Amlodipine in Moderate Aortic Regurgitation
Amlodipine is an appropriate antihypertensive agent for patients with moderate aortic regurgitation who have hypertension, as dihydropyridine calcium channel blockers like amlodipine provide vasodilation without slowing heart rate, which is critical to avoid increasing regurgitant volume. 1
Primary Indication and Rationale
Use amlodipine specifically when hypertension is present (systolic BP >140 mmHg) in patients with moderate aortic regurgitation. 2 The European Society of Cardiology explicitly endorses dihydropyridine calcium channel blockers such as amlodipine alongside ACE inhibitors as preferred vasodilators for blood pressure control in this population. 1
The physiologic rationale is straightforward:
- Vasodilators reduce left ventricular afterload and can decrease LV volume and mass while improving LV performance in aortic regurgitation 1
- Amlodipine's mechanism of peripheral and coronary vasodilation occurs without negative chronotropic effects 3
- Maintaining or slightly increasing heart rate is beneficial in aortic regurgitation, as it shortens diastolic filling time and thereby reduces the regurgitant volume per cardiac cycle 1
Critical Contraindication: Avoid Beta Blockers
Never use beta blockers as first-line therapy in moderate aortic regurgitation unless there are compelling indications such as heart failure with reduced ejection fraction, post-myocardial infarction, or life-threatening arrhythmias. 4 Beta blockers prolong diastole through bradycardia, which directly increases regurgitant volume—a hemodynamically detrimental effect in aortic regurgitation. 1, 4
When Amlodipine Should NOT Be Used
Do not use amlodipine or any vasodilator in normotensive patients with moderate aortic regurgitation and normal left ventricular cavity size, as there is no proven benefit. 5 The role of vasodilators in asymptomatic patients without hypertension to delay surgery remains unproven. 1
Alternative First-Line Options
Consider ACE inhibitors or ARBs as equally appropriate alternatives to amlodipine for hypertension management in moderate aortic regurgitation. 1, 2 RAS blockade may offer additional advantages through beneficial effects on LV fibrosis, though both drug classes are guideline-endorsed. 1
Surveillance Requirements
Monitor these patients with yearly clinical assessment and echocardiography every 1-2 years to detect progression to severe disease. 2 Increase imaging frequency to every 3-6 months if there are significant changes in LV ejection fraction or progressive LV dilatation. 2
Watch specifically for progression markers including:
- Vena contracta ≥0.6 cm
- Regurgitant volume ≥60 mL/beat
- Effective regurgitant orifice area ≥0.3 cm²
- LV ejection fraction decline below 50-55%
- Development of symptoms 2
Important Caveat About Aortic Stenosis
If the patient has concurrent moderate or severe aortic stenosis alongside moderate aortic regurgitation, exercise extreme caution with all antihypertensive agents and obtain mandatory cardiology consultation. 4 A 2020 study demonstrated that calcium channel blockers were associated with 7-fold increased mortality in patients with moderate-to-severe aortic stenosis, though this study did not specifically address isolated aortic regurgitation. 6 This highlights the critical importance of accurate valve assessment before initiating therapy.
Practical Implementation
Start amlodipine at standard antihypertensive doses (typically 5-10 mg daily) with the goal of reducing systolic blood pressure, though normalizing it may not be achievable due to increased LV stroke volume. 5, 3 The drug is well-tolerated with vasodilator side effects (peripheral edema, flushing) being the most common, which are generally mild to moderate. 3, 7