Aortic regurgitation physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [3], Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S.
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.
Tachycardia
There is often a compensatory tachycardia to compensate for the reduced stroke volume.
Head and Neck
- de Musset sign: There may be bobbing of the head with each heartbeat.
- Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
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Eyes
- Becker sign: There may be pulsations of the retinal arteries.
Throat
- Muller sign: There may be pulsations of the uvula.
Cardiac
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.
Auscultation
- S4: consistent with impaired [left ventricular]] filling against a hypertrophied left ventricular wall
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- 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
- 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.
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Peripheral Examination
- 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)
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- 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 [1]:
- Head: Lighthouse sign (blanching & flushing of forehead)
- Eyes:
- Ashrafian sign (Pulsatile pseudo-proptosis)[2]
- 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)[3]
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- Upper extremity: Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
- Abdomen:
- 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[4].
- Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)
References
- ↑ Ashrafian H. Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms. Int J Cardiol. 2006 Mar 8;107(3):421-3.
- ↑ Ashrafian H. Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms. Int J Cardiol. 2006 Mar 8;107(3):421-3.
- ↑ [1]
- ↑ 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.