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The Rational Clinical Examination | Clinician's Corner

Does This Patient Have Aortic Regurgitation?

Niteesh K. Choudhry, MD; Edward E. Etchells, MD, MSc
JAMA. 1999;281(23):2231-2238. doi:10.1001/jama.281.23.2231.
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Objective To review evidence as to the precision and accuracy of clinical examination for aortic regurgitation (AR).

Methods We conducted a structured MEDLINE search of English-language articles (January 1966-July 1997), manually reviewed all reference lists of potentially relevant articles, and contacted authors of relevant studies for additional information. Each study (n = 16) was independently reviewed by both authors and graded for methodological quality.

Results Most studies assessed cardiologists as examiners. Cardiologists' precision for detecting diastolic murmurs was moderate using audiotapes (κ=0.51) and was good in the clinical setting (simple agreement, 94%). The most useful finding for ruling in AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8-32.0 [95% confidence interval {CI}, 2.8-32 to 16-63] for detecting mild or greater AR and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 grade A studies). The most useful finding for ruling out AR is the absence of early diastolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater AR and 0.1 [95% CI, 0.0-0.3] for moderate or greater AR) (2 grade A studies). Except for a test evaluating the response to transient arterial occlusion (positive LR, 8.4 [95% CI, 1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display poor sensitivity and specificity for AR.

Conclusion Clinical examination by cardiologists is accurate for detecting AR, but not enough is known about the examinations of less-expert clinicians.

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Figure 1. Typical Location of Abnormal Diastolic Murmurs
Graphic Jump Location
There are 3 important areas to auscultate for diastolic murmurs. Area 1 is the second and third intercostal spaces at the right-sternal border. Area 2 is the second and fourth intercostal spaces at the left-sternal border. Aortic regurgitation murmurs may be heard in both areas 1 and 2. If the murmur is loudest in area 1, then the underlying cause of aortic regurgitation may be an ascending aortic aneurysm or aortic dissection. Pulmonic regurgitation murmurs are loudest in the superior part of area 2, and may radiate downward. The murmur of mitral stenosis and the Flint murmur of aortic regurgitation are best heard at the apex (area 3).
Figure 2. Selected Features of Diastolic Murmors
Graphic Jump Location
Diastolic murmurs are classified based on the time of onset of the murmur.15 An early diastolic murmur begins with the second heart sound (S2). Top, Early diastolic murmurs typically decrease in intensity (decrescendo) and disappear before the first heart sound (S1). In some cases, an early diastolic murmur can continue through diastole. Bottom, A mid-diastolic murmur begins clearly after S2 (in mitral stenosis, classically after an opening snap [OS]). A late diastolic (or presystolic) murmur begins in the interval immediately before S1. In mitral stenosis, the mid-diastolic murmur may merge with the late systolic murmur.



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