Approach to the Exam for Aortic Regurgitation

Patient positioning & palpation technique

To make it easier to appreciate the PMI it is important to have the patient assume the correct position. Ask your patient to sit upright and lean forward. Alternatively, you can ask the patient to lie down and move into the left lateral decubitus position. In both cases the heart will be closer to the chest making it easier to locate the PMI. Once the patient is in the correct position, palpate just below the nipple to appreciate the PMI. You can use either your fingertips or your full palm.

Ascending aortic aneurysm

It is also important to palpate the suprasternal notch and the 1^st and 2^nd right intercostal spaces. A significant pulsation here can indicate an ascending aortic aneurysm as the cause for the aortic regurgitation.

Correct technique

As a general rule, it is useful to palpate an artery during auscultation for heart murmurs. This makes much easier to determine if a murmur is diastolic or systolic. Any artery in the upper extremity can be used for this purpose.

It's also very important to position the patient in the right way. The murmur of aortic regurgitation is indeed best heard when the patient is sitting upright, leaning forward and in full expiration. In this way the heart will be closer to chest wall and the murmur easier to appreciate. However, it is important to make sure that the patient does not exhale too forcefully, since that would cause a Valsalva maneuver that can reduce the venous return to the heart and thus the intensity of the murmur of aortic regurgitation. Also, make sure to auscultate on the right sternal border as well for the presence of aortic root dilation.

Associated murmurs: systolic flow murmur

In a patient with aortic regurgitation there is an increase in the blood flow across the aortic valve. This may generate a systolic outflow tract murmur that is best heard on the aortic area at the right upper sternal border, intercostal spaces 1^st and 2^nd.

This systolic murmur is usually less loud than the murmur of aortic regurgitation. For this reason, and due to the contemporary presence of the diastolic murmur, it is not always easy to appreciate.

Associated murmurs: Austin-Flint murmur

The regurgitant blood flow across the aortic valve can cause a functional mitral stenosis by impacting on the anterior leaflet of the mitral valve and preventing it to fully open during diastole. This functional mitral stenosis presents as a low-pitched, mid to late diastolic murmur that is commonly referred to as Austin-Flint murmur.

Similar to the murmur of mitral stenosis, the Austin-Flint murmur can be best heard with the bell of the stethoscope at the 5^th intercostal space on the left midclavicular line and with the patient in the left lateral decubitus position.

Cardiac maneuvers: isometric handgrip

There are several cardiac maneuvers that can be used to better characterize heart murmurs by changing their intensity. The most useful maneuver for the exam of aortic regurgitation is the isometric handgrip.

To perform this maneuver, ask the patient to squeeze with both hands an object such as a rolled-up piece of paper. This will cause an increase in the afterload and as a consequence in the regurgitant blood flow across the aortic valve, making the aortic regurgitation murmur louder and easier to hear.

Corrigan’s pulse or sign

The Corrigan’s pulse is a bounding carotid pulse, characterized by a rapid systolic rise and a rapid diastolic collapse. To detect the Corrigan’s sign, inspect the base of the patient’s neck, right where the carotids are.

Click here to see an example of the Corrigan’s sign.

Watson’s water hammer pulse

The water hammer pulse is a bounding pulse with rapid systolic rising and diastolic collapse that can be appreciated at either the radial, ulnar or brachial artery.

It is accentuated by slightly lifting up the patient’s arm.

Click here to see an example of the Watson’s water hammer pulse (ulnar artery).

The water hammer pulse can also be palpated by placing the palm of your hand on the patient’s wrist so that you can feel both the radial and the ulnar arteries. Again, it is important to lift up the patient’s arm to make it easier to detect the pulsation.

Quincke’s capillary pulse

Repeated flushing and blanching of the capillaries in the nail beds and lips.

De Musset’s sign

Anterior-posterior bobbing movement of the head synchronous with the arterial pulse.

Müller's sign

Back and forth pulsation of the uvula.

Becker Sign

Visible pulsations of the retinal arteries on the ophthalmoscopic exam.

Lighthouse sign

Alternate blanching and flushing of the forehead and face.

Rosenbach Sign

This sign consists in systolic pulsations of the liver that can be appreciated by palpation of the RUQ.

Gerhard Sign

This sign is described as systolic pulsations of the spleen felt on palpation of the LUQ.

Landolfi's sign

Alternating systolic miosis and diastolic mydriasis in both pupils.

Lincoln Sign

Tremor of the foot when one leg is crossed above the other, caused by excessive pulsation of the popliteal artery.

Traube’s sign (pistol-shot sound)

While auscultating over the femoral arteries it is possible to hear a pistol shot sound both during systole and during diastole. The sound can be accentuated by compressing the femoral artery with the stethoscope. The quality of this sound is very similar to the Korotkoff ones used for measurement of the blood pressure.

Duroziez sign (murmur)

This is a diastolic-systolic murmur heard when applying firm pressure with the stethoscope on the femoral arteries. The sign is positive only if both the systolic and diastolic murmurs are heard. The diastolic murmur becomes louder when more pressure is applied on the distal rim of the stethoscope.

Hill’s sign

This sign is considered positive when the difference between the systolic blood pressure measured at the foot and at the arm is greater than 20 mmHg.

