Aortic regurgitation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Please Take Over This Page and Apply to be Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Signs on Peripheral Examination

Peripheral physical signs of aortic insufficiency are related to the high pulse pressure and the rapid decrease in blood pressure during diastole, although usefulness of some of the eponymous signs has been questioned[1].

  • 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 [2]:
    • Head: Lighthouse sign (blanching & flushing of forehead)
    • Eyes:
      • Ashrafian sign (Pulsatile pseudo-proptosis)[3]
      • 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)
    • Upper extremity: Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
    • Abdomen:
      • Rosenbach's sign (pulsatile liver)
      • Gerhardt's sign (enlarged spleen)
    • 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)

Signs on Cardiac Examination

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

  • Chronic aortic regurgitation murmurs:
    • Early diastolic decrescendo murmur:
    • Ejection Systolic ‘Flow’ murmur:
    • Austin Flint murmur:
      • 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.


Unfortunately, none of the above putative signs of aortic insufficiency is of utility in making the diagnosis[5]. What is of value is hearing a diastolic murmur itself, whether or not the above signs are present.

References

  1. 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.
  2. Ashrafian H. Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms. Int J Cardiol. 2006 Mar 8;107(3):421-3.
  3. Ashrafian H. Pulsatile pseudo-proptosis, aortic regurgitation and 31 eponyms. Int J Cardiol. 2006 Mar 8;107(3):421-3.
  4. 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.
  5. Choudhry NK, Etchells EE (1999). "The rational clinical examination. Does this patient have aortic regurgitation?". JAMA. 281 (23): 2231–8. PMID 10376577.

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