Aortic regurgitation symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Rim Halaby, M.D. [3]; Usama Talib, BSc, MD [4]

## Overview

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The symptoms of acute aortic regurgitation (AR) include dyspnea, chest pain (if aortic dissection is the cause of AR), weakness, and symptoms of congestive heart failure. Chronic AR may be asymptomatic for several years until there is a decrease in the stroke volume and cardiac output due to heart failure progression. Symptoms of chronic AR include exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitations.[1][2]

## History and Symptoms

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### Acute Aortic Regurgitation

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In acute severe AR, there is a sudden decrease in the stroke volume and increase in left ventricular end diastolic volume and left ventricular end diastolic pressure which manifests as either sudden and severe dyspnea and/or chest pain (if aortic dissection is the cause of AR). Based on the history and symptoms, the cause of the acute symptoms can be suspected.[3][4][5][6]

#### Type A Aortic Dissection

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The following findings may indicate presence of Aortic Dissection in a person with Aortic Regurgitation.[2][7][8][9]

* Chest pain
* Sudden onset
* Intense
* Tearing and sharp
* Worse with deep breath or cough
* Relieved by sitting upright
* Unexplained syncope
* Previous history of:
* Hypertension
* Marfan syndrome
* Connective tissue disorder
* Pregnancy

#### Infective Endocarditis

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The following factors can be present in a person with Infective Endocarditis and aortic regurgitation.[3][10][11]

* Persistent fever
* Previous positive blood culture
* High risk factors:
* Pre-existing cardiac abnormality
* Prosthetic valve
* Recent surgical or medical procedures
* Intravenous drug use
* Recent bacterial infection
* History of previous endocarditis

#### Symptomatic Severe Chronic Aortic Regurgitation

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* Previous history of aortic valve disease

### Chronic Aortic Regurgitation

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In chronic AR, patients are usually asymptomatic for many years as the stroke volume is maintained by increased force of left ventricular contraction secondary to increased left ventricular preload as explained by Frank-Starling mechanism. With the progression of AR, the compensatory mechanisms begin to fail causing gradual enlargement of the left ventricle, thereby progressively increasing the left ventricular end diastolic pressure as well as decreasing the stroke volume and the cardiac output leading to left ventricular failure that manifest as: [1][12][13]

* Dyspnea on exertion
* Orthopnea
* Paroxysmal nocturnal dyspnea
* Palpitations (due to compensatory tachycardia)
* Chest pain (if left ventricular end diastolic pressure compromises coronary perfusion)

Once symptoms arise, cardiac function usually worsens more rapidly and mortality may exceed 10% per year.

### Pertinent Elements in the Past Medical History

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The following are some important elements in the past medical history of a patient with suspected aortic regurgitation.

* Cardiac disease
* Hypertension[7]
* Bicuspid aortic valve[14]
* Rheumatic fever[15]
* Pulmonary disease
* Trauma[16][17]
* Syphilis[18]
* Ankylosing spondylitis[19]
* Acromegaly[20]
* Marfan syndrome[21]
* Ehlers-Danlos syndrome[22]
* Giant cell arteritis
* Takayasu's arteritis[23]
* Previous cardiac surgery[24]

