Aortic Regurgitation in Emergency Medicine Clinical Presentation

  • Author: Jerry Balentine, DO; Chief Editor: David FM Brown, MD   more...
 
Updated: Dec 5, 2011
 

History

  • General
    • The clinical signs of aortic regurgitation are caused by forward and backward flow of blood across the aortic valve, leading to increased stroke volume.[3]
    • The degree of regurgitation is determined by the degree of valvular incompetence; left ventricular compliance; and end-ventricular, end-diastolic volume.
  • Acute aortic regurgitation: Symptoms are manifestations of cardiovascular collapse.[3]
    • Weakness
    • Severe dyspnea
    • Hypotension
    • Angina
  • Chronic aortic regurgitation
    • Exertional dyspnea
    • Nocturnal dyspnea
    • Orthopnea
    • Diaphoresis
    • Abdominal discomfort
    • Uncomfortable awareness of heartbeat
    • Palpitations
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Physical

  • The hallmark of aortic regurgitation/insufficiency is a high-pitched decrescendo diastolic murmur at the left sternal border after the second heart sound.[3]
  • Acute aortic regurgitation
    • Patients who have CHF or shock associated with severe aortic regurgitation often appear gravely ill.
    • Tachycardia
    • Peripheral vasoconstriction
    • Cyanosis
    • Pulmonary edema
    • Arterial pulsus alternans; normal left ventricular impulse
    • Early diastolic murmur (lower pitched and shorter than in chronic aortic regurgitation) may be present. An Austin-Flint murmur, which is caused by the regurgitant flow causing vibration of the mitral apparatus, is lower pitched and short in duration. The decrescendo diastolic murmur is heard best with the patient leaning forward in full expiration in a quiet room. It is the cardiac murmur most commonly missed.
    • A murmur at the right sternal border is associated more often with dissection than any other cause of aortic regurgitation.
  • Chronic aortic regurgitation
    • All auscultatory phenomena indicate vasodilatation of peripheral circulation.
    • Hyperdynamic apical impulse displaced laterally and inferiorly may be associated with an ejection click.
    • Decrescendo diastolic murmur is heard best while the patient is leaning forward on deep expiration.
    • Apical middiastolic rumble
    • Austin-Flint murmur
    • Pulsus bisferiens; increased pulse pressure; visible, forceful, and bounding peripheral pulses (water hammer)
    • Corrigan pulse - Quickly collapsing pulses
    • Musset sign - Bobbing of the head
    • Quincke sign - Capillary pulsations of the nail bed
    • Muller sign - Pulsations of the uvula
    • Hill sign - Systolic pressure in lower extremity greater than systolic pressure in upper extremity by at least 100 mm Hg
    • Traube sign - Loud systolic sound over femoral arteries
    • Duroziez sign - Systolic-diastolic murmur produced by compression of femoral artery with a stethoscope
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Causes

  • Multiple causes of this valvular abnormality are known, including connective tissue disease and anatomic abnormalities. Acute aortic regurgitation is usually due to aortic dissection, bacterial endocarditis, or trauma, which may be either penetrating or blunt.[2, 4, 5]
  • Acute aortic regurgitation
    • Rheumatic
    • Infective endocarditis
    • Ruptured sinus of Valsalva
    • Trauma, prosthetic valve surgery
    • Aortic dissection, laceration of the aorta
  • Chronic aortic regurgitation
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Contributor Information and Disclosures
Author

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Eric C Appelbaum, DO  Associate Medical Director, Ambulatory Care, Associate Director, Emergency Department, St Barnabas Hospital, Bronx

Eric C Appelbaum, DO, is a member of the following medical societies: American College of Osteopathic Emergency Physicians, American College of Osteopathic Internists, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne White, MD  Medical Director, Regional Poison Control Center at Children's Hospital, Program Director of Medical Toxicology, Associate Professor, Departments of Emergency Medicine and Pediatrics, Wayne State University School of Medicine

Suzanne White, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American College of Epidemiology, American College of Medical Toxicology, American Medical Association, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Gary Setnik, MD  Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Elizabeth Kassapidis, DO, to the development and writing of this article.

References

  1. Saura D, Peñafiel P, Martínez J, de la Morena G, García-Alberola A, Soria F, et al. [The frequency of systolic aortic regurgitation and its relationship to heart failure in a consecutive series of patients]. Rev Esp Cardiol. Jul 2008;61(7):771-4. [Medline].

  2. Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. 3rd ed. Philadelphia, Pa: Saunders; 1988.

  3. Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence?. Ann Intern Med. May 6 2003;138(9):736-42. [Medline].

  4. Giuliani E. Cardiology: Fundamentals and Practice. 2nd ed. Philadelphia, Pa: Mosby Year Book; 1991.

  5. Kloner R. The Guide to Cardiology. 2nd ed. New York: Le Jacq Communications; 1990.

  6. Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr. Apr 2010;11(3):223-44. [Medline].

  7. Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J. Jun 2008;155(6):1114-20. [Medline].

  8. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. Feb 16 2000;283(7):897-903. [Medline].

  9. Hwang MS, Chu JJ, Su WJ. Natural history and risk stratification of discrete subaortic stenosis in children: an echocardiographic study. J Formos Med Assoc. Jan 2004;103(1):17-22. [Medline].

  10. Tops LF, Kapadia SR, Tuzcu EM, Vahanian A, Alfieri O, Webb JG, et al. Percutaneous valve procedures: an update. Curr Probl Cardiol. Aug 2008;33(8):417-57. [Medline].

 
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