History and exam
Key diagnostic factors
common
diastolic murmur
The absence of diastolic murmur significantly reduces the likelihood of AR.[23]
The severity of the AR correlates well with the duration of murmur, instead of the intensity of murmur. In mild AR the murmur is early diastolic, and increases in duration to holodiastolic in severe AR.
A diastolic murmur may be absent in acute AR.
Other diagnostic factors
common
dyspnea
Caused by pulmonary edema in acute AR, or progressive left ventricular dysfunction in chronic severe AR.
fatigue
Symptom of chronic AR due to progressive left ventricular dysfunction.
weakness
Symptom of chronic AR due to progressive left ventricular dysfunction.
orthopnea
Symptom of chronic AR due to progressive left ventricular dysfunction.
paroxysmal nocturnal dyspnea
Symptom of chronic AR due to progressive left ventricular dysfunction.
pallor
Sign of cardiogenic shock.
mottled extremities
Sign of cardiogenic shock.
rapid and faint peripheral pulse
Sign of cardiogenic shock.
jugular venous distension
Sign of cardiogenic shock and congestive heart failure.
basal lung crepitations
Sign of pulmonary edema.
altered mental status
Sign of cardiogenic shock.
urine output <30 mL/hour
Sign of cardiogenic shock.
soft S1
May be soft due to early coaptation of the mitral valve leaflets from increased end-diastolic pressure.
soft or absent A2
Caused by inadequate closure of aortic valve in severe AR
collapsing (water hammer or Corrigan) pulse
Arterial pulse shows rapid rise and a quick collapse resulting in widened pulse pressure >50 mmHg.
cyanosis
Sign of acute AR.
tachypnea
Sign of acute AR with pulmonary edema.
displaced, hyperdynamic apical impulse
Present on chronic AR with left ventricular enlargement.
uncommon
chest pain
Most common in chronic AR, although can be presenting symptom in acute AR. Acute severe central crushing pain may indicate myocardial ischemia, or, if referred to the back, aortic dissection.
pink frothy sputum
Sign of pulmonary edema.
wheeze (cardiac asthma)
Sign of pulmonary edema.
additional heart sounds
Left ventricular dysfunction can result in S3 gallop or occasionally S4 due to left ventricular hypertrophy.
Auscultation sounds: Third heart sound gallop
Auscultation sounds: Fourth heart sound gallop
arrhythmias
May be present in acute severe AR or chronic AR.
ejection systolic flow murmur
Sometimes associated with moderate to severe AR. The murmur occurs after S1 due to the flow of increased stroke volume across a nonstenotic aortic valve. It is an early peaking, crescendo-decrescendo systolic sound, best heard at second right intercostal space, and can be differentiated from an aortic stenosis murmur by the absence of an ejection click.
Austin Flint murmur
A soft, rumbling, mid to late diastolic murmur heard best at the apex. It is produced by the abutment of an aortic regurgitant jet against the left ventricular endocardium.[20] An Austin Flint murmur is distinguished from the murmur of mitral stenosis by the absence of an opening snap and loud S1. It is a specific finding for severe AR.
systolic thrill
May be palpable over the base of the heart or suprasternal notch due to increased stroke volume.
Hill sign
Systolic pressure over popliteal artery exceeds brachial systolic blood pressure by >60 mmHg. Peripheral hemodynamic sign associated with a bounding pulse and systolic hypertension of chronic severe AR.
Bisferiens pulse
Double systolic arterial impulse.
de Musset sign
Patient's head may bob in time with each heart beat. Peripheral hemodynamic sign associated with a bounding pulse and systolic hypertension of chronic severe AR.
Muller sign
Pulsations of the uvula.
Traube sign
Pistol shot sounds over the femoral artery with compression. Peripheral hemodynamic sign associated with a bounding pulse and systolic hypertension of chronic severe AR.
Quincke sign
Subungual or lip capillary pulsations due to the large stroke volume. Peripheral hemodynamic sign associated with a bounding pulse and systolic hypertension of chronic severe AR.
Duroziez sign
Systolic and diastolic murmurs heard over the femoral artery when compressed proximally and distally, respectively. Peripheral hemodynamic sign associated with a bounding pulse and systolic hypertension of chronic severe AR.
Mayen sign
Diastolic drop of blood pressure >15 mmHg with arm raised.
Lighthouse sign
Blanching and flushing of forehead.
Becker sign
Pulsations of retinal vessels.
Landolfi sign
Alternating constriction and dilation of pupil.
Rosenbach sign
Systolic pulsations of liver.
Gerhardt sign
Pulsatile spleen.
Lincoln sign
Pulsatile popliteal artery.
Sherman sign
Dorsalis pedis pulse is unexpectedly prominent in age >75 years.
palmar click
Palpable systolic flushing of palms.
syncope
Rare presentation.
Risk factors
strong
bicuspid aortic valve
rheumatic fever
One of the most common causes of AR in developing countries.[1]
endocarditis
Can lead to rupture of leaflets or even paravalvular leaks.
Vegetations on the valvular cusps can also cause inadequate closure of leaflets, resulting in leakage of blood.[7]
Marfan syndrome and related connective tissue disease
80% of Marfan patients present at an early age with a diastolic murmur.[12]
Disorders such as Marfan syndrome often lead to progressive dilation of aortic root resulting in AR.
aortitis
Inflammation of the aorta secondary to systemic diseases such as syphilis, Behcet, Takayasu, reactive arthritis, and ankylosing spondylitis results in weakening of the aortic root and dilation.[14]
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