You are asked to see a 59-year-old woman with liver cirrhosis and esophageal varices. When she was checked into the clinic, she had a pulse pressure of 70 mm Hg. Because of the wide pulse pressure, you wonder if she has aortic regurgitation (AR). You conduct a complete physical examination and hear no early-diastolic murmur in the third or fourth intercostal spaces at the left sternal border. You suspect that the wide pulse pressure is a peripheral hemodynamic consequence of cirrhosis, not AR. Do you need an echocardiogram to confirm your clinical impression that she does not have AR?
Why Is the Clinical Examination Important in Evaluating for Aortic Regurgitation?
Aortic regurgitation is a potentially serious cardiac abnormality that may be caused by important underlying disorders. Patients with AR require careful clinical monitoring to identify the optimal time for surgical intervention. Asymptomatic patients with severe AR may benefit from vasodilator therapy.1
The use of noninvasive cardiac testing, such as echocardiography, has increased in recent years. It is estimated that 2% of the general population undergo noninvasive cardiac diagnostic evaluation annually.2 If a careful clinical examination can exclude the presence of AR, then there would be no need to proceed with further cardiac evaluation.
Anatomic and Physiologic Origins of Diastolic Murmurs
The cardinal manifestation of AR is a diastolic murmur. Diastolic murmurs are important indicators of structural cardiac abnormalities or pathologic states of increased flow (Table 32-1). As discussed in a previous article in this series,3 heart murmurs are produced when turbulent blood flow causes prolonged auditory vibrations of cardiac structures. The intensity of the murmur depends on many factors, including blood viscosity, blood flow velocity and turbulence, the distance between the vibrations and the stethoscope, the angle at which the vibrations meet the stethoscope, the transmission qualities of the tissue between the vibration and the stethoscope, and the auditory skills of the examiner.4
Table 32-1Selected Causes of Diastolic Murmurs |Favorite Table|Download (.pdf) Table 32-1 Selected Causes of Diastolic Murmurs
|Abnormal cardiac structure |
|Aortic regurgitation |
|Mitral stenosis |
|Pulmonic regurgitation |
|Tricuspid stenosis |
|Atrial myxoma |
|Ventricular septal defecta |
|Atrial septal defecta |
|Mitral regurgitationa |
|Normal cardiac structure, increased flow |
|Renal failure with volume overload |
How to Examine for Aortic Regurgitation
A complete clinical history and physical examination are essential in the evaluation of a patient with a diastolic murmur. A diastolic murmur in a patient with renal failure and volume overload will have different significance than a diastolic murmur in a patient with a history of rheumatic fever and atrial fibrillation.
The examiner's ability to detect a diastolic murmur can be undermined by environmental factors such as noisy rooms, examiner factors such as fatigue or haste, and patient factors such as dyspnea or tachycardia.5 If examining conditions are not optimal, the examination should be repeated when conditions improve.
The precision and accuracy of many components of the examination for AR, including all of the cardiac history and most of the physical examination, have not been adequately evaluated. This article will focus on aspects of the cardiac physical examination that have been sufficiently assessed for precision or accuracy.
During routine auscultation, the examiner attempts to detect a diastolic murmur. Diastole is the period that begins with the closure of the aortic and pulmonic valves (second heart sound [S2]) and ends with the closure of the mitral and tricuspid valves (first heart sound [S1]). A common maneuver used to identify diastole is to palpate the carotid artery pulse during auscultation; S1 is synchronous with the carotid artery pulsation, whereas S2 follows the pulse. A diastolic murmur is a diastolic sound longer than a heart sound. Examiners should describe the grade, location of maximal intensity (Figure 32-1), timing (Figure 32-2), duration, pitch, and radiation of the murmur.
Typical Location of Abnormal Diastolic Murmurs
There are 3 important areas to auscultate for diastolic murmurs. Area 1 is the second and third intercostal spaces at the right sternal border. Area 2 is the second and fourth intercostal spaces at the left sternal border. Aortic regurgitation murmurs may be heard in both areas 1 and 2. If the murmur is loudest in area 1, then the underlying cause of aortic regurgitation may be an ascending aortic aneurysm or aortic dissection. Pulmonic regurgitation murmurs are loudest in the superior part of area 2 and may radiate downward. The murmur of mitral stenosis and the Flint murmur of aortic regurgitation are best heard at the apex (area 3).
