Acute aortic regurgitation medical therapy: Difference between revisions

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{{Aortic insufficiency}}
{{Aortic insufficiency}}
{{CMG}}; {{AE}} [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S; {{USAMA}}
{{CMG}}; {{AE}} {{Sara.Zand}} [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S; {{USAMA}}  


==Overview==
==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.
 
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==
==Medical Therapy==
In case [[cardiogenic shock]] is present in a patient with acute AR, resuscitation measures should be initiated immediately:
*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]].
* Secure airway
* [[Intra-aortic balloon counterpulsation]] is contraindicated in [[patients]] with acute severe [[AR]].
* Administer [[oxygen]]
* [[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]].<ref name="pmid33332149">{{cite journal |vauthors=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 |title=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 |journal=Circulation |volume=143 |issue=5 |pages=e35–e71 |date=February 2021 |pmid=33332149 |doi=10.1161/CIR.0000000000000932 |url=}}</ref>
* Secure wide bore IV 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 blocker]]s in high suspicion of [[aortic dissection]]. Do not use beta blockers for other causes as they will block the compensatory tachycardia.


==Therapeutic Options==
==Therapeutic Options==
===Nitroprusside===
===Nitroprusside===
[[Nitroprusside]] lowers [[afterload]] and thereby reduces retrograde flow and [[left ventricular end diastolic pressure]].<ref name="pmid24603191">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=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. | journal=J Am Coll Cardiol | year= 2014 | volume= 63 | issue= 22 | pages= e57-185 | pmid=24603191 | doi=10.1016/j.jacc.2014.02.536 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24603191  }} </ref>
[[Nitroprusside]] lowers [[afterload]] and thereby reduces retrograde flow and [[left ventricular end diastolic pressure]].<ref name="pmid983953">{{cite journal |vauthors=Miller RR, Vismara LA, DeMaria AN, Salel AF, Mason DT |title=Afterload reduction therapy with nitroprusside in severe aortic regurgitation: improved cardiac performance and reduced regurgitant volume |journal=Am J Cardiol |volume=38 |issue=5 |pages=564–7 |date=November 1976 |pmid=983953 |doi=10.1016/s0002-9149(76)80003-3 |url=}}</ref>


===Inotropic Agents===
===Inotropic Agents===
Inotropic agents such as [[dopamine]] and [[dobutamine]] can be used to increase the contractility of the [[heart]] resulting in improved forward flow.<ref name="pmid18820172">{{cite journal |author=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 |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 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18820172 |accessdate=2011-04-07}}</ref>
Inotropic agents such as [[dopamine]] and [[dobutamine]] can be used to increase the contractility of the [[heart]] resulting in improved forward flow.<ref name="pmid29340539">{{cite journal |vauthors=Dubin A, Lattanzio B, Gatti L |title=The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients |language=Portuguese |journal=Rev Bras Ter Intensiva |volume=29 |issue=4 |pages=490–498 |date=2017 |pmid=29340539 |pmc=5764562 |doi=10.5935/0103-507X.20170068 |url=}}</ref>
 
===Beta Blockers===
===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]].<ref name="pmid24603191">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=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. | journal=J Am Coll Cardiol | year= 2014 | volume= 63 | issue= 22 | pages= e57-185 | pmid=24603191 | doi=10.1016/j.jacc.2014.02.536 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24603191  }} </ref>
[[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]].


===Antibiotics===
===Intraaortic Balloon Pump===
Patients who are hemodynamically stable with mild AR secondary to [[infective endocarditis]] can be managed with [[antibiotic]]s alone.<ref name="pmid26373316">{{cite journal| author=Baddour LM, Wilson WR, Bayer AS, Fowler VG, Tleyjeh IM, Rybak MJ et al.| title=Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. | journal=Circulation | year= 2015 | volume= 132 | issue= 15 | pages= 1435-86 | pmid=26373316 | doi=10.1161/CIR.0000000000000296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26373316 }} </ref>
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>


===Intraaortic Balloon Pump===
== 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="pmid33332150">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=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. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150 }}</ref> ==
Insertion of an intraaortic balloon pump is contraindicated in the treatment of 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>
 
 
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.


==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseases (DO NOT EDIT)<ref>{{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>==


===Medical Therapy===
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.
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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).''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|}


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Medical therapy with [[ACE inhibitor]]s/[[ARB]]s and [[beta blocker]]s 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==Reference==
==Reference==

Latest revision as of 12:59, 8 December 2022
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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

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

  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).
  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.
  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.
  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.
  5. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "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". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).

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