AR Severity Criteria: How the Tool Reads the Signals
The AR Severity Tool counts concordant severe echo signs. Understanding what each parameter contributes — and what the tool does when they disagree — clarifies how to interpret the result.
One parameter alone rarely settles the question. The tool is designed around concordance: when multiple signals agree, the grade is established. When they conflict, the result tells you that too.
Key takeaway
The tool counts concordant severe echo signs. One alone leaves the grade uncertain; two together establish a pattern. Discordant results are a signal to investigate, not an error to override.
Key points
- Four quantitative severe echo signs: VC ≥ 0.60 cm, EROA ≥ 0.30 cm², RegVol ≥ 60 mL, RegFrac ≥ 50%.
- Qualitative grade of severe counts as one additional severe echo sign.
- Descending aortic holodiastolic reversal counts as one severe echo sign; abdominal reversal is strong supportive context — not a counted severe sign on its own.
- Two or more severe signals → severe_ar_pattern (Red). One signal alone → possible or discordant depending on other entries.
- Discordant means a severe signal and a non-severe signal coexist — measurement error, altered loading, or mixed disease should be considered.
When to read this
Your AR result is not severe_ar_pattern but clinical suspicion is high — or you have conflicting parameters and want to understand how the tool weighs them.
The four quantitative severe signals
The ACC/AHA VHD 2020 quantitative thresholds for severe AR are: vena contracta (VC) width ≥ 0.60 cm, PISA EROA ≥ 0.30 cm², regurgitant volume ≥ 60 mL/beat, and regurgitant fraction ≥ 50%. Each parameter above threshold counts as one severe echo sign. The tool also includes qualitative AR grade: selecting "severe" adds one severe signal.
Why concordance matters more than any single parameter
Each parameter has technical limitations. VC width is sensitive to gain settings and beam angle. EROA from PISA assumes a hemispherical flow convergence zone, which is approximate for eccentric or complex jets. Regurgitant volume depends on accurate LVOT diameter measurement. Regurgitant fraction depends on accurate total stroke volume. Because no single parameter is definitive, the tool uses concordance: when multiple independent measurements agree, the grade is more reliable.
Holodiastolic flow reversal: different roles by location
Holodiastolic flow reversal in the descending aorta is counted as one severe echo sign — the same weight as any quantitative parameter at threshold. Abdominal aortic holodiastolic reversal is not counted as a severe signal, but is classified as strong supportive context. If one quantitative severe signal is already present, abdominal reversal elevates the grade from possible_severe_ar to likely_severe_ar. Abdominal reversal alone, without any other primary quantitative input, yields supportive_severe_ar_finding_only (Amber) — a finding that supports significant AR but does not complete the severity picture.
What discordant results mean
discordant_ar fires when at least one severe signal and at least one non-severe signal are both present. This is not a judgment that the AR is moderate — it is a flag that the data is internally inconsistent. Common sources: LVOT diameter error affecting EROA and RegVol calculations, loading conditions affecting VC or qualitative appearance, or a genuinely mixed lesion. The next step is to identify the source of discordance rather than accepting either the severe or non-severe reading at face value.
What insufficient data means
The tool returns insufficient_data when no primary severity-grading parameter has been entered. LV data alone (LVEF, LVEdd), symptoms alone, or PHT alone are not sufficient to produce a grade — and this is intentional. Filling in the actual AR severity parameters is the correct next step.
PHT is not counted
Pressure half-time is accepted as a context field in the tool but is intentionally excluded from the severe signal count. PHT reflects the rate of aorto-LV diastolic pressure equalization — not regurgitant volume. It is affected by loading conditions, LV compliance, blood pressure, and acute versus chronic physiology. When PHT and quantitative parameters disagree, the quantitative data is the more direct measure of regurgitant burden.
Apply this in practice
Enter available severity parameters to see how the tool integrates them into a grade.
Open AR Severity Tool