Make the Diagnosis: Murmur, Diastolic
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
A variety of medical and traumatic conditions are associated with AR:
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 ||Download (.pdf) Table 32-5 Likelihood Ratio for Typical Murmur to Predict Aortic Regurgitation or an S3 to Predict Severe Aortic Regurgitation
|Finding (Type of Clinician) ||Severity by Echocardiogram or Cardiac Catheterization ||LR+ (Range or Point Estimate With 95% CI) ||LR– (Range or Point Estimate With 95% CI) |
|Typical murmur7, 8 (cardiologist) ||Mild or greater ||8.8-32 ||0.2-0.3 |
|Moderate or greater ||4.0-8.3 ||0-0.1 |
|Murmur intensity9 (generalist or cardiologist)a ||Grade 3 ||4.5 (1.6-14) || |
|Grade 2 ||1.1 (0.5-2.4) || |
|Grade 1 ||0 (0 -0.9) || |
|No murmur ||0 (0 -1.1) || |
|Third heart sound4 (cardiologist) ||Severe ||5.9 (1.4-25) ||0.83 (0.73-0.95) |
Echocardiography and angiography.
Original Article: Does This Patient Have Aortic Regurgitation?
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 ...