Increase cardiac silhouette (suggestive of aortic dissection) ❑ Widened mediastinum (suggestive of aortic root dilation) ❑ Pulmonary congestion (suggestive of HF) ❑ ECG ❑ Nonspecific changes of ST and T wave (due to LV enlargement) ❑ Right coronary artery ischemic changes (suggestive of aortic dissection) ❑ TTE (most important evaluation test) (Class I; Level of Evidence: B) Assess the following: ❑ Valve morphology ❑ Pressure gradient ❑ Aortic valve area ❑ Ejection fraction ❑ LV wall thickness and motility

Acute ❑ ❑

Chronic ❑ ❑

Interpret the results from TTE Risk of AI (Stage A) ❑ No regurgitation Mild (Stage B) ❑ Vena contracta <0.3 cm ❑ Jet/LVOT <25% ❑ Regurgitant volume <30 mL/beat ❑ Regurgitant fraction <30% ❑ Effective regurgitant orifice <0.10 cm² Moderate (Stage B) ❑ Vena contracta 0.3-0.6 cm ❑ Jet/LVOT 25-64% ❑ Regurgitant volume 30-59 mL/beat ❑ Regurgitant fraction 30-49% ❑ Effective regurgitant orifice 0.10-0.29 cm² Severe ❑ Vena contracta >0.6 cm ❑ Jet/LVOT ≥ 65% ❑ Regurgitant volume ≥60 mL/beat ❑ Regurgitant fraction ≥50% ❑ Effective regurgitant orifice ≥ 0.30 cm² ❑ Holodiastolic flow reversal in the proximal abdominal aorta

Asymptomatic (Stage C) Stage C1 ❑ Normal LVEF ❑ Mild to moderate dilatation Stage C2 ❑ LV systolic dysfunction ❑ Decreased LVEF or severe LV dilatation

Symptomatic (Stage D) ❑ Normal or decreased LV systolic function ❑ Moderate to severe LV dilatation

Stage	TTE findings
A	❑ No regurgitation
B	Mild ❑ Vena contracta <0.3 cm ❑ Jet/LVOT <25% ❑ Regurgitant volume <30 mL/beat ❑ Regurgitant fraction <30% ❑ Effective regurgitant orifice <0.10 cm² Moderate (Stage B) ❑ Vena contracta 0.3-0.6 cm ❑ Jet/LVOT 25-64% ❑ Regurgitant volume 30-59 mL/beat ❑ Regurgitant fraction 30-49% ❑ Effective regurgitant orifice 0.10-0.29 cm²
C1	cell
C2	cell
D	cell