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]; Usama Talib, BSc, MD [5]

Overview

Acute aortic regurgitation (AR) is characterized by the presence of a low pitched early diastolic murmur that is best heard at the right 2nd intercostal space, decreased or absent S1, and increased P2. Chronic AR is characterized by the presence of a high pitched holodiastolic decrescendo murmur that is best heard at the upper left sternal border and that increases with sitting forward, expiration, and handgrip. In chronic AR, a wide pulse pressure (≥ 60 mmHg), a S3, and Corrigan's pulse might be present. An ejection systolic 'flow' murmur may also be present. The apex beat is typically displaced down and to the left. A patient with chronic AR may present with signs of congestive heart failure.[1][2][3]

Physical Examination

Vital Signs

The following variations can be seen in Aortic Regurgitation.The following signs can be noticed in patients with Aortic Regurgitation.[4][5][6]

Pulse and Blood Pressure

Head and Neck

Eyes

Throat

Heart

Palpation

Auscultation

Heart Sounds
Murmurs
  • An early diastolic, low pitched, decrescendo murmur in acute AR vs high pitched holodiastolic decrescendo murmur in chromic AR.
  • Position: Patient seated and leans forward with breath held in expiration.
  • Best heard at the aortic area with the diaphragm.
  • Radiate to the right parasternal region (ascending aortic aneurysm should be excluded).
  • 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.
  • 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.

Lungs

Abdomen

Extremities

  • Upper extremities:
  • Lower extremities:

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:[10][11]

References

  1. Enriquez-Sarano M, Tajik AJ. Clinical practice. Aortic regurgitation. N Engl J Med 2004; 351:1539
  2. Desjardins VA, Enriquez-Sarano M, Tajik AJ, Bailey KR, Seward JB (1996). "Intensity of murmurs correlates with severity of valvular regurgitation.". Am J Med. 100 (2): 149–56. PMID 8629648. 
  3. Tribouilloy CM, Enriquez-Sarano M, Mohty D, Horn RA, Bailey KR, Seward JB; et al. (2001). "Pathophysiologic determinants of third heart sounds: a prospective clinical and Doppler echocardiographic study.". Am J Med. 111 (2): 96–102. PMID 11498061. 
  4. Babu AN, Kymes SM, Carpenter Fryer SM (2003). "Eponyms and the diagnosis of aortic regurgitation: what says the evidence?". Ann Intern Med. 138 (9): 736–42. PMID 12729428. 
  5. Grayburn PA, Smith MD, Handshoe R, Friedman BJ, DeMaria AN (1986). "Detection of aortic insufficiency by standard echocardiography, pulsed Doppler echocardiography, and auscultation. A comparison of accuracies.". Ann Intern Med. 104 (5): 599–605. PMID 3963660. 
  6. FRANK MJ, CASANEGRA P, MIGLIORI AJ, LEVINSON GE (1965). "THE CLINICAL EVALUATION OF AORTIC REGURGITATION, WITH SPECIAL REFERENCE TO A NEGLECTED SIGN: THE POPLITEAL-BRACHIAL PRESSURE GRADIENT.". Arch Intern Med. 116: 357–65. PMID 14325909. 
  7. Ashrafian H (2006). "Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms". International Journal of Cardiology. 107 (3): 421–3. PMID 16503268. doi:10.1016/j.ijcard.2005.01.060. Retrieved 2012-04-15. 
  8. Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. PMID 16855259. doi:10.1056/NEJMicm050642. Retrieved 2012-04-15. 
  9. 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. 
  10. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.". J Am Coll Cardiol. 63 (22): e57–185. PMID 24603191. doi:10.1016/j.jacc.2014.02.536. 
  11. Onorati F, De Santo LS, Carozza A, De Feo M, Renzulli A, Cotrufo M (2004). "Marfan syndrome as a predisposing factor for traumatic aortic insufficiency". The Annals of Thoracic Surgery. 77 (6): 2192–4. PMID 15172299. doi:10.1016/S0003-4975(03)01409-7. Retrieved 2011-03-28. 


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