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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Aortic regurgitation

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Acute severe aortic regurgitation can cause abrupt pulmonary oedema and shock with few classic peripheral signs. Call 999, obtain immediate echocardiography and involve cardiothoracic surgery urgently, particularly after endocarditis, aortic dissection or trauma.

Synopsis

Distinguish acute from chronic aortic regurgitation, quantify severity and LV response, and act before irreversible ventricular dysfunction develops.

  • Chronic AR produces LV volume overload, eccentric dilatation and a wide pulse pressure; symptoms can appear late after prolonged compensation.
  • An early diastolic decrescendo murmur at the left sternal edge is typical; leaning forward in expiration can make it clearer.
  • Acute severe AR may have a short, soft murmur and normal pulse pressure because the LV has had no time to dilate.
  • Echo grades regurgitation using several measures; severe markers include vena contracta over 6 mm, regurgitant volume at least 60 mL/beat or EROA at least 0.30 cm2.
  • Symptomatic severe AR and severe AR with LV systolic impairment or excessive LV dilatation require valve-surgery assessment.
  • Measure the aortic root and ascending aorta: bicuspid valve, connective-tissue disease and dissection can determine the operation as much as the valve lesion.
  • Vasodilators treat coexisting hypertension or heart failure when surgery is not yet possible; they do not replace timely surgery in operable severe AR.
  • New dyspnoea, falling LVEF or rising LV end-systolic size during surveillance should trigger valve-team review before irreversible damage.

Key red flags

Acute severe AR

Sudden pulmonary oedema, hypotension and tachycardia after endocarditis, dissection, trauma or iatrogenic injury may occur without classic peripheral signs.

Aortic disease clues

Unequal pulses, tearing chest/back pain, connective-tissue phenotype or rapid aortic enlargement suggests associated aortopathy or dissection.

Investigation priorities

01
Transthoracic echocardiographyFirst step

Define mechanism, quantify AR, measure LV size/function and examine the aortic root.

Management branches

acuteAcute severe aortic regurgitation

Sudden severe AR causes pulmonary oedema, hypotension or shock.

  1. Use ABCDE care, continuous monitoring, urgent TTE/TOE and immediate cardiology, critical-care and cardiothoracic-surgical involvement.
  2. Search simultaneously for dissection, endocarditis, trauma or procedure complication; obtain blood cultures promptly if infection is plausible.
  3. Support oxygenation and perfusion in critical care; avoid reflex bradycardia and recognise that intra-aortic balloon counterpulsation is contraindicated because it worsens regurgitation.
  4. Proceed to emergency surgery when severe acute AR is confirmed and treat the cause; medical therapy is only a bridge.

Key medicines

RamiprilFor hypertension, usually 2.5 mg orally once daily initially; use 1.25 mg once daily when the renin–angiotensin system is strongly activated, then titrate at 2–4-week intervals to a maximum 10 mg/day.Check creatinine and potassium before and 1–2 weeks after starting or titrating; avoid in pregnancy and previous ACE-inhibitor angioedema, and use caution in renal-artery stenosis.
FurosemideFor chronic oedema, 40 mg orally in the morning is a usual initial adult dose; maintenance may be 20 mg daily or 40 mg on alternate days, adjusted to response.Monitor weight, BP, renal function, sodium and potassium; over-diuresis can cause hypotension and renal injury. It does not delay a surgical indication.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG208: Heart valve disease presenting in adultsUK referral, intervention and surveillance principles.
  • ESC/EACTS 2025 valvular heart disease guidelineContemporary surgical triggers and aortic assessment.
  • ESC: Chronic aortic regurgitationIntegrated severity criteria and multimodality imaging.
  • NHS: Heart valve diseaseSymptoms and routes to urgent care.
  • eMC: Ramipril SmPCLicensed adult hypertension dosing and safety monitoring.
  • eMC: Furosemide tablets SmPCAdult oedema dosing and cautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom