From the Guidelines
Moderate aortic insufficiency alone does not automatically qualify a patient as having stage B heart failure. Stage B heart failure refers to patients who have structural heart disease but have never developed symptoms of heart failure. While moderate aortic insufficiency represents structural heart disease, the classification into stage B heart failure depends on additional factors such as left ventricular remodeling, ejection fraction, and other cardiac parameters. Some key points to consider in the management of patients with valvular heart disease, including those with aortic insufficiency, are outlined in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. Patients with moderate aortic insufficiency should be monitored regularly with echocardiography to assess for progressive left ventricular dilation or dysfunction, which could then qualify them for stage B heart failure. The key distinction is that aortic insufficiency represents valvular heart disease, while progression to heart failure depends on how this valvular problem affects ventricular function over time. Management typically involves regular clinical and echocardiographic follow-up every 1-2 years for moderate aortic insufficiency, with consideration of ACE inhibitors or ARBs if there is evidence of left ventricular enlargement or dysfunction, as suggested by guidelines for the management of heart failure 1. The underlying pathophysiology involves volume overload on the left ventricle due to regurgitant blood flow, which can eventually lead to ventricular dilation and heart failure if significant and progressive. Disease stages in patients with valvular heart disease, including aortic insufficiency, should be classified on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation 1. In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing, and further testing may be necessary if there is discordance between the physical examination and initial noninvasive testing 1. The decision to use specific treatments, such as oral anticoagulation, should be made in a shared decision-making process based on individual patient characteristics and guidelines 1. All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center 1. Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function, and earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis 1. Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation versus surgical aortic valve replacement, and the choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve and type of approach 1. Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload, and thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks 1. A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure 1. Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney 1. Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis, and catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection 1. The 2013 ACCF/AHA guideline for the management of heart failure also provides guidance on the management of patients with stage B heart failure, including those with valvular heart disease 1. In general, all recommendations for patients with stage A heart failure also apply to those with stage B heart failure, particularly with respect to control of blood pressure in the patient with left ventricular hypertrophy and the optimization of lipids with statins 1. Current evidence supports the use of ACE inhibitors and beta-blocker therapy to impede maladaptive left ventricular remodeling in patients with stage B heart failure and low left ventricular ejection fraction to improve mortality and morbidity 1. ARBs are reasonable alternatives to ACE inhibitors, and data with beta blockers are less convincing in a population with known coronary artery disease, although in one trial, carvedilol therapy in patients with stage B and low left ventricular ejection fraction was associated with a relative risk reduction in adverse long-term outcomes 1. Elevations in both systolic and diastolic blood pressure are major risk factors for developing left ventricular hypertrophy, another form of stage B heart failure, and effective hypertension treatment invariably reduces heart failure events 1. Consequently, long-term treatment of both systolic and diastolic hypertension reduces the risk of moving from stage A or B to stage C heart failure, and several large controlled studies have uniformly demonstrated that optimal blood pressure control decreases the risk of new heart failure by approximately 50% 1. It is imperative that strategies to control hypertension be part of any effort to prevent heart failure, and clinicians should lower both systolic and diastolic blood pressure in accordance with published guidelines, with target levels of blood pressure lowering depending on major cardiovascular risk factors 1. Diuretic-based antihypertensive therapy has been shown to prevent heart failure in a wide range of target populations, and in refractory hypertensive patients, spironolactone should be considered as an additional agent 1. Eplerenone, in synergy with enalapril, has also demonstrated reduction in left ventricular mass, and other ACCF/AHA guidelines addressing the appropriate management of patients with stage B heart failure are listed in the guideline 1. The 2009 focused update incorporated into the ACC/aha 2005 guidelines for the diagnosis and management of heart failure in adults also provides guidance on the management of patients with heart failure, including those with valvular heart disease 1. The 2001 acc/aha guidelines for the evaluation and management of chronic heart failure in the adult also provide guidance on the management of patients with heart failure, including those with valvular heart disease 1. The 2005 acc/aha 2005 guideline update for the diagnosis and management of chronic heart failure in the adult also provides guidance on the management of patients with heart failure, including those with valvular heart disease 1. In summary, moderate aortic insufficiency alone does not automatically qualify a patient as having stage B heart failure, and the classification into stage B heart failure depends on additional factors such as left ventricular remodeling, ejection fraction, and other cardiac parameters, as outlined in the guidelines for the management of heart failure 1.
From the Research
Definition of Stage B Heart Failure
Stage B heart failure is defined as patients with structural heart disease (e.g., left ventricular hypertrophy, left ventricular dilatation, or valvular heart disease) who are asymptomatic [no reference provided as this information is not present in the given studies].
Relationship Between Moderate Aortic Insufficiency and Stage B Heart Failure
- Moderate aortic insufficiency can lead to left ventricular remodeling, which is a key feature of heart failure progression 2, 3.
- Left ventricular remodeling can result in increased left ventricular volumes, leading to a rise in wall stress and a compensatory increase in myocardial mass 3.
- The presence of moderate aortic insufficiency may contribute to adverse outcomes in patients with heart failure with reduced ejection fraction (HFrEF) 4.
- Cardiac magnetic resonance (CMR) volumetric quantification can provide incremental risk stratification over standard clinical and echocardiographic evaluation in patients with chronic moderate or severe aortic regurgitation 5.
Clinical Implications
- Patients with moderate aortic insufficiency may be at increased risk of heart failure hospitalization and mortality 4.
- Aortic valve replacement (AVR) may be associated with improved survival in patients with HFrEF and moderate aortic stenosis 4.
- CMR quantification of left ventricular end-systolic volume index (LVESVi) and aortic regurgitant fraction may identify patients with chronic moderate or severe aortic regurgitation who are at risk of death or incident heart failure 5.