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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e106 CLINICAL STATEMENTS AND GUIDELINES 4.3 Chronic AR 4.3.1 Diagnosis of Chronic AR Recommendations for Diagnostic Testing of Chronic AR Referenced studies that support the recommendations are summarized in Online Data Supplement 14. COR LOE Recommendations 1 B-NR 1. In patients with signs or symptoms of AR, TTE is indicated for assessment of the cause and severity of regurgitation, LV size and systolic function, prognosis, and timing of valve intervention.1–19 1 B-NR 2. In patients with a BAV or with known dilation of the aortic sinuses or ascending aorta, TTE is indicated to evaluate the presence and severity of AR.1 1 B-NR 3. In patients with moderate or severe AR and suboptimal TTE images or a discrepancy between clinical and TTE findings, TEE, CMR, or cardiac catheterization is indicated for the assessment of LV systolic function, systolic and diastolic volumes, aortic size, and AR severity.20–25 Synopsis TTE provides diagnostic information about the etiology and mechanism of AR (including valve reparability), severity of regurgitation, morphology of the ascending aorta, and LV response to the increases in preload and afterload. Imaging with TEE, CMR, or aortic angiography provides additional information when needed. Recommendation-Specific Supportive Text 1. Although qualitative measures of AR severity are adequate in many situations, when AR is significant (Stages B and C), quantitative measures of regurgitant volume and effective regurgitant orifice (ERO) area1 are better predictors of clinical outcome.2,3 Measures of LV systolic function (LVEF or fractional shortening) and LV end-systolic dimension (LVESD) or LV end-systolic volume are predictive of the development of HF symptoms or death in initially asymptomatic patients (Stages B and C1) and are significant determinants of survival and functional results after surgery in asymptomatic and symptomatic patients (Stages C2 and D).2–18,26 Symptomatic patients (Stage D) with normal LVEF have a significantly better longterm postoperative survival rate than those with depressed systolic function. 2. Auscultation has high specificity for detecting AR but low sensitivity and diagnostic accuracy.27 TTE can identify AR in patients who have been deemed to be at risk on the basis of the presence of known aortic dilation or a condition associated with abnormal aortic valve function, such as a BAV. 3. TTE and CMR are useful for evaluating patients in whom there is discordance between clinical assessment and severity of AR by TTE or when TTE images are suboptimal. CMR imaging provides accurate and reproducible measures of regurgitant volume and regurgitant fraction in patients with AR, as well as assessment of aortic morphology, LV volume, and LV systolic function. Cardiac catheterization with LV and aortic angiography, as well as quantitation of regurgitation severity, is another option.20–25,28–30 4.3.2 Medical Therapy Recommendations for Medical Therapy of Chronic AR Referenced studies that support the recommendations are summarized in Online Data Supplement 14. COR LOE Recommendations 1 B-NR 1. In asymptomatic patients with chronic AR (Stages B and C), treatment of hypertension (systolic blood pressure >140 mm Hg) is recommended.1–3 1 B-NR 2. In patients with severe AR who have symptoms and/or LV systolic dysfunction (Stages C2 and D) but a prohibitive surgical risk, GDMT for reduced LVEF with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended.4 Synopsis There is no evidence that vasodilating drugs reduce severity of AR or alter the disease course in patients with significant AR in the absence of systemic hypertension. Recommendations for GDMT for hypertension and HF apply to patients with chronic asymptomatic AR, as for the general population. Recommendation-Specific Supportive Text 1. Severe AR is associated with a wide pulse pressure, such that systolic blood pressure is higher than in patients without AR even when systemic vascular resistance is normal. Transaortic stroke volume increases further with medications that lower heart rate, such as beta blockers, which may result in a paradoxical apparent increase in blood pressure. Vasodilating drugs, such as ACE inhibitors or ARBs, do not affect heart rate and thus may reduce systolic blood pressure without a substantial reduction in diastolic blood pressure in patients with chronic AR.1,2,5–8 2. In symptomatic patients who are candidates for surgery, medical therapy is not a substitute for AVR. However, medical therapy is helpful for alleviating symptoms in patients who are considered to be at very high surgical risk because of concomitant comorbid medical conditions.5,9 Downloaded from http://ahajournals.org by on October 7, 2026