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When angina does NOT =coronary artery disease...

Updated: Dec 3, 2019

Dr. Sharma presents a case of a younger gentleman with dyspnea, palpitations, and chest tightness ultimately diagnosed with aortic regurgitation.





1. What are the indications for an echo?

Diagnostic testing for structural heart disease should be considered in the following patients:

  • Systolic murmur grade 3/6 or higher

  • Late or holosystolic murmur

  • Diastolic or continuous murmur

  • Murmur + accompanying symptoms


2. How does aortic regurgitation lead to symptoms?

  • During diastole, blood flows from the aorta back into the LV (diastolic murmur)

  • This leads to increased LV end diastolic volume and pressure -> compensatory eccentric hypertrophy

  • Note increased stroke volume and increased aortic systolic pressure with decreased diastolic pressure

  • Increased LA pressure and pulmonary capillary wedge pressure leads to pulmonary congestion and edema

  • Epicardial coronary flow shifts from predominantly diastolic to systolic --> reduced coronary flow reserve



3. What are the etiologies of chronic aortic insufficiency?

  • Rheumatic heart disease

  • Congenital heart disease, particularly bicuspid aortic valve

  • Calcific valve disease

  • Genetic syndromes - Marfan, Ehler's Danlos, osteogenesis imperfecta

  • Systemic rheum disorders (GCA, takayasu, A.S, R.A, SLE)

  • Infection - endocarditis or infective aortitis

  • Aortic dissection/trauma


4. What is the classical murmur of A.I?

  • High pitched, blowing, early diastolic murmur

  • Can progress to holodiastolic

  • Typically at LSB at 3-4th intercostal space

  • Increases with squatting, decreases with valsalva


5. What do we do with aortic regurg?

  • Depends on severity - if low severity, monitor for changes in symptoms, and progression of LV systolic function

  • Valve surgery indicated in symptomatic AR or asymptomatic severe AR with LV systolic dysfunction (EF <50%, consider for End-diastolic dimension >50mm), or undergoing cardiac surgery for other indications



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