Selected Features of Diastolic Murmurs
Diastolic murmurs are classified according to the time of onset of the murmur.14 An early diastolic murmur begins with the second heart sound (S2). Top, Early diastolic murmurs typically decrease in intensity (decrescendo) and disappear before the first heart sound (S1). In some cases, an early diastolic murmur can continue through diastole. Bottom, A mid-diastolic murmur begins clearly after S2 (in mitral stenosis, classically after an opening snap [OS]). A late-diastolic (or presystolic) murmur begins in the interval immediately before S1. In mitral stenosis, the mid-diastolic murmur may merge with the late-diastolic (presystolic) murmur.
The Levine grading system,6 with slight modifications,7 was developed for systolic murmurs but may also be used to describe diastolic murmurs. A grade 1 murmur is not heard immediately on auscultation but is heard after the examiner focuses for a few seconds. Grade 2 murmurs are heard immediately on auscultation but are softer than the loud grade 3. Grade 4 murmurs are associated with a palpable precordial vibration called a thrill. Grades 5 and 6 murmurs are also associated with a thrill. A grade 5 murmur is audible when only one edge of the stethoscope is on the chest, and a grade 6 murmur is audible with the entire stethoscope lifted off the chest.
The typical AR murmur is an early-diastolic, decrescendo blowing sound (Figure 32-2) that may be accentuated with the patient sitting upright and leaning forward.8 In some cases, S2 can be obscured by the murmur. Most AR murmurs are high pitched and are best heard with the diaphragm of the stethoscope placed firmly on the chest wall. Some AR murmurs are low pitched and are better heard with the bell of the stethoscope placed lightly on the chest wall. For example, the AR murmur associated with endocarditis and a fenestrated aortic valve can be low pitched.
The examiner should apply the stethoscope to the chest wall in the third or fourth intercostal space at the left sternal border and listen between normal breaths at the end of expiration. The patient should not voluntarily breath-hold because it may inadvertently create a Valsalva maneuver. If the murmur is louder at the second to third right intercostal space, the underlying cause of AR may be an ascending aortic aneurysm or aortic dissection.9
Aortic regurgitation also may be associated with a systolic murmur,10 created by the flow of an abnormally large volume of blood through a nonstenotic aortic valve or a bicuspid aortic valve. The murmur is an early-peaking, crescendo-decrescendo systolic sound that is best heard with the diaphragm of the stethoscope applied to the second right intercostal space.
The Flint murmur is a low-pitched late-diastolic apical murmur, which is associated with AR. The murmur is likely produced when the regurgitant jet of blood collides with the left ventricular endocardium.11 The murmur may have a mid-diastolic component, but the original description by Flint12 referred only to “presystolic blubbering.”12 It is best heard with the patient in the left-lateral decubitus position, using the bell of the stethoscope. Differentiating the Flint murmur from the murmur of mitral stenosis can be difficult. The murmur of mitral stenosis is primarily mid-diastolic (possibly with a late-diastolic component) and may be associated with an opening snap (OS) and a loud S1 (Figure 32-2).13
The typical murmur of pulmonic regurgitation (PR) is an early-diastolic decrescendo murmur heard best in the second-left intercostal space at the sternal border. The murmur may radiate to the third and fourth left intercostal spaces and may increase during quiet inspiration. If there is splitting of S2, the astute examiner may note that the murmur begins after the pulmonic valve component (P2) of S2 rather than the aortic component. The murmur of PR may be lower pitched than the murmur of AR, unless pulmonary hypertension is present. A right-sided Flint murmur can be heard, particularly in patients with pulmonary hypertension.
Mitral stenosis is associated with a mid-diastolic, decrescendo, low-frequency rumble, which, if the patient is in sinus rhythm, may be followed by late-diastolic (presystolic) crescendo that ends with the mitral component of S1 (Figure 32-2). It is best heard using the bell of the stethoscope placed at the apex soon after moving the patient into the left lateral decubitus position. Rolling the patient onto the left side brings the left ventricle closer to the chest wall and serves as a form of exercise, increasing blood flow across the mitral valve and increasing the murmur's intensity.9 The murmur of mitral stenosis may be inaudible in patients with low cardiac output.
The S1 may be increased in intensity in mitral stenosis.13 A normal S1 is best appreciated near the apex, where it should be louder than S2. The S1 is normally softer than S2 in the second right and second left intercostal spaces adjacent to the sternum. If S1 is as loud as or louder than the S2 in these areas, then the S1 is increased in intensity.
