Valvular: Includes congenitally bicuspid valve, endocarditis, or rheumatic (especially if rheumatic mitral disease is present). Dilated aortic root: dilatation due to cystic medial necrosis, aortic dissection, ankylosing spondylitis, syphilis.

When chronic severe AR is symptomatic, manifests as awareness of forceful heartbeat, exertional dyspnea, and other signs of LV failure (orthopnea, paroxysmal nocturnal dyspnea) and sometimes angina pectoris. A widened pulse pressure, rapidly rising “water hammer” pulse, capillary pulsations (Quincke’s sign), and a heaving, laterally displaced LV impulse are common. On auscultation A₂ is soft or absent, an S₃ may be present, and there is a high-pitched, blowing, decrescendo early diastolic murmur along the left sternal border (but often along right sternal border when AR is due to aortic dilatation). In acute severe AR, the pulse pressure is typically not widened and the diastolic murmur is often short and soft.

ECG: Signs of LV hypertrophy with “strain.” CXR: apex is displayed downward and to the left; aneurysmal dilatation of the aorta may be present.

LV enlargement, possible aortic dilatation, high-frequency diastolic fluttering of mitral valve. Failure of coaptation of aortic valve leaflets may be present. Doppler studies detect and quantify AR. Cardiac magnetic resonance imaging helpful for quantification of AR, LV contractile function, and aortic enlargement if echo is inadequate.

Acute severe AR requires intravenous diuretics and vasodilators (e.g., sodium nitroprusside) and usually early surgical correction. For chronic AR, vasodilators (ACE inhibitor or long-acting nifedipine) are recommended if hypertension present. Avoid beta blockers, which prolong diastolic filling. Surgical valve replacement should be considered in pts with chronic severe AR when symptoms develop or in asymptomatic pts with LV dysfunction (e.g., LVEF <50%, end-systolic diameter >50 mm, or LV diastolic dimension >65 mm) by imaging studies.