Signs of systolic heart failure

Look for an S3 gallop, which develops as a consequence of heart enlargement in chronic aortic regurgitation. Other signs of systolic heart failure are peripheral cyanosis and cold and clammy extremities, both the result of poor peripheral blood flow secondary to the reduced cardiac output.
Lastly, in a patient with aortic regurgitation it is very important to calculate the pulse pressure (systolic BP – diastolic BP). Usually in presence of aortic regurgitation the pulse pressure is very high. A normal or decreased pulse pressure may indicate a reduced cardiac output and incipient systolic heart failure.

Signs of diastolic heart failure

These are signs of volume overload, both in the systemic and pulmonary circulation. In the systemic circulation the typical manifestation is peripheral edema. This usually happens in the dependent areas, that are the lower extremities in a sitting patient, and the sacrum in a bedridden patient. Another sign of systemic volume overload is jugular venous distension. Instead, volume overload in the pulmonary circulation manifests as rales on chest auscultation, which indicate pulmonary edema.

Endocarditis

Typical clinical findings include:

-       Osler nodes: painful red/violaceous nodules usually found on the pads of fingers and toes;

-       Janeway lesions: non painful red macules found on the palms and soles;

-       Roth spots: a red hemorrhagic lesion of the retina with a characteristic white center representing fibrin-platelet plugs;

-       Splinter hemorrhages: subungual hemorrhages appearing as linear non blanching brown-red lesions on the nail beds.

Genetic Diseases: Marfan’s syndrome

Genetic diseases affecting the connective tissue, like Marfan’s syndrome can cause dilation of the aortic root and, as a consequence, aortic regurgitation.

Typical clinical findings in patients with Marfan’s syndrome include:

-       Characteristic body habitus with very long limbs and fingers. These patients are usually very tall with an arm span that exceeds their height;

-       Positive thumb sign: to elicit this sign ask the patient to close the fist or just to cross the thumb on the palm. If the thumb extends beyond the palm, then the sign is positive;

-       Positive wrist sign: ask the patient to grip his or her hand with the other one. The sign is positive if the thumb overlaps with the fifth finger.

NB: both the thumb and wrist sign are due to the long fingers and joint hyperlaxity typical of a patient with Marfan’s syndrome.

Aortic Dissection

Patients present with severe tearing chest pain radiating to the back. Clinical signs useful to make a diagnosis include:

-       Asymmetric pulses in the extremities. Look for a delayed or absent pulse on one side only;

-       Difference in blood pressure between the two arms.

Infective Aortitis

Rarely seen today, infective aortitis was a common etiology of aortic regurgitation in the pre-antibiotic era. In particular, Syphilis was the most common cause.

The mechanism for aortic regurgitation in infective aortitis is the dilation of the aortic root secondary to aortic wall inflammation and damage. This results in an ascending aortic aneurysm.

Whenever an aortic aneurysm is causing aortic regurgitation there will be two characteristic signs on exam:

-       Palpable pulsations on the suprasternal notch and the 1^st and 2^nd intercostal spaces;

-       Early diastolic murmur of aortic regurgitation louder at the right sternal border rather than at the left lower sternal border.

Rheumatic Heart Disease

This is much more commonly seen as a cause of aortic regurgitation in developing countries.

Together with aortic regurgitation, such patients will almost always have rheumatic mitral valve disease presenting as mitral regurgitation or stenosis.

Chronic/Severe Hypertension

Patients with long standing severe hypertension may develop aortic valve disease usually manifesting as aortic regurgitation (secondary to dilation of the aortic root).

Since chronic severe hypertension damages blood vessels all over the body, in these patients it is possible to observe characteristic vascular lesions and ischemic changes on the retinal exam, like flame hemorrhages and cotton wool spots.

Here we describe the most significant evidence supporting the clinical utility of different signs and techniques in the exam for aortic regurgitation.

Inspection & palpation
The absence of an enlarged or sustained PMI reduces the chances that aortic regurgitation is present by almost 45% (negative Likelihood Ratio of 0.1).

Auscultation

The characteristic murmur of aortic regurgitation, early diastolic louder at the left lower sternal border, has a positive Likelihood Ratio of 9.9 for the diagnosis of mild or more severe aortic regurgitation. This means that hearing this murmur on physical exam increases the probability that aortic regurgitation is present by roughly 45%.

On the other hand, this finding has a negative Likelihood Ratio of 0.1 for moderate to severe aortic regurgitation. The clinical implication is that not detecting the characteristic early diastolic murmur of aortic regurgitation will decrease the probability that an aortic leak is actually present by almost 45%.

When the early diastolic murmur of aortic regurgitation is heard louder on the right sternal border there is a 30-45% increase in the probability that a dilated aortic root is the cause for the aortic regurgitation (positive Likelihood Ratio of 8.2).

Blood pressure
In a patient presenting with the characteristic murmur of aortic regurgitation, the following blood pressure changes have a high diagnostic utility:

-       Diastolic blood pressure < 50 mmHg (positive Likelihood Ratio 19.3 à more than 50 % increase in the chances that aortic regurgitation is present)

-       Pulse pressure > 80 mmHg (positive Likelihood Ratio 10.9 à more than 50 % increase in the probability that the patient has aortic regurgitation).

Hill sign
The Hill sign is positive if there is more than 20 mmHg difference in the systolic blood pressure between the arm and the foot. If the cutoff for positivity is moved up to more than 60 mmHg difference, the sign has a positive Likelihood Ratio of 17.3 for the presence of aortic regurgitation (increase in the probability that aortic regurgitation is present by more than 50%).