Aortic Regurgitation and Blood Pressure Effects

Hemodynamic Changes

Volume overload from significant aortic regurgitation leads to increased total stroke volume, resulting in systolic hypertension and afterload mismatch, according to the European Heart Journal 1.
The left ventricle ejects a larger total stroke volume to compensate for the regurgitant volume, which elevates systolic arterial pressure, as reported in Circulation 2.
Diastolic blood pressure falls because blood regurgitates from the aorta back into the left ventricle throughout diastole, reducing aortic diastolic pressure, as stated in Circulation 2.

Pulse pressure may not be increased in acute aortic regurgitation because systolic pressure is reduced and diastolic pressure equilibrates rapidly with elevated left ventricular diastolic pressure, according to Circulation 2.
The sudden volume overload on a normal-sized, non-compliant ventricle causes dramatic increases in left ventricular end-diastolic pressure, leading to pulmonary edema and cardiogenic shock, as reported in Circulation 2.

Blood pressure control with antihypertensive treatment is recommended for patients with aortic regurgitation and systolic blood pressure >140 mmHg, as recommended by the American Heart Association, based on information from Hypertension 3.
The American College of Cardiology recommends using vasodilators that do not slow heart rate, such as ACE inhibitors or dihydropyridine calcium channel blockers, for blood pressure management in aortic regurgitation 3.
Beta blockers should be avoided because they prolong diastole and increase regurgitant volume, potentially worsening aortic regurgitation, as stated in Hypertension 3.
Marked reduction in diastolic blood pressure may lower coronary perfusion pressure in severe aortic regurgitation, though outcomes data supporting this theoretical concern are lacking, according to Hypertension 3.

The American Heart Association recognizes that total LV stroke volume is the entire volume ejected by the left ventricle during systole, calculated as LV end-diastolic volume minus LV end-systolic volume 4
The European Society of Cardiology defines effective (forward) stroke volume as the volume that actually reaches systemic circulation, calculated as total stroke volume minus regurgitant volume 5

In chronic severe AR, the total LV stroke volume is markedly elevated because the ventricle must eject both the normal forward flow and the regurgitant volume that leaked back during diastole, as stated by the American College of Cardiology 6, 7
The high total stroke volume creates a substantial transvalvular gradient across the aortic valve, even in the absence of stenosis, according to the American Heart Association 6, 7

The European Heart Journal recommends using the pulse wave Doppler method to measure the elevated total stroke volume in AR, deriving total stroke volume from LVOT measurements 5
Cardiac magnetic resonance provides the most accurate assessment when AR coexists with other valvular lesions, measuring LV stroke volume as LV end-diastolic volume minus LV end-systolic volume 8, 9, 10

The European Society of Cardiology notes that peak velocity and mean gradient criteria are only valid for near-normal stroke volumes (50-90 mL), and flow-independent parameters (EOA, DVI) should be prioritized in high stroke volume conditions 11, 4
The American College of Cardiology states that a normal LV size almost excludes severe chronic AR, while LV dilatation is sensitive for chronic significant AR 11