Aortic Regurgitation: Physical Exam
Color flow Doppler with a hand-held device may underestimate the severity of aortic regurgitation
in a technically difficult patient. The physical findings below may help determine the hemodynamic
importance of a diastolic aortic regurgitation murmur.
Physical Findings in Chronic Severe
- Corrigan's pulse: prominent pulsations of the carotid arteries.
- Bisferiens pulse: double systolic arterial impulse - the so-called
twice beating heart.
De Musset's sign: head nodding with each heart beat.
Duroziez's sign: systolic and diastolic femoral artery bruit.
Hill's sign: accentuated leg systolic pressure with greater than
40 mm Hg difference from the brachial artery systolic pressure.
Muller's sign: pulsation of the uvula with each heart beat.
Palmar click: sometimes-palpable systolic flushing of the palms.
Quincke's pulse: cyclic reddening and blanching of the nail capillaries.
Traube's sign: loud "pistol shot" sound heard over the femoral artery.
Water hammer pulse: brisk femoral pulsation similar to that felt with
a water hammer - a Victorian toy. The water hammer was a glass tube
filled partly with water or mercury in a vacuum. The water or mercury
produced a slapping impact when the glass tube was turned over.
Differentiation from the Graham Steell Murmur
A diastolic murmur at the left sternal border may be due
to aortic regurgitation, or to pulmonary hypertension (Graham Steell
murmur). Aortic regurgitation is accompanied by the physical
signs above. If the diastolic murmur is also heard at the
right sternal border - it is likely to be due to aortic regurgitation.
Conversely, if the diastolic murmur at the left
sternal border is accompanied by a second heart sound that is
louder at the left sternal border than at the right sternal
border - pulmonary hypertension should be suspected, and tricuspid regurgitation velocity should be measured with Doppler.
Diagnosis by Auscultation
JAMA. 1999 Jun 16;281(23):2231-8.
The rational clinical examination. Does this patient have
Choudhry NK, Etchells EE.
Department of Medicine, University of Toronto and the
University Health Network, Ontario, Canada.
OBJECTIVE: To review evidence as to the precision and accuracy
of clinical examination for aortic regurgitation (AR). METHODS:
We conducted a structured MEDLINE search of English-language
articles (January 1966-July 1997), manually reviewed all reference
lists of potentially relevant articles, and contacted authors
of relevant studies for additional information. Each study (n = 16)
was independently reviewed by both authors and graded for methodological
quality. RESULTS: Most studies assessed cardiologists as examiners.
Cardiologists' precision for detecting diastolic murmurs was moderate
using audiotapes (kappa = 0.51) and was good in the clinical setting
(simple agreement, 94%). The most useful finding for ruling in AR
is the presence of an early diastolic murmur (positive likelihood
ratio [LR], 8.8-32.0 [95% confidence interval [CI], 2.8-32 to 16-63]
for detecting mild or greater AR and 4.0-8.3 [95% CI, 2.5-6.9 to
6.2-11] for detecting moderate or greater AR) (2 grade A studies).
The most useful finding for ruling out AR is the absence of early
diastolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4)
for mild or greater AR and 0.1 [95% CI, 0.0-0.3] for moderate or
greater AR) (2 grade A studies). Except for a test evaluating the
response to transient arterial occlusion (positive LR, 8.4 [95% CI,
1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display
poor sensitivity and specificity for AR. CONCLUSION: Clinical
examination by cardiologists is accurate for detecting AR, but
not enough is known about the examinations of less-expert clinicians.
Back to Hand-Held Echocardiography Home Page.
The contents and links on this page were last verified on
July 2000 by Dr. Olga Shindler.