An OS is a high-frequency, early-diastolic sound that is associated with the opening of a stenotic mitral valve. It occurs 50 to 100 ms after the aortic valve component (A2) of S2 and is best heard in the area from the left sternal border to the apex. Much like the murmur of mitral stenosis, it may be accentuated by auscultating while the patient is in the left lateral decubitus position shortly after the patient has performed exercise. The A2-OS interval shortens with increasing severity of mitral stenosis. The OS may be absent in the case of a heavily calcified immobile mitral valve. It is often difficult to differentiate an OS from the P2 of S2. The OS usually decreases in intensity with inspiration and S2-OS interval widens on standing. Conversely, P2 becomes louder with inspiration, and the A2-P2 interval remains the same or narrows with standing.13 In addition, P2 is not expected to be heard at the apex unless the patient has pulmonary hypertension.
Selective use of maneuvers can enhance the detection and interpretation of diastolic murmurs. There is no point in doing maneuvers if a loud AR murmur has been detected during routine auscultation. However, if the clinician is unsure about the presence of a faint diastolic murmur, then a maneuver that increases murmur intensity may clarify the situation. If the clinician has a heightened suspicion for AR (eg, after hearing an aortic ejection sound), or if examining conditions are not optimal, then a maneuver to augment murmur intensity might bring out an otherwise inaudible murmur. Finally, the maneuvers may help distinguish PR from AR. In this latter situation, the clinician should listen where the murmur is just barely audible, so that it is easy to detect a decrease or increase in murmur intensity during the maneuver.
Quiet inspiration increases venous return and augments right-sided heart murmurs such as PR. To determine the effect of inspiration on the intensity of the murmur, the examiner should listen during quiet inspiration, rather than asking the patient to breathe deeply, because the murmur may be obscured by breath sounds.
Transient arterial occlusion primarily increases systemic arterial resistance that intensifies left-sided regurgitant lesions such as AR and may help distinguish the murmur from PR. To perform this maneuver, sphygmomanometers are placed around both of the patient's arms and are inflated to 20 to 40 mm Hg above the previously recorded systolic blood pressure. Any changes in murmur intensity are noted 20 seconds after cuff inflation.15
Peripheral Hemodynamic Signs
There are a variety of peripheral hemodynamic signs traditionally associated with AR. Some of these signs have been adequately evaluated, including de Musset head-bobbing sign,16 a wide pulse pressure,17 the brachial-popliteal pulse gradient (Hill sign18), Duroziez femoral murmur,16 the femoral pistol shot murmur,13 and Corrigan water hammer pulse.19 The de Musset head-bobbing sign consists of a forward shaking of the head with every heartbeat; it is best observed in patients who are sitting.16
Pulse pressure refers to the difference between systolic and diastolic blood pressures. A widened pulse pressure may be defined as greater than 50 mm Hg.20 Other definitions include a pulse pressure greater than 50% of the systolic pressure.17 Determination of the blood pressure has been described in another article in this series.21
The brachial-popliteal pulse gradient (Hill sign) can be defined as a systolic blood pressure in the lower extremities that is at least 20 mm Hg higher than that in the arms.20 To determine a popliteal blood pressure, an appropriately sized blood pressure cuff should be placed on the patient's thigh13 with the artery marker over the popliteal artery. The cuff should be inflated and the systolic pressure can then be determined in the popliteal fossa either by palpation, as judged by the point where the pulse reappears as the cuff is deflated, or by auscultation, listening for Korotkoff sounds to appear. Both the brachial and popliteal blood pressures should be measured while the patient is supine. The average of repeated readings should be used, especially in patients with irregular heart rates, such as atrial fibrillation.
Duroziez double intermittent femoral bruit is elicited by first gently compressing the femoral artery with the diaphragm of the stethoscope. This will yield a systolic bruit in all patients. As increasing pressure is applied to the diaphragm, an early-diastolic bruit will become audible in patients with AR. While listening to the diastolic bruit, the clinician should tilt the stethoscope so that the distal rim (closest to the patient's feet) is compressing the femoral artery. If the bruit becomes louder with this maneuver, then the diastolic bruit is due to the retrograde flow of blood toward the heart in AR. The stethoscope should then be tilted such that the proximal rim (closest to the patient's head) is compressing the femoral artery. If the diastolic bruit becomes softer, this can be taken as supportive evidence of the presence of retrograde blood flow. If, however, the bruit becomes louder with proximal pressure (and softer with distal pressure), then this sign should not be used as evidence of AR but may indicate the presence of a high-flow state such as renal failure with volume overload.22
Femoral pistol shot sounds are elicited by auscultating with the diaphragm of the stethoscope over the femoral arteries. A high-pitched pistol shot sound may be heard in AR. Corrigan water hammer pulse refers to an increased volume and rate of increase of the radial pulse when the wrist is elevated perpendicular to the body of a supine patient. The radial pulse should first be assessed while the patient is lying supine with his or her arms resting at the sides. Sufficient pressure should be applied to obliterate the pulse. While this pressure is maintained, the patient's arm should be elevated so that it is perpendicular to the plane of the body. In AR, the pulse will become palpable despite applying an equivalent amount of pressure as when the arm was at the patient's side.
