Aortic regurgitation (AR) primarily affects men and often develops in patients during their late 50s, with symptoms like exertional dyspnea and palpitations occurring before overt left ventricular dysfunction. Characteristic examination findings include a collapsing pulse, widened pulse pressure, and distinctive heart murmurs such as the early diastolic murmur of AR. Acute AR presents suddenly with severe symptoms like shortness of breath and chest pain, alongside signs of heart failure and potential cardiogenic shock.

1. Clinical features of aortic
regurgitation
N. Juhi Sravani

2. Epidemiology
• Approximately three-fourths of patients with pure or
predominant valvular AR are men; women predominate
among patients with primary valvular AR who have
associated rheumatic mitral valve disease.
• Chronic AR often begins in patients when they are in their
late 50s. In general, the prevalence and severity of AR
increase with age.
• Patients with bicuspid aortic valve and, especially, those
with Marfan syndrome tend to present much earlier

3. Symptoms - Chronic AR
• Relatively asymptomatic for as long as 10-15 years.
• Palpitations, especially on lying down. Sinus tachycardia,
during exertion or with emotion, or ventricular premature
contractions may produce uncomfortable palpitations and
head pounding, these maybe present before symptoms of
overt LV dysfunction develop.
• Exertional dyspnea is usually the first symptom of
diminished cardiac reserve. The dyspnea is followed by
orthopnea, paroxysmal nocturnal dyspnea, and excessive
diaphoresis.

4. • Anginal chest pain even in the absence of CAD - at rest
as well as during exertion.
• Nocturnal angina may be a particularly troublesome
symptom, and it may be accompanied by marked
diaphoresis (occurs due to slow heart rate and fall in
diastolic pressure).
• The anginal episodes can be prolonged and often do not
respond satisfactorily to sublingual nitroglycerin.

5. Physical examination - Chronic AR
-Arterial pulse
Collapsing Pulse (Water-Hammer pulse, Corrigans pulse) -It is a large volume
pulse with a rapid upstroke and a rapid downstroke . The rapid upstroke is
because of an increased stroke volume. The rapid downstroke is because of
diastolic run-off into the left ventricle, and decreased peripheral resistance and
rapid run-off to the periphery.
• Measured at radial artery, it is exaggerated by lifting arm up above the heart
level
• also seen in - PDA

6. • Pulsus bisferiens- In some patients with AR or with
combined AS and AR, the carotid arterial pulse may be
bisferiens.
• two systolic waves separated by a trough
• it is due to rapid ejection of blood through aortic valve
Single
central
pulse
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• An
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• The
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ery
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.

7. • Blood Pressure-
• Systolic arterial pressure is elevated, and diastolic pressure
is abnormally low
• Widening of pulse pressure is seen
• Korotkoff sounds often persist to zero even though the intra-
arterial pressure rarely falls below 30 mm Hg. The point of
change in Korotkoff sounds (i.e., the muffling of these sounds
in phase IV) correlates with the diastolic pressure.
• As HF develops, peripheral vasoconstriction may occur and
arterial diastolic pressure may rise, even though severe AR
is present.

8. Peripheral signs
• Becker sign - Visible systolic pulsations of the retinal arterioles
• Müller sign - Visible systolic pulsations of the uvula
• Light-house sign - Alternate flushing & blanching of forehead
• Landolfi's sign - Change in pupil size with each systole
• de Musset sign - Bobbing motion of the patient's head with each heartbeat
• Corrigan pulse ("water-hammer" pulse) - Abrupt distention and quick
collapse on palpation of the peripheral arterial pulse
• Corrigan's sign - Dancing carotid in neck
• Quincke sign - Visible pulsations of the fingernail bed with light
compression of the fingernail

9. • Gerhardt's sign - Visible systolic pulsations of spleen
• Rosenbach's sign - Visible systolic pulsations of liver
• Traube sign ("pistol-shot" pulse) - Booming systolic and diastolic sounds
auscultated over the femoral artery
• Hill sign - Popliteal cuff systolic blood pressure 20 mm Hg higher than
brachial cuff systolic blood pressure.
• Duroziez sign - Systolic murmur over the femoral artery with proximal
compression of the artery, and diastolic murmur (Duroziez murmur) over
the femoral artery withdistal compression of the artery

11. Systemic examination
Palpation-
• Apical impulse is well sustained and is displaced laterally
and inferiorly.
• A rapid ventricular filling wave often is palpable at the
apex.
• The augmented stroke volume may create a systolic thrill
at the base of the heart or suprasternal notch and over
the carotid arteries.

12. Auscultation
• S1- soft (in cases severe AR as increase in LVEDP leads
to early closure of mitral valve)
• S2 (A2 component)- soft in rheumatic AR, “tambour” like
in syphilitic AR
• S3- heard in LV failure
• S4-heard in prominent LV hypertrophy

13. Murmurs
• Early Diastolic Murmur of AR -typically a high-pitched,
blowing, decrescendo murmur, heard best in the third
intercostal space along the left sternal border in rheumatic AR
and right sternal border in aneurysmal dilatation of aortic root.
-The murmur can be heard best with the diaphragm of the
stethoscope and with the patient sitting up, leaning forward, and
with the breath held in forced expiration.
-Radiation to left axilla may be present (Cole-Cecil murmur)

14. • Mid-systolic ejection murmur- heard best at the base
of the heart and is transmitted along the carotid arteries.It
is often higher pitched and shorter than murmur in AS.
Palpation of the carotid pulses will elucidate the cause of
the systolic murmur and differentiate it from the murmur
of AS.

15. • Austin Flint murmur (mid diastolic murmur)- It a
soft, low-pitched, rumbling mid-to-late diastolic murmur,
best heard at the apex,no pre-systolic accentuation
present.
• -It is probably produced by the diastolic displacement of
the anterior leaflet of the mitral valve by the AR stream.
• -Seen in severe AR
• The auscultatory features of AR are intensified by
strenuous and sustained handgrip, which augments
systemic vascular resistance and increases LV afterload.

16. Symptoms - Acute AR
• Sudden, severe shortness of breath
• Chest pain if myocardial perfusion pressure is decreased
or an aortic dissection is present
• Rapidly developing heart failure, Pulmonary edema &
Cardiogenic shock

17. Physical Examination - Acute AR
• Tachycardia
• Peripheral vasoconstriction
• Cyanosis
• Pulmonary edema
• Arterial pulsus alternans; normal LV impulse
• Early mitral valve closure can cause soft S1
• Early diastolic murmur (lower pitched and shorter than in chronic
AR) may be present.
• The Austin Flint murmur often is present but is of brief duration and
ceases when LV pressure exceeds left atrial pressure in diastole