Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 47-year-old man is evaluated during a routine examination. He has no symptoms. Medical history is significant for a bicuspid aortic valve. He is not taking any medications.

On physical examination, he is afebrile, blood pressure is 130/70 mm Hg, pulse rate is 56/min, and respiration rate is 15/min. Cardiac examination reveals a grade 1/6 diastolic murmur at the left lower sternal border.

Echocardiogram shows a bicuspid aortic valve with moderate aortic regurgitation, normal left ventricular systolic function, and normal left ventricular chamber size.

Which of the following is the most appropriate management?

A: Aortic valve replacement
B: Clinical reassessment in 1 year
C: Endocarditis prophylaxis
D: Start an ACE inhibitor
E: Start a calcium channel blocker

MKSAP Answer and Critique

The correct answer is B: Clinical reassessment in 1 year.

This patient with moderate aortic regurgitation should be reassessed clinically in 1 year. Patients with moderate aortic regurgitation should be evaluated on a yearly basis and echocardiography performed every 1 to 2 years.

Aortic valve replacement is indicated for symptomatic patients with chronic severe aortic regurgitation irrespective of left ventricular (LV) systolic function, asymptomatic patients with chronic severe aortic regurgitation and LV systolic dysfunction (LV ejection fraction ≤50%), and patients with chronic severe aortic regurgitation undergoing coronary artery bypass graft (CABG) or surgery on the aorta or other heart valves. This patient is not a candidate for aortic valve replacement.

Endocarditis prophylaxis is not recommended for patients with bicuspid aortic valves in the absence of another specific indication such as a prior episode of infective endocarditis, previous valve replacement, prior cardiac transplantation with valvulopathy, and certain forms of complex congenital heart disease.

Medical therapy for chronic aortic regurgitation is limited. ACE inhibitors or angiotensin receptor blockers may be used in patients with chronic severe aortic regurgitation and heart failure as well as in patients with aortic regurgitation and concomitant hypertension, but these agents, as well as dihydropyridine calcium channel blockers, have not been shown to delay surgery in asymptomatic patients without hypertension. There is no established benefit in medical therapy for this patient with moderate aortic regurgitation without other specific indications for treatment.

Key Point

• Asymptomatic patients with moderate aortic regurgitation should be evaluated on a yearly basis and have echocardiography performed every 1 to 2 years.

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