prolonged therapy with hydralazine11 and nifedipine12 in patients with severe aortic regurgitation and preserved LV function might act to minimize structural changes in the ventricle and thereby possibly delay the need for surgical intervention; however, these drugs are often poorly tolerated in this setting, and no trial has shown that these vasodilators can reduce the risk of HF or death. Conversely, there are no long-term studies of vasodilator therapy in patients with severe asymptomatic mitral regurgitation.
The recommendations for patients with asymptomatic left ventricular systolic dysfunction can be summarized as follows:
Class I recommendations
All Class I recommendations for Stage A should apply to patients with cardiac structural abnormalities who have not developed HF. (Levels of Evidence: A, B, and C as appropriate)
Beta-blockers and ACEI should be used in all patients with a recent or remote history of MI regardless of EF or presence of HF. (Level of Evidence: A)
Beta-blockers are indicated in all patients without a history of MI who have a reduced LVEF with no HF symptoms. (Level of Evidence: C)
ACEI should be used in patients with a reduced EF and no symptoms of HF, even if they have not experienced MI. (Level of Evidence: A)
An ARB should be administered to post-MI patients without HF who are intolerant of ACE inhibitors and have a low LVEF. (Level of Evidence: B)
CLASS IIA recommendations
ACEI or ARBs can be beneficial in patients with hypertension and LVH and no symptoms of HF. (Level of Evidence B)
Angiotensin II receptor blockers can be beneficial in patients with low EF and no symptoms of HF who are intolerant of ACEIs. (Level of Evidence: C)
Placement of an ICD is reasonable in patients with ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are NYHA functional class I on chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: B)
11 Greenberg B, Massie B, Bristow JD, et al. Long-term vasodilator therapy of chronic aortic insufficiency: a randomized doubleblinded, placebo-controlled clinical trial. Circulation 1988;78:92-103.
12 Scognamiglio R, Rahimtoola SH, Fasoli G, Nistri S, Dalla VS. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med 1994;331:689-94.