Chest Pain from Aortic Regurgitation

[MrP]

I found an article in which aortic regurgitation and chest pain are discussed and thought I'd share this with those of you interested...see excerpts below. Some of us had chest pains (sometimes sharp chest pains on the order of seconds) that were no longer present after AVR and resection of ascending aortic aneurysm. We discussed in an earlier thread how this chest pain may have been a result of stretching of the aorta or aortic regurgitation. This information may be helpful to some currently experiencing chest pain. The entire article may be found at:

http://emedicine.com/RADIO/topic45.htm

The extent and severity of aortic regurgitation depends on the size of the diastolic aortic valve opening, the diastolic gradient between the aortic and LV pressure, and the length of the diastolic period. During dynamic exercise, as the heart rate increases, the diastolic period tends to shorten, leading to a decrease in the amount of aortic regurgitation. The increased systolic output into the aorta, and the diastolic blood reflux into the LV cause an increased pulse pressure manifesting as Corrigan pulse, Hill sign, etc.

Lower diastolic aortic pressure further leads to a lower-pressure head in the coronary circulation, which may manifest as ischemia. The regurgitant jet may hit the anterior mitral cusp, causing its reverse doming in diastole. Fast moving blood produces a drop in pressure (Bernoulli effect), which can pull the anterior mitral leaflet and/or submitral chordae towards the outflow tract (systolic anterior motion [SAM]). The ascending aorta may progressively dilate in turn, leading to poorer aortic cusp coaptation and increasing regurgitation.

Most patients with aortic regurgitation are asymptomatic, and the diagnosis is made with the detection of a heart murmur during physical examination.

Symptoms

Although a heart murmur and heart failure may develop rapidly in acute aortic regurgitation, patients with chronic regurgitation develop symptoms late in the time course of the disease.

Chronic regurgitation may be present for a decade before exertional dyspnea develops as its presenting symptom. Patients whose functional capacity is reduced to NYHA class III generally have underlying LV dysfunction. Heart pounding is another frequent symptom, whereas chest pain occurs in 20% of the patients with aortic regurgitation. Concomitant coronary stenosis may also be present in 20% of the patients.

Chest pain occurs less often in aortic regurgitation than in aortic stenosis; however, nocturnal angina often accompanied by diaphoresis may occur when the heart rate slows and arterial diastolic pressure falls to extremely low levels. Some patients with aortic regurgitation also report abdominal pain, presumably secondary to splanchnic ischemia.

 

[MrP]

I forgot to add that beta-blockers are often taken to slow growth of an ascending aortic aneurysm, and interestingly, this article indicates this may result in a greater degree of regurgitation. Seems like a reasonable tradeoff, but is more pain a result?

Use of beta-blockers is relatively contraindicated in patients with aortic regurgitation. Use of these agents leads to prolongation of the diastolic interval, facilitating a greater degree of regurgitation.