Is Mild Aortic Regurgitation a Normal Finding?

Mild aortic regurgitation, a small backward leak through one of the heart’s valves, is a frequent finding on heart ultrasounds and becomes more common with age. Cardiologists treat it a little differently from tiny leaks in the heart’s other valves, which are usually called normal. It is best thought of as common and usually harmless, but not quite the same as nothing at all. For most people the real question isn’t whether the leak is there but whether it will change, and most of the time it doesn’t.

What Your Report Means and Why Doctors Don’t Call It Normal

The aortic valve is the door between the heart’s main pumping chamber and the aorta, the big artery that carries blood to the body. Aortic regurgitation means a little blood slips backward through that door after each beat. It’s usually spotted on an echocardiogram, an ultrasound of the heart that shows blood flow in color. “Mild” is the lowest grade of leak that gets reported, above “trace” or “trivial” and below moderate and severe.

The wording on a report can sound worse than it is. “Regurgitation” here only means backward flow, and it has nothing to do with the stomach. “Insufficiency” and “incompetence” describe the same leak and aren’t a judgment of how bad it is. A mild leak is not heart failure and usually causes no symptoms. If your report lists leaks in several valves together, that is common, and they are often all trivial.

Many people learn about the leak from an ultrasound ordered for something else, like a murmur check or chest pain. Mild leaks are often too quiet for a stethoscope to pick up.

On the ultrasound, blood moving through the heart is painted in color. A leak shows up as a small jet streaming backward into the pumping chamber during the resting phase between beats. The technician looks at how far the jet reaches and how wide it is at its start, and that is how the leak gets its grade. A thin, short jet is what “mild” usually describes, while a wide jet reaching deep into the chamber would be called more serious.

Tiny leaks in the heart’s other three valves are considered a normal quirk of a healthy heart.1Escardio. Chronic aortic regurgitation: diagnosis and therapy in the modern era The aortic valve is the exception to that rule.2Escardio. Chronic aortic regurgitation: diagnosis and therapy in the modern era A purely normal aortic leak with no cause is rare, found in under 1% of cases.3Heart. Imaging assessment of mitral and aortic regurgitation: current state of the art So heart specialists treat an aortic leak as having an underlying cause until proven otherwise.4Heart. Imaging assessment of mitral and aortic regurgitation: current state of the art Your doctor may therefore look at the shape of your valve and the width of your aorta, not just the leak.

How Doctors Decide a Leak Is Mild

Often a leak is plainly mild on the ultrasound, and careful measuring adds little.5PubMed Central. Echocardiographic assessment of aortic regurgitation: a practical guideline from the British Society of Echocardiography In that case, confirming that it looks mild from several viewing angles is considered enough.6PubMed Central. Echocardiographic assessment of aortic regurgitation: a practical guideline from the British Society of Echocardiography

A jet can look wider or narrower depending on the direction the ultrasound beam hits it, so the grade usually rests on several images that agree. That is why a report may say only “mild” with no numbers.

If measurements do appear on your report, these are the ones that fit a mild leak:

Ultrasound is the main test, but a heart MRI can help when results don’t agree or are incomplete.11PubMed. Imaging Methods for Evaluation of Chronic Aortic Regurgitation in Adults: JACC State-of-the-Art Review MRI uses somewhat different cutoffs, with one scale calling under 21% leaking back mild.12PubMed Central. Grading of aortic regurgitation by cardiovascular magnetic resonance and pulsed Doppler of the left subclavian artery: harmonizing grading scales between imaging modalities

Grades can also differ from one scan to the next. Different technicians and machines can grade the same leak slightly differently, and blood pressure and heart rate on the day can change how a leak looks. A shift between “trace” and “mild” on two reports often reflects measurement, not a real change.

How Common Mild Aortic Regurgitation Is

In one large US study, about 13% of men and 8.5% of women had some degree of aortic leak on ultrasound.13Escardio. Chronic aortic regurgitation: diagnosis and therapy in the modern era Among healthy volunteers, about 11% had a trivial or mild leak, all in the older group.14PubMed. Age-related prevalence of valvular regurgitation in normal subjects: a comprehensive color flow examination of 118 volunteers In another community study, about 14% of people 60 and older had a leak versus about 6% of younger people, with men and women equally affected.15PubMed. Prevalence and correlates of aortic regurgitation in American Indians: the Strong Heart Study Undiagnosed mild or moderate leaks turn up in 8–14% of older adults with no known valve disease.16PubMed Central. Incidence and Pathology of Aortic Regurgitation In that study, only 0.3% had moderate-to-severe or severe leaks. The percentages differ because the studies looked at different groups and counted different grades, but they agree on the main picture of roughly one in ten adults, more in older people.

Common doesn’t mean the leak has no cause. Age-related stiffening of the valve and aorta is a likely reason it rises with age.

