Can aortic regurgitation cause chest pain?

Can Aortic Regurgitation Cause Chest Pain?

Yes, aortic regurgitation can cause chest pain, though the mechanism and presentation differ significantly between acute and chronic forms of the disease.

Acute Aortic Regurgitation and Chest Pain

Acute aortic regurgitation is a medical emergency that commonly presents with chest pain as a prominent symptom, particularly when it occurs in the context of aortic dissection 1.

• When acute AR develops from aortic dissection, patients typically experience abrupt onset of severe, sharp chest pain that is maximal at the time of onset, occurring in up to 90% of cases 2.
• The pain mechanism involves sudden separation of aortic wall layers, stretching pain-sensitive nerve fibers in the adventitia, which creates the characteristic severe, sharp quality 3.
• A new diastolic murmur of aortic regurgitation is a high-risk examination finding in patients presenting with acute chest pain and should raise immediate concern for aortic dissection 1.
• Acute AR from dissection is accompanied by severe pulmonary edema and hypotension, requiring immediate surgical intervention 4, 5, 6.

Chronic Aortic Regurgitation and Chest Pain

Chronic severe aortic regurgitation can also cause chest pain, though through different mechanisms than acute AR 1.

• The primary mechanism is coronary microvascular dysfunction in the presence of very elevated left ventricular pressure caused by high afterload and associated left ventricular hypertrophy 1.
• Chest pain occurs even in the absence of obstructive epicardial coronary artery disease, distinguishing it from typical angina 1.
• The pain results from the combined volume and pressure overload on the left ventricle, which causes systolic hypertension and wide pulse pressure 5.
• Many patients with chronic severe AR may remain clinically compensated for years without symptoms, but when chest pain develops it signals significant hemodynamic burden 5.

Physical Examination Findings

When evaluating chest pain in the context of AR, specific examination findings are critical 1:

• Characteristic murmurs and pulse alterations are produced by noncoronary causes of chest pain including aortic regurgitation 1.
• Bounding pulses and wide pulse pressure are peripheral physical findings that accompany chronic severe AR with systolic hypertension 5.
• A new aortic regurgitation murmur in the setting of acute chest pain should prompt immediate evaluation for aortic dissection before any anticoagulation or thrombolytic therapy 7.

Critical Diagnostic Considerations

The most important clinical pitfall is distinguishing AR-related chest pain from acute coronary syndrome, as the treatments differ dramatically and misdiagnosis can be fatal 7.

• Check for pulse deficits, blood pressure differential between arms (>20 mmHg), and new AR murmur to aid in diagnosis of aortic dissection as the cause of acute AR 1, 7.
• Echocardiography is the primary diagnostic test for determining the presence and severity of AR and its effect on left ventricular size and function 5, 8.
• Never administer thrombolytics or anticoagulation until aortic dissection is excluded in patients with risk factors presenting with chest pain and signs of AR 7.

Clinical Context and Severity

The relationship between AR and chest pain depends heavily on acuity and severity 1, 4:

• Mild to moderate AR in individuals with normal LV dimensions is generally benign and unlikely to cause chest pain 9.
• Severe AR without LV enlargement may not be associated with symptoms initially, but once LV dilation occurs, symptoms including chest pain can develop 9.
• The typical patient with acute AR from dissection is a male in his 60s with hypertension presenting with abrupt onset chest pain 2.