Other peripheral hemodynamic signs, such as Mayne sign (a decrease in diastolic blood pressure of 15 mm Hg when the arm is held above the head compared with when the arm is held at the level of the heart),23 Quinke capillary pulsation, Muller pulsatile uvula, and Rosenbach liver pulsation, have not been adequately evaluated for precision or accuracy.
To identify articles pertaining to the precision and accuracy of the physical examination for AR, we used standard methods for conducting research overviews.24 Our data collection strategy involved 3 steps and was deliberately broad to reduce the possibility of overlooking important articles. First, we searched MEDLINE for English-language articles published from 1966 through July 1997, using a structured search strategy (available on request from the authors). Second, we manually reviewed potentially relevant articles and their reference lists. Third, we contacted the authors of relevant studies for additional information. Studies were excluded if they were review articles, involved patients younger than 18 years, were small (ie, <20 participants), involved prosthetic heart valves, had no clinical examination performed or reported, or had no acceptable reference standard (Doppler echocardiography or cardiac catheterization).
Table 1-7 for a summary of Evidence Grades and levels).25 Grade A studies involve the independent comparison of a sign or symptom with a reference standard of diagnosis among a large number of consecutive patients suspected of having the target condition. Grade B studies meet the criteria for grade A studies but have a small number of patients. Grade C studies involve nonconsecutive patients, patients who are known to have the target condition and healthy individuals, nonindependent comparisons between the sign or symptom and the reference standard, or nonindependent comparisons with a reference standard of uncertain validity. Grade C studies tend to overestimate the accuracy of the sign or symptom.
We created contingency tables for all studies and determined the likelihood ratios (LRs) for aortic regurgitation.26, 27 We also sought information on the examination for other causes of diastolic murmurs, such as mitral stenosis or PR. Unfortunately, we found few studies of sufficient methodologic quality for these conditions. This relative lack of information implies that methodologically sound studies are needed but does not imply that the clinical examination for these conditions is imprecise, inaccurate, or unimportant.
Precision of the Examination Related to Diastolic Murmurs
Precision refers to agreement regarding a particular clinical finding between different physicians (interobserver) or between multiple assessments by the same physician (intraobserver). The precision of the clinical examination for diastolic murmurs has been evaluated in usual clinical situations by auscultating patients28, 29 or in controlled nonclinical circumstances by listening to recorded audiotapes (Table 32-2).30
Table 32-2Interobserver Reliability (Precision) for Detecting Diastolic Murmurs |Favorite Table|Download (.pdf) Table 32-2 Interobserver Reliability (Precision) for Detecting Diastolic Murmurs
|Finding ||Type of Examiner ||No. of Examiners ||No. of Patients ||κa ||Simple Agreement, % |
|Murmur absent vs present ||Cardiologists (tapes)30 ||5 ||100 ||0.51 ||79 |
|Cardiologists28 ||2 ||32 ||… ||94 |
|Noncardiologists28 ||3 ||32 ||… ||78 |
|Intensity of murmur ||Not stated29,b ||5 ||25 ||… ||92 |
There have been 4 studies that address the interobserver precision of cardiac auscultation to detect diastolic murmurs (Table 32-2). Although simple agreement is high in these studies, the one study for which it was possible to calculate agreement adjusted for chance (κ) showed only moderate agreement. The experience of observers likely affects precision. The one study28 that compared cardiologists with noncardiologists found a higher simple agreement for cardiologists.
The interobserver agreement between examiners on the intensity of heart sounds is excellent (92%).29 In this study, examiners progressively inserted 0.5-mm-thick paper disks between the patient's chest and the stethoscope. The total thickness of the disks was used as a measure of heart sound intensity. Murmur intensity was also assessed with this technique (Table 32-2).
The Bottom Line for Precision
The interobserver precision of cardiologists examining for any diastolic murmur is moderate with audiotapes (κ = 0.51) and good in the clinical setting (simple agreement, 94%). Noncardiologists may be less precise than cardiologists. The precision of examining for the intensity of murmurs and heart sounds with a standardized series of paper disks to assess intensity is good (simple agreement, 92%-96%).
