PassFinals
Cardiovascular

Aortic Regurgitation

Aortic regurgitation allows blood to leak back into the LV during diastole, causing volume overload and progressive ventricular dilatation.

In a nutshell

Aortic regurgitation is diastolic backflow with LV volume overload. Separate acute emergency AR from chronic disease; quantify it with integrated echo and refer severe symptomatic or LV-decompensating disease for intervention.

Classic presentation

Patient with exertional breathlessness or a forceful heartbeat, wide pulse pressure and an early diastolic decrescendo murmur.

Key points

  • Acute AR can cause rapid pulmonary oedema or shock because the LV has no time to adapt.
  • Chronic AR may be silent while LV dilatation progresses; symptoms and serial measurements matter.
  • Use integrated echocardiography; TOE, cardiac MRI or CT may be needed when measurements are discordant or anatomy is unclear.
  • Offer intervention for symptomatic severe AR; consider it when asymptomatic severe AR has EF below 55%, ESD above 50 mm or indexed ESD above 24 mm/m².
  • Surgery is usual for suitable low/intermediate-risk patients; native-AR TAVI is a specialist pathway.
  • Think of endocarditis and dissection when AR is new, acute or accompanied by fever, embolic signs or severe pain.

First-line investigation

Urgent TTE, with TOE or other imaging if acute, severe or technically uncertain.

Management

Identify acute severe AR

  • Pulmonary oedema, hypotension or shock with new AR is an emergency; involve cardiology, critical care and the surgical/valve team.2,1

Quantify and define mechanism

  • Use integrated TTE; escalate to TOE, cardiac MRI or CT when severity, cusp anatomy, aortic root or acute cause is uncertain.2

Refer severe disease for intervention

  • Offer intervention for symptomatic severe AR and consider it for the NICE LV dysfunction or dilatation triggers.1

Consider aortic and inherited disease

  • Assess bicuspid valve, aortic-root disease and family history where relevant through specialist services.2,1

Trend LV and aortic response

  • Use serial symptoms, LV measurements and aortic dimensions; new breathlessness, chest pain or syncope should prompt urgent review.2,1

Exam traps

  • A collapsing pulse supports significant chronic AR but does not grade severity alone.
  • Normal EF does not exclude important chronic AR; use LV size and serial change.
  • Do not treat acute AR like stable chronic HF while delaying surgery or cause-specific treatment.
  • Do not offer routine native-AR TAVI outside specialist assessment of operability, anatomy and current NICE technology guidance.

Illustrations

Severe aortic regurgitation on colour DopplerTransoesophageal echocardiography showing a large diastolic regurgitant jet through the aortic valve, with 3D views of the cusp abnormality and regurgitant orifice.Ma Q et al., European heart journal. Case reports 2026, CC-BY-4.0 · CC-BY-4.0

Key sources

  1. NICE NG208: Heart valve disease presenting in adults (Referral, investigation, pharmacological management, intervention and follow-up recommendations)Published 17 Nov 2021 | Updated 24 Oct 2025
  2. British Society of Echocardiography: Echocardiographic assessment of aortic regurgitation (UK assessment guideline for acute and chronic aortic regurgitation)Published 28 Jan 2025
  3. NICE HTG752: Transcatheter aortic valve implantation for native aortic valve regurgitation (Specialist-only native-AR TAVI recommendations)Published 26 Jun 2024
  4. NICE NG208: Heart valve disease presenting in adults — overview (Current guideline status and update information)Published 17 Nov 2021 | Updated 24 Oct 2025
  5. BSE/BHVS: Clinical indications and triage for echocardiography in heart valve disease (UK consensus on referral, red flags and surveillance)Published 1 Aug 2024

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.