Aortic regurgitation physical examination

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The physical examination of an individual with aortic insufficiency involves auscultation of the heart to listen for the murmur of aortic insufficiency and the S4 heart sound (which would indicate left ventricular filling against a hypertrophied LV wall). The murmur of chronic aortic insufficiency is typically described as early diastolic and decresendo, which is best heard at aortic area when the patient is seated and leans forward with breath held in expiration. The murmur is usually soft and seldom causes thrill. If there is radiation to the right parasternal region, ascending aortic aneurysm has to be excluded.

If there is increased stroke volume of the left ventricle due to volume overload, an ejection systolic 'flow' murmur may also be present when auscultating the same aortic area. Unless there is concomittant aortic valve stenosis, the murmur should not start with an ejection click.

There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet.

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

• large-volume, 'collapsing' pulse
• bounding peripheral pulses; also known as Watson's water hammer pulse
• low diastolic and increased pulse pressure
• Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
• de Musset's sign (head nodding in time with the heart beat)
• Quincke's sign (pulsation of the capillary bed in the nail)
• 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 :

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

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.

Ear Nose and Throat

The uvula may bob

Extremities

The pulses are bounding with a "water hammer pulse"