What Causes a Mild Aortic Leak

The most common explanation is age-related wear. Over decades the valve flaps can thicken or stiffen slightly, and they may no longer close perfectly. The base of the aorta can also stretch a little with age, which can leave a small gap between the flaps. When these changes are the only finding, the leak is usually mild and slow to change.

A bicuspid aortic valve, born with two flaps instead of three, is the most common heart defect in adults.17PubMed. Outcomes in adults with bicuspid aortic valves If your report mentions a two-flap valve, it’s a likely reason for the leak. Two-flap valves can run in families, so mention any family history of valve or aorta problems.

High blood pressure slightly widens the base of the aorta,18PubMed. Effect of hypertension on aortic root size and prevalence of aortic regurgitation though in healthy people with high blood pressure, aortic leaks weren’t more common or more severe.19PubMed. Effect of hypertension on aortic root size and prevalence of aortic regurgitation A widened aorta can pull the flaps apart, and widening was behind most leaks that became severe.20Circulation. Natural History of Mild and Moderate Aortic Regurgitation: Worsening Severity is the Exception not the Rule That’s why it’s worth asking whether your valve has three flaps or two, and what the size of your aorta is and whether it’s normal.

Rheumatic fever, a reaction to untreated strep throat, can scar valves, sometimes without causing a murmur.21PubMed Central. Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease These hidden valve changes can persist for years.22PubMed Central. Prospective comparison of clinical and echocardiographic diagnosis of rheumatic carditis: long term follow up of patients with subclinical disease Tell your doctor about any childhood rheumatic fever.

Infection is a rare cause. A valve infection can suddenly worsen a leak.23Circulation. Natural History of Mild and Moderate Aortic Regurgitation: Worsening Severity is the Exception not the Rule Fever with new breathlessness needs prompt medical care, and good dental hygiene lowers the risk of infection reaching the valves.

Will It Get Worse

Among 600 people with mild or moderate leaks, about 88% saw no change over follow-up.24Circulation. Natural History of Mild and Moderate Aortic Regurgitation: Worsening Severity is the Exception not the Rule Under 1% progressed to severe, and most of those had a widening aorta or an infection.25Circulation. Natural History of Mild and Moderate Aortic Regurgitation: Worsening Severity is the Exception not the Rule When it happened, going from mild to severe took about 7 years on average.26Circulation. Natural History of Mild and Moderate Aortic Regurgitation: Worsening Severity is the Exception not the Rule

Some small changes do happen. In another group, about 10% moved up at least one grade, typically after around 4 years.27PubMed Central. Clinical events and echocardiographic lesion progression rate in subjects with mild or moderate aortic regurgitation Mild leaks moved up a grade more often than moderate ones, 15% versus 4%, but only about 2% reached severe.28PubMed Central. Clinical events and echocardiographic lesion progression rate in subjects with mild or moderate aortic regurgitation Moving from mild to moderate isn’t unusual and isn’t an emergency. A moderate leak is still usually well tolerated and typically means closer monitoring, not treatment.

A widening aorta is the main thing doctors watch, and a two-flap valve deserves closer follow-up. Leaks in more than one valve made progression more likely.29PubMed Central. Clinical events and echocardiographic lesion progression rate in subjects with mild or moderate aortic regurgitation

Symptoms worth reporting include breathlessness on exertion that’s new for you, unusual tiredness or reduced exercise tolerance, and chest discomfort, palpitations, or a pounding heartbeat when lying down.

Follow-Up and Treatment

Mild leaks are usually rechecked with a heart ultrasound every few years, sooner if the aorta is widened or symptoms appear. Keep copies of your reports so changes can be compared. Some blood pressure medicines that relax the arteries have been studied for reducing the heart’s workload in leaky valves.30PubMed. Vasodilator therapy in chronic asymptomatic aortic regurgitation: enalapril versus hydralazine therapy Mild leaks typically don’t need specific medication, though.

In between, keep your blood pressure in a healthy range and attend scheduled scans even if you feel well. Tell any new doctor or dentist about your valve finding. Call sooner for new breathlessness, fainting, or chest pain, for a fever lasting days without an obvious cause, or if a doctor hears a new or louder murmur.

Exercise, Pregnancy and Daily Life

Endurance athletes’ leaks were all mild and no different from non-athletes’.31PubMed. Relationship of ventricular and atrial dilatation to valvular function in endurance athletes Regular exercise doesn’t appear to worsen mild leaks, and most people with mild leaks can stay fully active. Walking, swimming, cycling and gym workouts are generally fine. Feeling unusually breathless or faint during exercise is a reason to stop and tell your doctor. If you’re thinking of starting very intense training, mention it at your next visit so your aorta size can be considered.

Women with aortic leaks have a low risk of heart problems during pregnancy, about 5%.32PubMed. Risk Associated With Valvular Regurgitation During Pregnancy Pregnancy increases blood volume, so tell your obstetrician about the finding so it can be checked.