Accuracy of the Examination for Aortic Regurgitation
We consider Doppler echocardiography and cardiac catheterization to be acceptable reference standards for AR (Table 32-3). In one study,37 the reference standard was open-heart surgery.
Table 32-3Accuracy of the Physical Examination for Detecting Aortic Regurgitation |Favorite Table|Download (.pdf) Table 32-3 Accuracy of the Physical Examination for Detecting Aortic Regurgitation
|Study, y ||Patient Population ||Reference Standard ||No. of Patients With AR ||LR+ (95% CI) ||LR– (95% CI) ||Quality Gradea |
|Typical Murmur With Severity of AR Specified |
|Aronow and Kronzon33 (1989) ||Elderly patients ||Echocardiography (n = 450) ||A |
|Mild or greater AR ||131 ||32 (16-63) ||0.2 (0.1-0.3) || |
|Moderate or greater AR ||74 ||8.3 (6.2-11) ||0.1 (0.0-0.2) || |
|Grayburn et al34 (1986) ||Referred for catheterization ||Catheterization (n = 106) ||A |
|Mild or greater AR ||82 ||8.8 (2.8-32) ||0.3 (0.2-0.4) || |
|Moderate or greater AR ||57 ||4.0 (2.5-6.9) ||0.1 (0.1-0.3) || |
|Roldan et al35 (1996) ||Asymptomatic connective tissue disease and controls ||Echocardiography (n = 143) ||C |
|Mild or greater AR ||10 ||80 (14-470) ||0.4 (0.2-0.7) || |
|Moderate or greater AR ||5 ||69 (18-270) ||0.0 (0.0-0.6) || |
|Rahko36 (1989) ||Referred for echocardiogram ||Echocardiography (n = 403) ||C |
|Mild or greater AR ||134 ||27 (13-60) ||0.4 (0.3-0.5) || |
|Moderate or greater AR ||82 ||12 (8.1-19) ||0.2 (0.1-0.3) || |
|Cohn et al37 (1967) ||Mitral valve repair ||Open-heart surgery (n = 156) ||C |
|Mild or greater AR ||50 ||5.2 (3.3-8.4) ||0.3 (0.2-0.4) || |
|Moderate or greater AR ||37 ||3.9 (2.6-5.7) ||0.2 (0.1-0.4) || |
|Meyers et al38 (1982) ||Referred for aortography ||Catheterization (n = 75) ||C |
|Mild or greater AR ||66 ||3.3 (1.3-12) ||0.4 (0.2-0.7) || |
|Moderate or greater AR ||39 ||1.6 (1.2-2.4) ||0.4 (0.2-0.7) || |
|Dittmann et al39 (1987) ||Valvular heart disease ||Catheterization (n = 55) ||Cb |
|Mild or greater AR ||42 ||16 (2.1-155) ||0.4 (0.3-0.6) || |
|Severe AR ||19 ||3.6 (2.1-6.6) ||0.1 (0.0-0.4) || |
|Meyers et al40 (1985) ||Valvular heart disease ||Catheterization (n = 20) ||C |
|Mild or greater AR ||11 ||9.8 (1.3-96) ||0.5 (0.2-0.9) || |
|Moderate or greater AR ||3 ||5.7 (1.4-14) ||0.0 (0.0-0.9) || |
|Linhart41 (1971) ||Mitral stenosis ||Catheterization (n = 28) ||C |
|Mild or greater AR ||11 ||6.2 (1.9-23) ||0.3 (0.1-0.7) || |
|Moderate or greater AR ||7 ||7.0 (2.5-20) ||0.0 (0.0-1.3) || |
|Typical Murmur Without AR Severity Specified (May Include Trivial AR) |
|Come et al42 (1986) ||Mitral valve prolapse, plus patients with systolic flow murmurs ||Echocardiography (n = 165) ||7 ||90 (8-982) ||0.7 (0.4-0.9) ||C |
|Nienaber et al43 (1993) ||Clinically suspected aortic dissection ||Echocardiography (n = 110) ||32 ||33 (9.4-120) ||0.2 (0.1-0.3) ||Cc |
|Ward et al44 (1977) ||Clinically suspected aortic dissection ||Catheterization (n = 65) ||49 ||13 (2.9-75) ||0.2 (0.1-0.3) ||Cc |
|Esper45 (1982) ||AR and other heart disease ||Echocardiography (n = 43) ||24 ||12 (2.4-67) ||0.4 (0.3-0.7) ||C |
|Saal et al46 (1985) ||Mitral stenosis ||Catheterization (n = 45) ||35 ||8.0 (1.9-45) ||0.2 (0.1-0.4) ||C |
|With transient arterial occlusion murmur increases in intensity15 ||Patients with AR, mitral stenosis, and pulmonic regurgitation ||Catheterization or echocardiography (n = 16) ||10 ||8.4 (1.3-81) ||0.3 (0.1-0.8) ||C |
|Associated Physical Findings |
|Flint murmur48 ||Isolated AR and controls ||Echocardiography (n = 36) ||C |
|Mild or greater AR ||28 ||4 (0.5-40) ||0.8 (0.6-1.3) || |
|Moderate or greater AR ||13 ||25 (2.8-243) ||0.5 (0.2-0.7) || |
|Any systolic murmur48 ||Isolated AR and controls ||Echocardiography (n = 36) ||C |
