Physical Examination Maneuvers to Elicit Aortic Regurgitation and Aortic Stenosis Murmurs
For aortic regurgitation (AR), have the patient sit up, lean forward, and hold their breath in full expiration while listening at the left sternal border; for aortic stenosis (AS), the murmur is best heard during expiration and increases in intensity after a premature ventricular beat or with amyl nitrite inhalation. 1, 2, 3
Aortic Regurgitation Maneuvers
Optimal Positioning
- Patient sitting up and leaning forward in full expiration is the classic position to accentuate the AR murmur at the left sternal border (3rd-4th intercostal space)
- The diastolic murmur becomes louder during expiration as left-sided murmurs typically do 1, 2, 4
Dynamic Maneuvers That Increase AR Murmur Intensity
Handgrip exercise (isometric exercise): The AR murmur increases with sustained handgrip because this maneuver increases afterload and systemic vascular resistance, thereby increasing the regurgitant volume across the incompetent aortic valve 1, 2, 3. This has 68% sensitivity and 92% specificity for detecting regurgitant murmurs 5.
Transient arterial occlusion: Inflate blood pressure cuffs on both arms to 20-40 mm Hg above systolic pressure for 20 seconds. This augments AR murmurs by acutely increasing afterload 1, 2, 3, 4, 3. This maneuver has excellent specificity (100%) and 78% sensitivity for left-sided regurgitant murmurs 5, 6.
Squatting: Brisk squatting increases venous return and afterload, making most murmurs louder including AR 1, 2, 3. Passive leg raising produces similar results.
Dynamic Maneuvers That Decrease AR Murmur Intensity
Amyl nitrite inhalation: During the initial hypotensive phase after amyl nitrite inhalation, the AR murmur decreases due to reduced afterload and decreased regurgitant volume 1, 2, 3, 4, 3. This has 80% sensitivity and 90% specificity for identifying regurgitant murmurs 5.
Standing: Most murmurs diminish with standing, including AR 1, 2, 3.
Valsalva maneuver: The AR murmur decreases during the strain phase due to reduced venous return and cardiac output 1, 2, 3, 4, 3.
Aortic Stenosis Maneuvers
Optimal Positioning
- Listen at the 2nd right intercostal space with radiation to the carotids
- The AS murmur is typically louder during expiration 1, 2
Dynamic Maneuvers That Increase AS Murmur Intensity
Post-premature ventricular beat or long R-R interval in atrial fibrillation: The AS murmur increases in the beat following a PVC or after a long cycle length because semilunar valve murmurs augment with increased stroke volume from enhanced ventricular filling 1, 2, 3, 4, 3. This distinguishes AS from mitral regurgitation, which does not change or decreases.
Amyl nitrite inhalation: During the initial hypotensive phase, the AS murmur paradoxically increases due to increased stroke volume despite reduced afterload 1, 2, 3, 4, 3. This is the opposite response to regurgitant murmurs and helps differentiate AS.
Exercise (handgrip or isotonic): Murmurs caused by flow across stenotic valves become louder with both isometric and isotonic exercise 1, 2, 3.
Squatting: The AS murmur increases with brisk squatting due to increased venous return and stroke volume 1, 2, 3.
Dynamic Maneuvers That Decrease AS Murmur Intensity
Valsalva maneuver: The AS murmur decreases during the strain phase (unlike hypertrophic cardiomyopathy, which increases) 1, 2, 3, 4, 3. This is critical for differentiating valvular AS from hypertrophic obstructive cardiomyopathy.
Standing: The AS murmur diminishes with standing 1, 2, 3.
Key Differentiating Features
Distinguishing AS from Hypertrophic Cardiomyopathy
The Valsalva maneuver is the most useful: AS murmur decreases while HCM murmur increases (65% sensitivity, 96% specificity for HCM) 1, 3, 5. Similarly, squatting-to-standing increases HCM (95% sensitivity, 84% specificity) but decreases AS 5.
Distinguishing AR from Mitral Stenosis
When evaluating an Austin-Flint murmur (the diastolic rumble of severe AR that mimics mitral stenosis), amyl nitrite helps differentiate: the Austin-Flint murmur decreases while true mitral stenosis increases during the tachycardia phase 1, 2, 3, 4, 3.
Clinical Pearls
- Respiration matters: Right-sided murmurs increase with inspiration; left-sided murmurs (AR and AS) increase with expiration 1, 2, 4, 3
- The combination of maneuvers is more accurate than any single maneuver for diagnosis 5
- Transient arterial occlusion is highly specific for regurgitant lesions and does not augment stenotic murmurs 1, 2, 6
- In elderly patients with severe AS, the typical parvus et tardus pulse may be absent due to vascular aging 2, 3