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Make the Diagnosis: Murmur, Diastolic

Prior Probability

One study of randomly selected elderly (75-86 years old) Finnish persons found a 29% prevalence of mild or greater AR.5 Evaluation of more than 3000 men and women (aged 54 ± 10 years) in the Framingham heart study detected AR of trace or greater severity in 13.0% of men and 8.5% of women.6 Increasing age was associated with higher prevalence of AR.

Population for Whom the Signs Should Be Evaluated

  • Any patient undergoing cardiac auscultation

A variety of medical and traumatic conditions are associated with AR:

  • Rheumatic fever

  • Endocarditis

  • Conditions associated with aortic valve leaflet abnormalities (eg, Marfan syndrome, rheumatoid arthritis, ankylosing spondylitis)

  • Diseases that affect the aortic root (eg, hypertension, syphilis, inherited connective tissue disorders, aortic aneurysm)

Physical Examination Signs Useful in the Diagnosis of Aortic Regurgitation

The presence of a typical murmur of AR (an early diastolic, decrescendo murmur) should prompt echocardiographic evaluation (Table 32-5). Many eponymic peripheral pulse findings are associated with AR, but they are not useful for screening or for distinguishing the severity of regurgitation.

Table 32-5Likelihood Ratio for Typical Murmur to Predict Aortic Regurgitation or an S3 to Predict Severe Aortic Regurgitation

Reference Standard Tests

Echocardiography and angiography.

Original Article: Does This Patient Have Aortic Regurgitation?

Clinical Scenario

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 ...

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