|Mild or greater AR ||28 ||1.3 (0.9-2.7) ||0.5 (0.2-1.6) || |
|Moderate or greater AR ||13 ||1.5 (1.0-2.1) ||0.0 (0.0-1.0) || |
|Popliteal-brachial gradient > 20 mm Hg20 ||Mild to severe AR ||Catheterization (n = 33) ||C |
|Moderate or greater AR ||28 ||8.2 (1.5-78) ||0.2 (0.1-0.5) || |
|Peripheral hemodynamic signs20d ||Mild to severe AR ||Catheterization (n = 34) ||C |
|Moderate or greater AR ||28 ||2.1 (0.3-22) ||0.8 (0.7-1.7) || |
|Pulse pressure > 50 mm Hg20 ||Mild to severe AR ||Catheterization (n = 33) ||C |
|Moderate or greater AR ||28 ||1.0 (0.7-2.2) ||0.9 (0.2-5.5) || |
Cardiologists conducted the clinical examinations in most studies. Too few studies, using few patients, allow for reasonable estimates of the accuracy of noncardiologists, although noncardiologists are likely less adept at detecting the diastolic murmur of AR. Approximately 20% of residents and medical students correctly identified the murmur of AR on high-fidelity digitized audiotapes,31 whereas 46% of internal medicine residents correctly identified an AR murmur on a patient simulator.32
The best-studied physical finding is the typical early-diastolic murmur of AR.33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, and 46 If an examiner does not hear a typical AR murmur, then the likelihood that the patient has moderate or greater AR is significantly reduced (negative likelihood ratio [LR–], 0.1 for grade A studies); the likelihood of mild or greater AR is also significantly reduced (LR–, 0.2-0.3 for grade A studies).If an examiner hears the typical AR murmur, the likelihood that the patient has moderate or greater AR is increased (positive likelihood ratio [LR+], 4.0-8.3 for grade A studies); the likelihood of mild or greater AR is also significantly increased (LR+, 8.8-32 for grade A studies).33, 34
The intensity of the murmur correlates with the severity of echocardiographic AR. Desjardins et al47 studied 40 patients with echocardiographic AR, including 17 with severe AR. A grade 3 diastolic murmur had an LR of 4.5 (95% CI, 1.6-14) for distinguishing severe AR from less severe AR, whereas a grade 2 murmur had an LR of 1.1 (95% CI, 0.5-2.4), a grade 1 murmur had an LR of 0.0 (95% CI, 0.0-0.9), and absence of a diastolic murmur had an LR of 0.0 (95% CI, 0.0-1.1).47
Two grade C studies of the Flint murmur and some peripheral hemodynamic findings are reported in Table 32-3. Grade C studies tend to overestimate diagnostic test accuracy. Despite this tendency, one study found that absence of a Flint murmur did not rule out AR (LR–, 0.5-0.8).48 Another study of patients with mild to severe AR found only that a wide pulse pressure or peripheral hemodynamic sign (Duroziez bruit, femoral pistol shots, and Corrigan pulses) was not helpful for distinguishing mild AR from moderate or severe AR.20 The de Musset head-bobbing sign was seen in only 1 of 20 patients (sensitivity, 5%), while Duroziez femoral bruit was observed in 8 of 12 patients (sensitivity, 67%),16 making them interesting but not particularly useful findings.
The Bottom Line for Aortic Regurgitation
When a cardiologist hears the typical murmur of AR, the likelihood of mild or greater AR is increased significantly (2 grade A studies). The absence of a typical diastolic murmur significantly reduces the likelihood of AR (2 grade A studies). Noncardiologists may be less proficient than cardiologists at detecting the murmur of AR.
Mitral Stenosis and Pulmonic Regurgitation
In one grade A study of 529 unselected nursing home residents (31 with mitral stenosis), a cardiologist detected a mid-diastolic murmur in all cases of mitral stenosis, with no false-positive or -negative examinations.49 Only 1 patient had an audible OS.
