Acute aortic regurgitation medical therapy

# Overview
In patients with acute severe AR resulting from infectious endocarditis or aortic dissection, reduction  LV afterload by medications may be a temporary stabilization, but surgery should not be delayed, especially in the presence of hypotension, pulmonary edema, or evidence of low flow. Intra-aortic balloon counterpulsation is contraindicated in patients with acute severe AR. Beta blockers  are often used in treating aortic dissection. However, these agents should be used very cautiously because of block the compensatory tachycardia and reduction in blood pressure.

# Medical Therapy
- In patients with acute severe AR resulting from infectious endocarditis or aortic dissection, reduction  LV afterload by medications may be a temporary stabilization, but surgery should not be delayed, especially in the presence of hypotension, pulmonary edema, or evidence of low flow.
- Intra-aortic balloon counterpulsation is contraindicated in patients with acute severe AR.
- Beta blockers  are often used in treating aortic dissection. However, these agents should be used very cautiously because of block the compensatory tachycardia and reduction in blood pressure.

# Therapeutic Options

## Nitroprusside
Nitroprusside lowers afterload and thereby reduces retrograde flow and left ventricular end diastolic pressure.

## Inotropic Agents
Inotropic agents such as dopamine and dobutamine can be used to increase the contractility of the heart resulting in improved forward flow.

## Beta Blockers
Beta blockers which are often used in managing aortic dissection should be used very cautiously in the presence of acute AR as beta blockers can block the compensatory tachycardia and worsen the cardiac output.

## Intraaortic Balloon Pump
Insertion of an intraaortic balloon pump is contraindicated in acute AR, as it may worsen the severity of the regurgitation.

# 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
Medical treatment to lower LV afterload may temporarily stabilize patients with acute severe AR brought on by IE or aortic dissection, but surgery should not be postponed, especially if there is hypotension, pulmonary edema, or indications of low flow.
Aortic dissection is frequently treated with beta-blockers. However, these medications should only be used very sparingly, if at all, for other acute AR reasons because they will prevent compensatory tachycardia and may induce a significant drop in blood pressure.

# Reference
-  Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C (February 2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e35e71. doi:10.1161/CIR.0000000000000932. PMID 33332149 Check |pmid= value (help)..mw-parser-output cite.citation{font-style:inherit}.mw-parser-output q{quotes:"\"""\"""'""'"}.mw-parser-output code.cs1-code{color:inherit;background:inherit;border:inherit;padding:inherit}.mw-parser-output .cs1-lock-free a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-limited a,.mw-parser-output .cs1-lock-registration a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-lock-subscription a{background:url("")no-repeat;background-position:right .1em center}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration{color:#555}.mw-parser-output .cs1-subscription span,.mw-parser-output .cs1-registration span{border-bottom:1px dotted;cursor:help}.mw-parser-output .cs1-hidden-error{display:none;font-size:100%}.mw-parser-output .cs1-visible-error{display:none;font-size:100%}.mw-parser-output .cs1-subscription,.mw-parser-output .cs1-registration,.mw-parser-output .cs1-format{font-size:95%}.mw-parser-output .cs1-kern-left,.mw-parser-output .cs1-kern-wl-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right,.mw-parser-output .cs1-kern-wl-right{padding-right:0.2em}
-  Miller RR, Vismara LA, DeMaria AN, Salel AF, Mason DT (November 1976). "Afterload reduction therapy with nitroprusside in severe aortic regurgitation: improved cardiac performance and reduced regurgitant volume". Am J Cardiol. 38 (5): 5647. doi:10.1016/s0002-9149(76)80003-3. PMID 983953.
-  Dubin A, Lattanzio B, Gatti L (2017). "The spectrum of cardiovascular effects of dobutamine - from healthy subjects to septic shock patients". Rev Bras Ter Intensiva (in Portuguese). 29 (4): 490498. doi:10.5935/0103-507X.20170068. PMC 5764562. PMID 29340539.CS1 maint: Unrecognized language (link)
-  Rius JB, Merce AS, del Blanco BG, Aguasca GM, Mas PT, Garcia-Dorado Garcia D (2011). "Resolution of shock-induced aortic regurgitation with an intraaortic balloon pump". Circulation. 124 (4): e131. doi:10.1161/CIRCULATIONAHA.111.038653. PMID 21788594.CS1 maint: Multiple names: authors list (link)
-  Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F;  et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).CS1 maint: Multiple names: authors list (link)
CME Category::Cardiology