Aortic regurgitation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief:; Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S. [3]; Lakshmi Gopalakrishnan, M.B.B.S. [4]

Overview

Upon physical examination, a patient with suspected aortic insufficiency may have early diastolic heart murmur and S3 gallop correlates with development of left ventricular dysfunction. An ejection systolic 'flow' murmur may also be present. The apex beat is typically displaced down and to the left. A patient with chronic aortic insufficiency may present with signs of congestive heart failure.

Vital Signs

Wide Pulse Pressure

  • In acute aortic insufficiency, there may initially be a wide pulse pressure, but as the left ventricle fails, the pulse pressure may narrow as the left ventricular end diastolic pressure rises to equal the diastolic blood pressure, and stroke volume of the left ventricle declines reducing the systolic blood pressure. In some cases, the sharply rising left ventricular end diastolic pressure causes the mitral valve to close earlier during diastole. This early closure fortunately prevents backward flow of blood into the pulmonary vascular bed and often keeps the aortic diastolic pressure from falling too low and sometimes there may not be a wide pulse pressure.
  • In chronic AI, there is often a wide pulse pressure during the early compensatory period. The diastolic blood pressure is often < 60 mm Hg, and the pulse pressure often exceeds 100 mm Hg. In younger patients the vasculature is more compliant, and the pulse pressure may not be as wide.

Bounding Pulse

Tachycardia

There is often a compensatory tachycardia to compensate for the reduced stroke volume.

Head and Neck

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Eyes

Throat

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Heart

I. Palpation:

Apical Impulse:
The point of maximal impulse is diffuse and hyperdynamic. The apical impulse is displaced laterally and inferiorly.
Systolic Thrill:
Systolic thrill (palpable ventricular filling wave) is felt at the apex and at the base of the heart.

II. Auscultation:

Heart sounds:
Chronic AR Murmurs:
  • An early early diastolic decrescendo murmur is present
  • Ejection systolic flow murmur:

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  • Austin Flint murmur:
  • Quality: soft mid-diastolic rumble
  • Best heard: at apex
  • The regurgitant jet from the severe aortic regurgitation renders partial closure of the anterior mitral leaflet causing Austin Flint murmur.

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Lungs

Abdomen

Peripheral Examination

Upper Extremities

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Lower Extremities

  • 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)
  • Lincoln sign: A pulsatile popliteal pulse.
  • 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[3].
  • Sherman's sign: The dorsalis pedis pulse is located quickly and is unexpectedly prominent in a patient over 75 years of age.

Underlying Causes of Aortic Insufficiency to Be Cognizant of During the Physical Examination

During the physical exam, you should be looking for signs that would indicate the underlying cause of aortic insufficiency including signs of:

References

  1. Ashrafian H (2006). "Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms". International Journal of Cardiology. 107 (3): 421–3. doi:10.1016/j.ijcard.2005.01.060. PMID 16503268. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)
  2. Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. doi:10.1056/NEJMicm050642. PMID 16855259. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)
  3. Kutryk M, Fitchett D (1997). "Hill's sign in aortic regurgitation: enhanced pressure wave transmission or artefact?". The Canadian journal of cardiology. 13 (3): 237–40. PMID 9117911.

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