Noncardiologists may be less proficient at detecting the physical findings of mitral stenosis. Less than 10% of residents and medical students correctly identified a mid-diastolic murmur of mitral stenosis on a high-fidelity digitized audiotape,31 whereas 43% of medical residents identified a mid-diastolic murmur of mitral stenosis with a patient simulator. In the latter study, only 21% identified the OS of mitral stenosis.32
The only evaluated element of the clinical examination for PR is the presence of a typical diastolic decrescendo murmur best audible in the second intercostal space at the left-upper sternal border, which may increase in intensity with quiet inspiration. All studies used cardiologists as examiners and were of poor methodologic quality (grade C).
When a cardiologist hears the murmur of PR, the likelihood of PR increases (LR+, 17 in both studies), but the absence of a PR murmur was not helpful for ruling out PR (LR, 0.9 in both studies).36, 42
The Bottom Line for Mitral Stenosis and Pulmonic Regurgitation
The presence of a mid-diastolic murmur significantly increases the likelihood of mitral stenosis, whereas the absence of a mid-diastolic murmur significantly reduces the likelihood of mitral stenosis (1 grade A study). When a cardiologist hears a typical PR murmur, the likelihood of PR increases significantly. The absence of a typical murmur does not alter the likelihood of PR (2 grade C studies). Noncardiologists may be less proficient at detecting the mid-diastolic murmur of mitral stenosis.
Diastolic Murmurs in Patients With Renal Failure
Diastolic murmurs caused by abnormal flow states, rather than abnormal cardiac structure, may be associated with a variety of conditions. Renal failure with volume overload is the only abnormal flow state associated with diastolic murmurs that has been evaluated.
Up to 9% of patients with end-stage renal disease have diastolic murmurs, particularly when these patients also have volume overload, anemia, and hypertension.50 These murmurs typically disappear after the treatment of volume overload, as was demonstrated in 2 small studies (grade C).50, 51 These murmurs are probably due to transient pulmonary hypertension and dilatation of the pulmonary artery root, leading to PR.51
The Bottom Line for Diastolic Murmurs in Patients With Renal Failure
Although there is an insufficient amount of data on which to make rigorous recommendations, if an early-diastolic murmur is heard in a dialysis patient with volume overload, the patient should be reexamined after treatment because the murmur may disappear.
When to Examine for Aortic Regurgitation
There are no evaluative data on which to base a recommendation regarding when to examine for AR. Undetected AR may be common in elderly persons: 13% (n = 552) of asymptomatic elderly Finnish persons had moderate or severe echocardiographic AR.52 Unfortunately, that study does not indicate how many of these patients had audible diastolic murmurs. Audible diastolic murmurs may be relatively uncommon findings in asymptomatic persons. In one study, only 1% (n = 103) of elderly asymptomatic nursing home residents had an audible diastolic murmur.53
Despite the lack of evaluative data, we think that a prudent clinician will examine for AR in most clinical settings. AR is a serious cardiac abnormality, which may be caused by underlying disorders and may be asymptomatic. The clinician's suspicion for AR may be heightened by evidence of systemic disease, such as ankylosing spondylitis, a peripheral hemodynamic finding (although these are by no means indicative of underlying AR), or an abnormality detected during routine auscultation (such as an aortic ejection sound). Other findings may suggest different cardiac abnormalities associated with diastolic murmurs, such as evidence of pulmonary hypertension (for PR), a wide-fixed split S2 (for atrial-septal defect), or a holosystolic apical murmur (for mitral regurgitation).
Recommendations for Further Research
Most studies used cardiologists to conduct clinical examinations. There are some data that suggest that noncardiologists may be less accurate then cardiologists, so studies evaluating techniques to improve the skills of noncardiologists are needed. There are also no studies defining the optimal examination technique for detecting the AR murmur.
Author Affiliations at the Time of the Original Publication
Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, University of Toronto and the University Health Network, Toronto, Ontario, Canada.
This work was funded in part by grant 98-01R from Physicians Services Incorporated Foundation.
The views expressed in this article are those of the authors and do not reflect those of any sponsoring or supporting agency.
We thank Eugene Oddone, MD, MHS, for his helpful comments on earlier drafts of this article, and Wilbert S. Aronow, MD, and A. Nienaber, MD, for providing additional data and methodologic information about their studies.
