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Does This Patient Have Aortic Regurgitation?

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Does This Patient Have Aortic Regurgitation? THE RATIONAL CLINICAL EXAMINATION Does This Patient Have Aortic Regurgitation? Niteesh K. Choudhry, MD Objective To review evidence as to the precision and accuracy of clinical examina- Edward E. Etchells, MD, MSc tion for aortic regurgitation (AR). Methods We conducted a structured MEDLINE search of English-language articles CLINICAL SCENARIO (January 1966-July 1997), manually reviewed all reference lists of potentially relevant You are asked to see a 59-year-old articles, and contacted authors of relevant studies for additional information. Each study woman with liver cirrhosis who will be (n = 16) was independently reviewed by both authors and graded for methodological undergoing sclerotherapy for esopha- quality. geal varices. When she was examined by Results Most studies assessed cardiologists as examiners. Cardiologists’ precision for her primary care physician, she had a detecting diastolic murmurs was moderate using audiotapes (k = 0.51) and was good pulse pressure of 70 mm Hg. The pri- in the clinical setting (simple agreement, 94%). The most useful finding for ruling in mary care physician is concerned about AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8- the possibility of aortic regurgitation 32.0 [95% confidence interval {CI}, 2.8-32 to 16-63] for detecting mild or greater AR (AR) and asks you whether endocardi- and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 tis prophylaxis is necessary for sclero- grade A studies). The most useful finding for ruling out AR is the absence of early di- astolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater therapy. You conduct a complete physi- AR and 0.1 [95% CI, 0.0-0.3] for moderate or greater AR) (2 grade A studies). Except cal examination and hear no early for a test evaluating the response to transient arterial occlusion (positive LR, 8.4 [95% diastolic murmur in the third or fourth CI, 1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display poor sensitivity intercostal spaces at the left-sternal bor- and specificity for AR. der. You feel that the patient is unlikely Conclusion Clinical examination by cardiologists is accurate for detecting AR, but to have AR and that endocarditis pro- not enough is known about the examinations of less-expert clinicians. phylaxis is not needed. You suspect that JAMA. 1999;281:2231-2238 www.jama.com the wide pulse pressure is a peripheral hemodynamic consequence of cirrho- creased in recent years. It is estimated ing blood viscosity, blood flow veloc- sis, not AR. The primary care physi- that 2% of the general population un- ity and turbulence, the distance between cian, however, wonders whether the pro- dergoes noninvasive cardiac diagnos- the vibrations and the stethoscope, the cedure should be delayed until an tic evaluation annually.3 If a careful angle at which the vibrations meet the echocardiogram can be obtained. clinical examination can exclude the stethoscope, the transmission quali- presence of AR, then there would be no ties of the tissue between the vibra- WHY IS THE CLINICAL need to proceed with further cardiac tion and the stethoscope, and the au- EXAMINATION IMPORTANT evaluation. ditory capabilities of the examiner.5 IN EVALUATING FOR AR? Aortic regurgitation is a potentially se- Anatomical and Physiological How to Examine for AR rious cardiac abnormality that may be Origins of Diastolic Murmurs A complete clinical history and physi- caused by important underlying disor- The cardinal manifestation of AR is a cal examination are essential in the ders. Patients with AR require careful diastolic murmur. Diastolic murmurs Author Affiliations: Division of General Internal Medi- clinical monitoring to identify the op- are important indicators of structural cine and Clinical Epidemiology, Department of Medi- timal time for surgical intervention. cardiac abnormalities or pathological cine, University of Toronto and the University Health Asymptomatic patients with severe AR states of increased flow (TABLE 1). As Network, Toronto, Ontario. 