Symptoms of Aortic Regurgitation
Clinical Presentation Depends on Acuity
The symptoms of aortic regurgitation differ dramatically between acute and chronic presentations, with acute AR causing severe pulmonary edema and hypotension requiring emergency surgery, while chronic AR progresses insidiously with exertional dyspnea, fatigue, and palpitations developing only after years of compensation. 1, 2
Acute Aortic Regurgitation Symptoms
- Severe pulmonary edema develops rapidly due to sudden volume overload on a non-compliant left ventricle that has not had time to adapt 3, 2
- Hypotension and cardiogenic shock occur because the left ventricle cannot maintain adequate forward cardiac output 3, 4
- Acute dyspnea at rest is the predominant symptom, reflecting flash pulmonary edema 4
- This represents a surgical emergency requiring immediate intervention, as medical therapy only serves as a temporizing bridge 5, 3
Chronic Aortic Regurgitation Symptoms
Many patients with chronic severe AR remain asymptomatic for years despite significant hemodynamic burden, because compensatory eccentric LV remodeling initially normalizes wall stress 1, 6
Early/Compensated Phase (Often Asymptomatic)
- Patients may notice palpitations due to increased stroke volume and bounding pulses 2
- Awareness of heartbeat, particularly when lying on the left side 2
- Some patients remain completely asymptomatic despite severe AR if LV function is preserved 6, 7
Symptomatic Phase (Indicates LV Decompensation)
- Exertional dyspnea is typically the first symptom, developing insidiously as compensatory mechanisms fail 1, 3
- Orthopnea and paroxysmal nocturnal dyspnea emerge as heart failure progresses 4
- Fatigue and reduced exercise tolerance reflect declining cardiac output 4
- Angina pectoris can occur even without coronary disease, due to increased myocardial oxygen demand and reduced diastolic coronary perfusion 2
- Symptoms herald left ventricular decompensation and represent the strongest indication for surgical intervention 1, 5
Critical Timing Considerations
Once symptoms develop, annual mortality rises to 10-25%, making symptom onset an absolute indication for surgery regardless of LV function. 5, 3 Within 10 years of diagnosis of severe AR, 75% of patients die or require aortic valve replacement 1
The Insidious Nature Problem
- Disease progression is often insidious, and symptoms do not correlate well with objective evidence of ventricular dysfunction 6, 7
- Patients may unconsciously reduce activity levels, masking symptoms 6
- Exercise testing can help unmask symptoms related to valve dysfunction in patients who report being asymptomatic 6
Physical Findings (Not Symptoms, But Aid Diagnosis)
- Wide pulse pressure with systolic hypertension and low diastolic pressure 2
- Bounding peripheral pulses (water-hammer pulse) 2
- Holodiastolic decrescendo murmur best heard at the left sternal border 2
Key Clinical Pitfall
Never delay surgery in symptomatic patients to "optimize" medical therapy—symptoms indicate decompensation and mortality risk increases substantially. 5, 3 Even in asymptomatic severe AR, mortality can be as high as 19% within 6.6 years of diagnosis 1