## References

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1. ↑ 1.0 1.1 van der Steen DA, Hulsbergen-Zwarts MS (2016). "[A woman with palpitations, dyspnoea and a heart murmur]". Ned Tijdschr Geneeskd. 160: A9696. PMID 26883843.
2. ↑ 2.0 2.1 Icli A, Mutlu H, Karabag T, Kahraman H (2015). "Decreased coronary blood flow velocity in patients with aortic insufficiency but normal coronary arteries: the use of TIMI frame count in aortic insufficiency cases". Int J Clin Exp Med. 8 (9): 16358–63. PMC 4659045. PMID 26629157.CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 Seizer P, Rockenstiehl M, Fateh-Moghadam S, Haen S, Artunc F, Müller MR; et al. (2016). "[An unexpected cause of dyspnea and degradation of performance]". Dtsch Med Wochenschr. 141 (19): 1386. doi:10.1055/s-0042-109741. PMID 27642739.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ Stout KK, Verrier ED (2009). "Acute valvular regurgitation". Circulation. 119 (25): 3232–41. doi:10.1161/CIRCULATIONAHA.108.782292. PMID 19564568.
5. ↑ Blaszyk H, Witkiewicz AJ, Edwards WD (1999). "Acute aortic regurgitation due to spontaneous rupture of a fenestrated cusp: report in a 65-year-old man and review of seven additional cases". Cardiovasc Pathol. 8 (4): 213–6. PMID 10724525.CS1 maint: Multiple names: authors list (link)
6. ↑ Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
7. ↑ 7.0 7.1 Kim, M.; Roman, MJ.; Cavallini, MC.; Schwartz, JE.; Pickering, TG.; Devereux, RB. (1996). "Effect of hypertension on aortic root size and prevalence of aortic regurgitation". Hypertension. 28 (1): 47–52. PMID 8675263. Unknown parameter `|month=` ignored (help)
8. ↑ Amako M, Spear R, Clough RE, Hertault A, Azzaoui R, Martin-Gonzalez T; et al. (2016). "Total Endovascular Aortic Repair in a Patient with Marfan Syndrome". Ann Vasc Surg. doi:10.1016/j.avsg.2016.07.069. PMID 27890843.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
9. ↑ Kamel H, Roman MJ, Pitcher A, Devereux RB (2016). "Pregnancy and the Risk of Aortic Dissection or Rupture: A Cohort-Crossover Analysis". Circulation. 134 (7): 527–33. doi:10.1161/CIRCULATIONAHA.116.021594. PMC 4987245. PMID 27492904.CS1 maint: Multiple names: authors list (link)
10. ↑ Pape LA, Awais M, Woznicki EM, Suzuki T, Trimarchi S, Evangelista A; et al. (2015). "Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection". J Am Coll Cardiol. 66 (4): 350–8. doi:10.1016/j.jacc.2015.05.029. PMID 26205591.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
11. ↑ Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ (2007). "Neurological symptoms in type A aortic dissections". Stroke. 38 (2): 292–7. doi:10.1161/01.STR.0000254594.33408.b1. PMID 17194878.CS1 maint: Multiple names: authors list (link)
12. ↑ Enriquez-Sarano M, Tajik AJ (2004). "Clinical practice. Aortic regurgitation". N Engl J Med. 351 (15): 1539–46. doi:10.1056/NEJMcp030912. PMID 15470217.
13. ↑ Devlin WH, Petrusha J, Briesmiester K, Montgomery D, Starling MR (1999). "Impact of vascular adaptation to chronic aortic regurgitation on left ventricular performance". Circulation. 99 (8): 1027–33. PMID 10051296.CS1 maint: Multiple names: authors list (link)
14. ↑ Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter `|month=` ignored (help)
15. ↑ Spagnuolo, M.; Kloth, H.; Taranta, A.; Doyle, E.; Pasternack, B. (1971). "Natural history of rheumatic aortic regurgitation. Criteria predictive of death, congestive heart failure, and angina in young patients". Circulation. 44 (3): 368–80. PMID 4255488. Unknown parameter `|month=` ignored (help)
16. ↑ Prêtre R, Faidutti B (1993). "Surgical management of aortic valve injury after nonpenetrating trauma". The Annals of Thoracic Surgery. 56 (6): 1426–31. PMID 8267458. Retrieved 2011-03-28. Unknown parameter `|month=` ignored (help)
17. ↑ Onorati F, De Santo LS, Carozza A, De Feo M, Renzulli A, Cotrufo M (2004). "Marfan syndrome as a predisposing factor for traumatic aortic insufficiency". The Annals of Thoracic Surgery. 77 (6): 2192–4. doi:10.1016/S0003-4975(03)01409-7. PMID 15172299. Retrieved 2011-03-28. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
18. ↑ Aizawa, H.; Hasegawa, A.; Arai, M.; Naganuma, F.; Hatori, M.; Kanda, T.; Suzuki, T.; Murata, K.; Satoh, Y. (1998). "Bilateral coronary ostial stenosis and aortic regurgitation due to syphilitic aortitis". Intern Med. 37 (1): 56–9. PMID 9510401. Unknown parameter `|month=` ignored (help)
19. ↑ Palazzi C, D' Angelo S, Lubrano E, Olivieri I. Aortic involvement in ankylosing spondylitis. Clin Exp Rheumatol. May-Jun 2008;26(3 Suppl 49):S131-4.
20. ↑ Pereira, AM.; van Thiel, SW.; Lindner, JR.; Roelfsema, F.; van der Wall, EE.; Morreau, H.; Smit, JW.; Romijn, JA.; Bax, JJ. (2004). "Increased prevalence of regurgitant valvular heart disease in acromegaly". J Clin Endocrinol Metab. 89 (1): 71–5. PMID 14715829. Unknown parameter `|month=` ignored (help)
21. ↑ Brown, OR.; DeMots, H.; Kloster, FE.; Roberts, A.; Menashe, VD.; Beals, RK. (1975). "Aortic root dilatation and mitral valve prolapse in Marfan's syndrome: an ECHOCARDIOgraphic study". Circulation. 52 (4): 651–7. PMID 1157278. Unknown parameter `|month=` ignored (help)
22. ↑ Wunderlich, C.; Schulze, MR.; Strasser, RH. (2005). "Severe aortic regurgitation in Ehlers-Danlos syndrome type IV". Heart. 91 (1): 126. doi:10.1136/hrt.2004.035097. PMID 15604357. Unknown parameter `|month=` ignored (help)
23. ↑ Ferreira TF, Freire M, Teodoro RB (2016). "Difficulties in the differential diagnosis between Takayasu arteritis and rheumatic fever: case report". Rev Bras Reumatol Engl Ed. 56 (1): 90–2. doi:10.1016/j.rbre.2015.07.001. PMID 27267341.CS1 maint: Multiple names: authors list (link)
24. ↑ Isner JM (1991). "Acute catastrophic complications of balloon aortic valvuloplasty. The Mansfield Scientific Aortic Valvuloplasty Registry Investigators". J Am Coll Cardiol. 17 (6): 1436–44. PMID 2016464.

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