What is the management and treatment of an aortic murmur?

From the Guidelines

The management of an aortic murmur should focus on the underlying cause, with treatment prioritizing the specific valve pathology rather than the murmur itself, as recommended by the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1.

Key Considerations

• For aortic stenosis, management ranges from watchful waiting with regular echocardiographic monitoring for mild cases to surgical valve replacement or transcatheter aortic valve implantation (TAVI) for severe symptomatic cases.
• Medical therapy includes blood pressure control with ACE inhibitors like lisinopril (10-40 mg daily) or ARBs such as losartan (25-100 mg daily), and statins like atorvastatin (10-80 mg daily) to slow valve degeneration.
• For aortic regurgitation, treatment includes afterload reduction with nifedipine (30-90 mg daily) or hydralazine (10-75 mg three times daily), along with diuretics like furosemide (20-80 mg daily) for symptom management.

Diagnostic Approach

• Standard Doppler echocardiography is the cornerstone of the evaluation of aortic stenosis, and in approximately 65% to 70% of patients, this imaging modality is sufficient to guide therapeutic management 1.
• Multimodality imaging strategies may be necessary in approximately 25% to 30% of patients to confirm disease stage and guide therapeutic decision making 1.

Treatment Goals

• The goal of treatment is to prevent complications like heart failure, sudden cardiac death, and irreversible ventricular dysfunction by intervening before significant cardiac damage occurs.
• Regular follow-up with echocardiography every 6-12 months for moderate disease and more frequently for severe disease is essential to monitor progression and determine optimal timing for intervention.

From the Research

Management and Treatment of Aortic Murmur

The management and treatment of an aortic murmur depend on the underlying cause and severity of the condition.

• For aortic regurgitation, echocardiography plays a crucial role in assessing the severity of the disease and guiding patient management 2.
• In patients with severe, symptomatic, calcific aortic valve stenosis, aortic valve replacement is the only effective treatment 3.
• Echocardiography is essential in selecting and monitoring surgical and endovascular treatment and in detecting possible complications 4.
• The American Society of Echocardiography (ASE) guidelines for echocardiographic evaluation of aortic regurgitation have been validated against cardiac magnetic resonance (CMR) and can be used to reliably identify significant aortic regurgitation 5.

Diagnostic Approaches

Diagnostic approaches for aortic murmur include:

• Echocardiography, which enables the delineation of valvular morphology, the mechanism of the lesion, and the grading of severity 2.
• Physical examination and focused cardiac ultrasound (FoCUS) to determine whether patients with a systolic ejection murmur should be referred for standard echocardiography 6.
• Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) to assess aortic size, biophysical properties, and atherosclerotic involvement of the thoracic aorta 4.

Treatment Options

Treatment options for aortic murmur depend on the underlying cause and severity of the condition, and may include:

• Aortic valve replacement for patients with severe, symptomatic, calcific aortic valve stenosis 3.
• Surgical and endovascular treatment for patients with aortic regurgitation or aortic stenosis 4.
• Medical management, such as blood pressure control and monitoring, for patients with mild or moderate aortic regurgitation or aortic stenosis.