Your patient has a wide pulse pressure but no typical early-diastolic murmur. The likelihood of mild or moderate AR is significantly reduced by the absence of a typical early-diastolic murmur (LR–, 0.1-0.3; 2 grade A studies). You perform transient arterial occlusion, and no diastolic murmur appears, which enhances your confidence (LR–, 0.3). You are confident in your assessment because it was conducted in a quiet room with a comfortable and cooperative patient. Therefore, AR is unlikely and echocardiography is not necessary.
The following disclosures were reported at the time this original article was first published in JAMA.
Funding/Support: This work was funded in part by grant 98-01R from Physicians Services Incorporated Foundation.
SD. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med.
VP. Melton LJ. Population-based study of echocardiography. Int J Technol Assess Health Care.
et al.. Variability in detection and interpretation of heart
murmurs. Am J Dis Child.
Massa.R. The unheard diastolic murmur in acute rheumatic fever. N Engl J Med.
SA. The clinical significance of the systolic murmur: a study of 1000 consecutive cases. Ann Intern Med.
EJ. Diagramming and grading heart
sounds and murmurs. Am Heart J.
J. Essentials of Bedside Cardiology. 2nd ed. Totowa, NH: Human Press; 2003:243–263.
WP. Cardiac pearls. Dis Mon. 1994;40(2):43–113.
JA. Cardiac auscultation. Curr Probl Cardiol.
CB. Cheitlin MD. Etiology of the Austin Flint murmur. J Am Coll Cardiol.
A. On cardiac murmurs. Am J Med Sci. 1862;44:29–54.
JD. The Art and Science of Bedside Diagnosis. Baltimore, MD: Urban & Schwarzenberg; 1990:283–330.
et al.. Glossary of cardiologic terms related to physical diagnosis and history. Am J Cardiol.
RA. Diagnosis of left-sided regurgitant murmurs by transient arterial occlusion: a new maneuver using blood pressure cuffs. Ann Intern Med.
JD. Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations. South Med J.
M. Aortic insufficiency. Circulation. 1968;37(suppl V):V77–V92.
L. The measurement of systolic blood pressure in man. Heart.
HW. Effect of elevating the wrist on the radial pulse in aortic regurgitation. Am J Cardiol.
PAR. Confidence intervals for the ratio of two binomial proportions. Biometrics.
J. The Two by Two Analyzer. Birmingham, AL: CenterSoft Statistical Programs for Medical Decision Making Research; 1992.
CA. A study of physician variation in heart-sound interpretation. Med Ann Dist Columbia.
GR. Feussner JR. Assessing housestaff diagnostic skills using a cardiology patient simulator. Ann Intern Med.
and severity of aortic regurgitation detected by pulsed Doppler echocardiography with the murmur of aortic regurgitation in elderly patients in a long-term health care facility. Am J Cardiol.
AN. Detection of aortic insufficiency by standard echocardiography, pulsed Doppler echocardiography, and auscultation. Ann Intern Med.
MH. Value of the cardiovascular physical examination for detecting valvular heart
disease in asymptomatic subjects. Am J Cardiol.
of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography. Ann Intern Med.
E. Preoperative assessment of aortic regurgitation in patients with mitral valve disease. Am J Cardiol.
DW. Diagnosis of aortic insufficiency. South Med J.
L. Diagnosis and quantification of aortic regurgitation by pulsed Doppler echocardiography in patients with mitral valve disease. Eur Heart J.
DA. Auscultation, M-mode echocardiography and pulsed Doppler echocardiography compared with angiography for diagnosis of chronic aortic regurgitation. Am J Cardiol.
S. Pulsed Doppler echocardiographic evaluation of valvular regurgitation in patients with mitral valve prolapse. J Am Coll Cardiol.
et al.. The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med.
SL. Detection of aortic insufficiency by pulse Doppler echocardiography. J Clin Ultrasound.
RJ. Detection of mild aortic regurgitation by range-gated pulsed Doppler echocardiography. Am J Cardiol.
AS. Noninvasive detection of aortic insufficiency in patients with mitral stenosis by pulsed Doppler echocardiography. J Am Coll Cardiol.
JB. Intensity of murmurs correlates with severity of valvular regurgitation. Am J Med.
SP. Chang MS. Reappraisal of cardiac murmurs related to aortic regurgitation. Chin Med J (Engl). 1995;56:152.
of murmurs of mitral stenosis and mitral regurgitation with presence or absence of mitral annular calcium in person older than 62 years in a long-term health care facility. Am J Cardiol.
A. Early diastolic murmurs in end-stage renal failure. Br Heart J.
VN. Pulmonic valve insufficiency. Ann Intern Med.