Aortic Insufficiency - Physical Examination

Physical Examination

The physical examination of an individual with aortic insufficiency involves auscultation of the heart to listen for the murmur of aortic insufficiency and the S3 heart sound (S3 gallop correlates with development of LV dysfunction). The murmur of chronic aortic insufficiency is typically described as early diastolic and decrescendo, which is best heard in the third left intercostal space and may radiate along the left sternal border.

If there is increased stroke volume of the left ventricle due to volume overload, an ejection systolic 'flow' murmur may also be present when auscultating the same aortic area. Unless there is concomitant aortic valve stenosis, the murmur should not start with an ejection click.

There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet.

Peripheral physical signs of aortic insufficiency are related to the high pulse pressure and the rapid decrease in blood pressure during diastole due to blood returning to the heart (the wrong way) from the aorta through the incompetent aortic valve, although the usefulness of some of the eponymous signs has been questioned:

• large-volume, 'collapsing' pulse also known as:
  • Watson's water hammer pulse
  • Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
• low diastolic and increased pulse pressure
• de Musset's sign (head nodding in time with the heart beat)
• Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke)
• Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery; named for Ludwig Traube)
• Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

Also, these are usually less detectable in acute cases.

Less used signs include:

• Lighthouse sign (blanching & flushing of forehead)
• Landolfi's sign (alternating constriction & dilatation of pupil)
• Becker's sign (pulsations of retinal vessels)
• Müller's sign (pulsations of uvula)
• Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
• Rosenbach's sign (pulsatile liver)
• Gerhardt's sign (enlarged spleen)
• Hill's sign - a ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AI. Considered to be an artefact of sphygmomanometric lower limb pressure measurement.
• Lincoln sign (pulsatile popliteal)
• Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)
• Ashrafian sign (Pulsatile pseudo-proptosis)

Unfortunately, none of the above putative signs of aortic insufficiency is of utility in making the diagnosis, but they may help as pointers. What is of value is hearing a diastolic murmur itself, whether or not the above signs are present.