A 62-year-old woman with known aortic regurgitation presents with acute chest pain and pulmonary oedema. Blood pressure is 86/40 mmHg, pulse 128/min. Echo shows severe acute aortic regurgitation with premature closure of the mitral valve and early diastolic mitral opening. Which management step is most appropriate?
- A Urgent aortic valve replacement with inotropic support such as dopamine or dobutamine ✓
- B Give nifedipine orally and reassess in 24 hours
- C Start intra-aortic balloon counterpulsation as a bridge to surgery
- D Begin beta blocker therapy to slow the heart rate and reduce regurgitant volume
Correct answer: A. Urgent aortic valve replacement with inotropic support such as dopamine or dobutamine
Explanation
Acute severe aortic regurgitation with cardiogenic shock demands emergency valve replacement. Premature diastolic mitral valve closure signals a steeply rising left ventricular diastolic pressure approaching aortic diastolic pressure. Intra-aortic balloon counterpulsation worsens regurgitation and is contraindicated, beta blockers may precipitate collapse by blocking compensatory tachycardia, and pure vasodilators alone are inadequate in established hypotension.
Reference: Braunwald's Heart Disease, 12th ed.
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Written and medically reviewed by the StethoPrep medical team.