1 Corresponding Author: Edward E. Etchells, MD, MSc, may benefit from vasodilator therapy. discussed in a previous article in this University Health Network, 200 Elizabeth St, eng- Endocarditis prophylaxis may be indi- series,4 heart murmurs are produced 248, Toronto, Ontario, Canada M5G 2C4 (e-mail: [email protected]). cated for patients with AR who are un- when turbulent blood flow causes pro- The Rational Clinical Examination Section Editors: dergoing various procedures.2 longed auditory vibrations of cardiac David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, The use of noninvasive cardiac test- structures. The intensity of the mur- Durham, NC; Drummond Rennie, MD, Deputy Edi- ing, such as echocardiography, has in- mur depends on many factors, includ- tor (West), JAMA. ©1999 American Medical Association. All rights reserved. JAMA, June 16, 1999—Vol 281, No. 23 2231 Downloaded from www.jama.com at University of Florida, on May 24, 2005 AORTIC REGURGITATION evaluation of patients with a diastolic The precision and accuracy of many systolic murmurs but may also be used murmur. A diastolic murmur in a pa- individual components of the examina- to describe diastolic murmurs. A grade tient with renal failure and volume over- tion for AR, including all of the cardiac 1 murmur is not heard immediately on load will have different significance than history and most of the physical exami- auscultation, but is heard after the ex- a diastolic murmur in a patient with a nation, have not been adequately evalu- aminer focuses for a few seconds. Grade history of rheumatic fever and atrial fi- ated. This article will focus on aspects 2 murmurs are heard immediately on brillation. of the cardiac physical examination that auscultation but are softer than the loud The examiner’s ability to detect a di- have been sufficiently assessed for pre- grade 3. Grade 4 murmurs are associ- astolic murmur can be undermined by cision or accuracy. ated with a palpable precordial vibra- environmental factors such as noisy tion called a thrill. (Grade 5 and 6 mur- rooms, examiner factors such as fa- Cardiac Auscultation murs are also associated with a thrill. A tigue or haste, and patient factors such During routine auscultation, the ex- grade 5 murmur is audible when only as dyspnea or tachycardia.6 If examin- aminer attempts to detect a diastolic 1 edge of the stethoscope is on the chest, ing conditions are not optimal, the ex- murmur. Diastole is the period that be- and a grade 6 murmur is audible with amination should be repeated when gins with the closure of the aortic and the entire stethoscope lifted off the conditions improve. pulmonic valves (second heart sound chest.) [S2]) and ends with the closure of the The typical murmur of AR is an early mitral and tricuspid valves (first heart Table 1. Selected Causes of Diastolic diastolic, decrescendo blowing sound Murmurs sound [S1]). A common maneuver used (Figure 2), which may be accentuated to identify diastole is to palpate the ca- Abnormal cardiac structure with the patient sitting upright and lean- Aortic regurgitation rotid artery pulse during auscultation; 9 ing forward. In some cases, S2 can be Mitral stenosis S is synchronous with the carotid ar- Pulmonic regurgitation 1 obscured by the murmur. Most AR mur- Tricuspid stenosis tery pulsation while S2 follows the pulse. murs are high pitched and are best heard Atrial myxoma A diastolic murmur is a diastolic sound Ventricular septal defect* with the diaphragm of the stethoscope Atrial septal defect* longer than a heart sound. Examiners placed firmly on the chest wall. Some AR Mitral regurgitation* should describe the grade, location of murmurs are low pitched and are bet- Normal cardiac structure, increased flow IGURE Renal failure with volume overload maximal intensity (F 1), timing ter heard with the bell of the stetho- Thyrotoxicosis (FIGURE 2), duration, pitch, and radia- scope placed lightly on the chest wall. Anemia tion of the murmur. Sepsis For example, the AR murmur associ- The Levine grading system,7 with Diastolic murmurs are caused by abnormally increased ated with endocarditis and a fenes- * 8 diastolic flow across the mitral or tricuspid valves. slight modifications, was developed for trated aortic valve can be low pitched. The examiner should apply the stetho- Figure 1. Typical Location of Abnormal Diastolic Murmurs scope to the chest wall in the third or Figure 2. Selected Features of Diastolic Murmors 1 S S 2 2 1 S2 OS S1 Diastolic murmurs are classified based on the time of 15 3 onset of the murmur. An early diastolic murmur be- gins with the second heart sound (S2). Top, Early di- astolic murmurs typically decrease in intensity (decre- scendo) and disappear before the first heart sound (S1). In some cases, an early diastolic murmur can con- There are 3 important areas to auscultate for diastolic murmurs. Area 1 is the second and third intercostal spaces tinue through diastole. Bottom, A mid-diastolic mur- at the right-sternal border. Area 2 is the second and fourth intercostal spaces at the left-sternal border. Aortic mur begins clearly after S2 (in mitral stenosis, classi- regurgitation murmurs may be heard in both areas 1 and 2. If the murmur is loudest in area 1, then the un- cally after an opening snap [OS]). A late diastolic (or derlying cause of aortic regurgitation may be an ascending aortic aneurysm or aortic dissection. Pulmonic re- presystolic) murmur begins in the interval immedi- gurgitation murmurs are loudest in the superior part of area 2, and may radiate downward. The murmur of ately before S1.
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