Aortic regurgitation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

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HEAD TO TOE

Peripheral physical signs of aortic insufficiency are related to the high pulse pressure and the rapid decrease in blood pressure during diastole, although usefulness of some of the eponymous signs has been questioned.

• Head:
  • de Musset's sign (head nodding in time with the heart beat)
  • Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)

• Upper extremity:
  • low diastolic and increased pulse pressure
  • large-volume, collapsing pulse
  • bounding peripheral pulses (known as Watson's water hammer pulse)
  • Quincke's sign (pulsation of the capillary bed in the nail)

• Lower extremity:
  • Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed)
  • Duroziez's sign (a double sound heard over the femoral artery when it is compressed distally)

• Rarer signs include :
  • Head: Lighthouse sign (blanching & flushing of forehead)
  • Eyes:
    • Ashrafian sign (Pulsatile pseudo-proptosis)
    • Landolfi's sign (alternating constriction & dilatation of pupil)
    • Becker's sign (pulsations of retinal vessels)
  • Ear, Nose and Throat: Müller's sign (pulsations of uvula)
  • Upper extremity: Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
  • Abdomen:
    • Rosenbach's sign (pulsatile liver)
    • Gerhardt's sign (enlarged spleen)
  • Lower extremity:
    • Lincoln sign (pulsatile popliteal)
    • Hill's sign - a ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AR. Considered to be an artefact of sphygmomanometric lower limb pressure measurement.
    • Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)

HEART EXAMINATION:

INSPECTION:

PALPATION:

• Apical impulse : Diffuse and hyperdynamic. The apical impulse is displaced laterally and inferiorly.
• Systolic Thrill (palpable ventricular filling wave) is felt at the apex and at the base of the heart.

ASCULTATION:

• S4 (indicates left ventricular filling against a hypertrophied left ventricular wall)

• Chronic aortic regurgitation murmurs:
  • Early diastolic decrescendo murmur:
    • Position: patient seated and leans forward with breath held in expiration
    • Quality: Soft Early diastolic and decrescendo
    • Best heard: at Aortic area with the diaphragm
    • Radiation: to the right parasternal region (ascending aortic aneurysm should be excluded)
  • Ejection Systolic ‘Flow’ murmur:
    • Best heard: at Aortic area (only a concomitant aortic stenosis causes murmur with an ejection click)
    • Heard in cases of increased stroke volume due to left ventricular volume overload
  • Austin Flint murmur:
    • Quality: soft mid-diastolic rumble
    • Best heard: at apex
    • The regurgitant jet from the severe AR renders partial closure of the anterior mitral leaflet causing Austin flint murmur.

Unfortunately, none of the above putative signs of aortic insufficiency is of utility in making the diagnosis. What is of value is hearing a diastolic murmur itself, whether or not the above signs are present.