cardiovascular disorders
Aortic Regurgitation
Symptoms and Signs of Aortic Regurgitation
Acute aortic regurgitation causes symptoms of Symptoms and Signs (dyspnea, fatigue, weakness, edema) and Chronic aortic regurgitation is typically asymptomatic for years; progressive exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and palpitations develop insidiously. Symptoms of heart failure correlate poorly with objective measures of left ventricular function. Chest pain ( Angina Pectoris ) affects only about 5% of patients who do not have coexisting coronary artery disease (CAD) and, when it occurs, is especially common at night. Patients may present with Signs vary by severity and acuity. Signs in acute aortic regurgitation reflect heart failure and cardiogenic shock and typically include tachycardia, cool extremities, lung crackles, and low blood pressure (BP). The first heart sound (S1) is usually absent (because aortic and LV diastolic pressures equalize), and a third heart sound (S3) is common. An AR murmur may be absent even if AR is severe, although an Austin Flint murmur is common. As chronic disease progresses, systolic blood pressure increases while diastolic blood pressure decreases, creating a widened pulse pressure. With time, the LV impulse may become enlarged, increased in amplitude, and displaced downward and laterally, with systolic depression of the entire left parasternal area, giving a rocking motion to the left chest. A systolic apical or carotid thrill may become palpable in later stages of AR; it is caused by large forward stroke volumes and low aortic diastolic pressure. Auscultatory findingsinclude a normal S1 and a nonsplit, loud, sharp or slapping second heart sound (S2) caused by increased elastic aortic recoil. The murmur of AR is often unimpressive. The murmur is blowing, high-pitched, diastolic, and decrescendo, beginning soon after the aortic component of S2 (A2); it is loudest at the third or fourth left parasternal intercostal space. The murmur is heard best with the diaphragm of the stethoscope when the patient is leaning forward, with breath held at end-expiration. It increases in volume in response to maneuvers that increase afterload (eg, squatting, isometric handgrip). If AR is slight, the murmur may occur only in early diastole. If LV diastolic pressure is very high, the murmur is short because aortic and LV diastolic pressures equalize earlier in diastole. Other abnormal sounds include a forward ejection and backward regurgitant flow (to-and-fro) murmur, an ejection click soon after the S1, and an aortic ejection flow murmur. A diastolic murmur heard near the axilla or mid left thorax (Cole-Cecil murmur) is caused by fusion of the aortic murmur with the S3, which is due to simultaneous filling of LV from the left atrium and AR. A mid-to-late diastolic rumble heard at the apex (Austin Flint murmur) may result from rapid regurgitant flow into the LV, causing mitral valve leaflet vibration at the peak of atrial flow; this murmur mimics the diastolic murmur of mitral stenosis. Other signs are unusual; sensitivity and specificity are low or unknown. Visible signs include Head bobbing (de Musset sign) Pulsation of the fingernail capillaries (Quincke sign, best seen while applying slight pressure) Pulsation of the uvula (Müller sign) Palpable signs include Large-volume pulse with rapid rise and fall (slapping, water-hammer, or collapsing pulse) Pulsation of the carotid arteries (Corrigan sign) Pulsation of the retinal arteries (Becker sign) Pulsation of the liver (Rosenbach sign) Pulsation of the spleen (Gerhard sign) BP findings may include Popliteal systolic pressure≥60 mm Hg higher than brachial pressure (Hill sign) A fall in diastolic BP of>15 mm Hg with arm elevation (Mayne sign) Auscultatory signs include a Sharp sound heard over the femoral pulse (pistol-shot sound, or Traube sign) Femoral systolic bruit distal and a diastolic bruit proximal to arterial compression (Duroziez sign) 