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 which usually is a high-pitched sound best heard at the left sternal border. 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.

Physical Examination

Vital Signs

Pulse and Blood 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 aortic insufficiency, 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 peripheral pulses (known as Watson's water hammer pulse) may be present.
• There is often a compensatory tachycardia to compensate for the reduced stroke volume.

Head and Neck

• De Musset sign: Bobbing of the head with each heartbeat may be present.
• Lighthouse sign: Blanching and flushing of the forehead may be present.
• Corrigan's pulse: A rapid upstroke and collapse of the carotid artery pulse may be present.

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Eyes

• Becker sign: Systolic pulsations of the retinal arteries may be present.
• Ashrafian sign: Pulsatile pseudo-proptosis may be present.
• Landolfi's sign Alternating constriction and dilatation of the pupil may be present.

Throat

• Müller's sign: Systolic pulsations of the uvula may be present.

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Heart

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.

Auscultation

Heart Sounds

• An S3 gallop is present if left ventricular dysfunction is present.
• An S4 may be present consistent with impaired left ventricular filling against a hypertrophied left ventricular wall.

Chronic AR Murmurs

• An early early diastolic decrescendo murmur is present

• Position: Patient seated and leans forward with breath held in expiration
• Quality: Soft early diastolic and decrescendo
• Best heard: at the aortic area with the diaphragm
• Radiation: to the right parasternal region (ascending aortic aneurysm should be excluded)

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• Ejection systolic flow murmur:

• Best heard: at the 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

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• Austin Flint murmur:

• Quality: Soft mid-diastolic rumble
• Best heard: at the cardiac apex
• Anterior mitral valve leaflet hit by regurgitant blood flow from the severe aortic regurgitation results in partial closure of the mitral leaflets causing Austin Flint murmur.

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Lungs

• Pulmonary edema and rales may be present.

Abdomen

• Rosenbach's sign: Pulsatile liver.
• Gerhardt's sign: Enlarged pulsatile spleen.

Extremities

• Upper Extremities

• Mayen's sign: Diastolic drop of > 15 mm Hg with the arm raised.
• Quincke's sign: Pulsation of the capillary bed in the nail.

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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: Systolic and diastolic murmurs heard over the femoral artery with proximal or distal compression of the femoral artery respectively.
• Lincoln's 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.
• 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:

• Infective endocarditis
• Marfan syndrome
• Spondyloarthropathy