Treatment-aortic-regurgitation

• Acute decompensation (consider endocarditis as possible acute precipitant): surgery usually urgently needed for acute severe AR, which is poorly tolerated by LV IV afterload reduction (nitroprusside) and inotropic support (dobutamine) ± chronotropic support (↑ HR → ↓ diastole → ↓ time for regurgitation) pure vasoconstrictors and IABP contraindicated
• In chronic AR, management decisions based on LV size and fxn (and before sx occur); low diastolic BP and high resting HR associated with mortality (JACC 2020;75:29)
• Surgery (AVR, replacement or repair if possible): Severe and sx (if equivocal, consider stress test) Asx and either EF ≤55%, LV dilation [LVESD >50 mm or LVESDi (indexed to BSA) ≥ 25 mm/m2 (JACC 2019;73:1741)], or undergoing cardiac surg
• Transcatheter AoV implantation (TAVI) being explored (JACC 2013;61:1577 & 2017;70:2752)
• Medical therapy: vasodilators (nifedipine, ACEI/ARB, hydralazine) if severe AR w/ sx or LV dysfxn & not operative candidate or to improve hemodynamics before AVR.