Medical Therapy Recommendations for Medical Therapy for Chronic Primary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 29. COR LOE Recommendations In symptomatic or asymptomatic patients with severe primary MR and LV systolic dysfunction (Stages C2 and D) in whom surgery is not possible or must be delayed, GDMT for systolic dysfunction is reasonable.1 3 Benefit B-NR In asymptomatic patients with primary MR and normal LV systolic function (Stages B and C1), vasodilator therapy is not indicated if the patient is normotensive.4 8 Synopsis In patients with primary MR, there is no convincing evidence that vasodilator therapy reduces MR severity. However, GDMT for LV systolic dysfunction or systemic hypertension should be implemented as in any patient with these conditions. Recommendation-Specific Supportive Text 1. Patients with MR and LV dysfunction experience myocardial damage and HF. With onset of LV systolic dysfunction, surgery is usually indicated. However, in those patients in whom surgery (or transcatheter repair) is not performed or will be delayed, medical therapy for systolic dysfunction may be helpful to treat the LV dysfunction alone. Although data specific to patients with MR with LV dysfunction are sparse, treatment of such patients would consist of the standard regimen for HF, including beta-adrenergic blockade, ACE inhibitors or ARBs, and possibly aldosterone antagonists.1 3 Perhaps the best data exist for the use of beta which reverse LV dysfunction in experi- Patients who are receiving beta block- ers may have better surgical outcomes and delayed onset of LV dysfunction as compared with those not taking these medications.3 ACE inhibition has not been effective in experimental MR with LV dysfunction. Because aldosterone antagonism is thought to work in part by inhibiting fibrosis, its role in MR, where little fibrosis occurs, is unclear. 2. 