Today's physical exam rounds were on aortic insufficiency. Some key points:
May be caused by disease involving aortic leaflets or root.
Valvular: Calcific (some element of AI in 75% or pts with AS); endocarditis, trauma (ascending aortic tear), rheumatic disease.
Root: Age-related, cystic medial necrosis (isolated or with Marfan's), bicuspid valve, syphilis, ank spond, Behcet's, psoriatic, UC
Regardless of etiology, AI causes dilation and hypertrophy of LV +/- LA.
Compensation is by increased LVEDV (and therefore pressure, to decrease regurgitant volume, and also by tachycardia because it reduces diastolic time (and regurgitant volume)
Compensation is by increased LVEDV (and therefore pressure, to decrease regurgitant volume, and also by tachycardia because it reduces diastolic time (and regurgitant volume)
Exam:
1) Peripheral: deMusset (head bobbing), Quinke's (capillary pulsations), Muller's (uvula), many others...
2) Vitals: High pulse pressure. With more severe disease, peripheral vasoconstriction can cause increase in diastolic pressure. Tachycardia may be present (compensatory). May see A-fib because of LA enlargement.
3) Pulses: "water hammer": abrupt distension and quick collapse (Corrigan's), esp radial with arm elevated. Traube's (pistol shot femorals- booming systolic sound over femoral), Duroziez (systolic murmur over femoral when proximally constricted and diastolic when distally)
4) JVP: No specific findings except possible A-fib from dilation (no a-wave in this case)
5) Palpation: apical impulse is diffuse and hyperdynamic. It is laterally and inferiorly displaced. May feel ventricular filling wave at apex
6) Heart sounds: S1 may be soft because of long PR. A2 may be normal or loud if root; soft if valve. S3 may be present from dilation
7) Murmurs: high frequency right after A2. Best heard with diaphragm with pt sitting up and leaning forward in end-expiration. If root/aorta, heard at RSB. If valve, LSB 3rd or 4th ICS (classically). Mid and late diastolic murmur (apical rumble) is Austin Flint. Caused by flow across mitral and reflux. MS murmur is different because OS is present and S1 is usually loud.
1) Peripheral: deMusset (head bobbing), Quinke's (capillary pulsations), Muller's (uvula), many others...
2) Vitals: High pulse pressure. With more severe disease, peripheral vasoconstriction can cause increase in diastolic pressure. Tachycardia may be present (compensatory). May see A-fib because of LA enlargement.
3) Pulses: "water hammer": abrupt distension and quick collapse (Corrigan's), esp radial with arm elevated. Traube's (pistol shot femorals- booming systolic sound over femoral), Duroziez (systolic murmur over femoral when proximally constricted and diastolic when distally)
4) JVP: No specific findings except possible A-fib from dilation (no a-wave in this case)
5) Palpation: apical impulse is diffuse and hyperdynamic. It is laterally and inferiorly displaced. May feel ventricular filling wave at apex
6) Heart sounds: S1 may be soft because of long PR. A2 may be normal or loud if root; soft if valve. S3 may be present from dilation
7) Murmurs: high frequency right after A2. Best heard with diaphragm with pt sitting up and leaning forward in end-expiration. If root/aorta, heard at RSB. If valve, LSB 3rd or 4th ICS (classically). Mid and late diastolic murmur (apical rumble) is Austin Flint. Caused by flow across mitral and reflux. MS murmur is different because OS is present and S1 is usually loud.
Evidence:
From JAMA "Does this Patient have Aortic Regurgitation?"
Most sensitive test (i.e. good for ruling out if absent):
Early diastolic murmur
Most specific test (i.e. good for ruling in if present):
Early diastolic murmur if heard by an expert (!)
None of the peripheral signs described above are very powerful in ruling in or out AI.
Of all of them, Hill's sign (SBP over 20mmHg higher in legs than arms) has highest positive LR and lowest negative LR.
Most sensitive test (i.e. good for ruling out if absent):
Early diastolic murmur
Most specific test (i.e. good for ruling in if present):
Early diastolic murmur if heard by an expert (!)
None of the peripheral signs described above are very powerful in ruling in or out AI.
Of all of them, Hill's sign (SBP over 20mmHg higher in legs than arms) has highest positive LR and lowest negative LR.
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