Aortic Regurgitation in Emergency Medicine

Author: Jerry Balentine, DO; Chief Editor: David FM Brown, MD more...

Updated: Dec 5, 2011

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Background
Pathophysiology
Epidemiology
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Background

Aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle. Regurgitation is due to incompetence of the aortic valve or any disturbance of the valvular apparatus (eg, leaflets, annulus of the aorta) resulting in diastolic flow of blood into the left ventricular chamber.

Pathophysiology

Incompetent closure of the aortic valve can result from intrinsic disease of the cusp, diseases of the aorta, or trauma. Aortic regurgitation may be a chronic disease process or it may occur acutely, presenting as heart failure.^[1]The most common cause of chronic aortic regurgitation used to be rheumatic heart disease, but presently it is most commonly bacterial endocarditis.^[2]In developed countries, it is caused by dilatation of the ascending aorta (eg, aortic root disease, aortoannular ectasia).

Diastolic reflux through the aortic valve can lead to left ventricular volume overload. The severity of the aortic regurgitation is dependent on the diastolic valve area, the diastolic pressure gradient between the aorta and left ventricle, and the duration of diastole. An increase in systolic stroke volume and low diastolic aortic pressure produces an increased pulse pressure.

Frequency

United States

Rheumatic fever and syphilis used to be major causes of aortic regurgitation, but these diseases have diminished in recent years because of the introduction of new antibiotics.

Mortality/Morbidity

Three fourths of patients with significant aortic regurgitation survive 5 years after diagnosis; half survive for 10 years. Patients with mild-to-moderate regurgitation survive 10 years in 80-95% of the cases.
Average survival after onset of congestive heart failure (CHF) is less than 2 years.
Acute aortic regurgitation is associated with significant morbidity, which can progress from pulmonary edema to refractory heart failure and cardiogenic shock.

Age

Chronic aortic regurgitation often begins in the late 50s and is documented most frequently in patients older than 80 years.

Proceed to Clinical Presentation

Contributor Information and Disclosures

Author

Jerry Balentine, DO Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Eric C Appelbaum, DO Associate Medical Director, Ambulatory Care, Associate Director, Emergency Department, St Barnabas Hospital, Bronx

Eric C Appelbaum, DO, is a member of the following medical societies: American College of Osteopathic Emergency Physicians, American College of Osteopathic Internists, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne White, MD Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Elizabeth Kassapidis, DO, to the development and writing of this article.

References

Saura D, Peñafiel P, Martínez J, de la Morena G, García-Alberola A, Soria F, et al. [The frequency of systolic aortic regurgitation and its relationship to heart failure in a consecutive series of patients]. Rev Esp Cardiol. Jul 2008;61(7):771-4. [Medline].
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Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence?. Ann Intern Med. May 6 2003;138(9):736-42. [Medline].
Giuliani E. Cardiology: Fundamentals and Practice. 2^nd ed. Philadelphia, Pa: Mosby Year Book; 1991.
Kloner R. The Guide to Cardiology. 2^nd ed. New York: Le Jacq Communications; 1990.
Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr. Apr 2010;11(3):223-44. [Medline].
Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J. Jun 2008;155(6):1114-20. [Medline].
Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. Feb 16 2000;283(7):897-903. [Medline].
Hwang MS, Chu JJ, Su WJ. Natural history and risk stratification of discrete subaortic stenosis in children: an echocardiographic study. J Formos Med Assoc. Jan 2004;103(1):17-22. [Medline].
Tops LF, Kapadia SR, Tuzcu EM, Vahanian A, Alfieri O, Webb JG, et al. Percutaneous valve procedures: an update. Curr Probl Cardiol. Aug 2008;33(8):417-57. [Medline].

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