Aortic regurgitation: disease progression and management

Aortic regurgitation (AR) is a common valvular heart disease that unless appropriately managed is associated with morbidity and mortality. Left ventricular (LV) mechanics and aortic impedance are the main determinants of outcome in patients with AR and govern clinical management. Mild and moderate AR in individuals with normal LV dimensions are both generally benign. In the absence of symptoms and before LV dimensions increase, even severe AR is not generally associated with increased morbidity or mortality. Once LV enlargement occurs, however, symptoms and/or a decline in ejection fraction can develop, and both represent an indication for surgical intervention. Disease progression occurs at a variable rate, and is often insidious. Hence, symptoms do not correlate with objective evidence of ventricular dysfunction. Exercise testing can help highlight symptoms related to valve dysfunction. Asymptomatic patients with severe AR and preserved LV function can benefit from vasodilator drug therapy. Several agents from this class can reduce AR severity, but results are inconsistent. In this Review, we examine the epidemiology of AR in terms of the interplay between arterial and ventricular forces marking progression of disease over time, and analyze the practice guidelines regarding diagnosis and treatment.