From the Guidelines
Aortic regurgitation (AR) is characterized by a high-pitched, blowing, decrescendo diastolic murmur best heard at the left sternal border, while Mitral regurgitation (MR) produces a holosystolic murmur radiating to the axilla, Tricuspid regurgitation (TR) manifests as a holosystolic murmur at the lower left sternal border increasing with inspiration, and Pulmonary regurgitation (PR) creates a decrescendo diastolic murmur heard best at the left upper sternal border. The auscultatory findings of valvular regurgitation are crucial for diagnosis and are based on the timing, location, radiation, and respiratory variation of the murmurs.
- Aortic regurgitation (AR) presents with a diastolic regurgitant murmur, which may not always be audible in patients with mild or moderate AR, as noted in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1.
- Mitral regurgitation (MR) is identified by a holosystolic (pansystolic) murmur that radiates to the axilla, best heard at the apex with the patient in left lateral decubitus position.
- Tricuspid regurgitation (TR) is characterized by a holosystolic murmur at the lower left sternal border that increases with inspiration, known as a positive Carvallo's sign.
- Pulmonary regurgitation (PR) produces a decrescendo diastolic murmur heard best at the left upper sternal border. These characteristic murmurs are a result of regurgitant blood flow creating turbulence as it moves backward through incompetent valves, and their distinction is vital for accurate diagnosis during physical examination, as further explained in the eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities 2. Additional findings such as S3 gallops in MR or wide pulse pressure in AR may accompany these murmurs, providing further diagnostic clues. It is essential to note that while auscultation is a valuable tool, its sensitivity for detecting AR, for instance, is relatively low (21%) compared to its high specificity (96%), highlighting the importance of combining physical examination with other diagnostic methods like echocardiography for accurate assessment 1.
From the Research
Auscultatory Findings of Valvular Regurgitation
The auscultatory findings of valvular regurgitation can be summarized as follows:
- Aortic Regurgitation (AR): characterized by a diastolic murmur best heard at the left sternal border or over the right second intercostal space 3
- Mitral Regurgitation (MR): typically presents with a systolic murmur, often described as a late systolic click-murmur, best heard at the apex 4
- Tricuspid Regurgitation (TR): usually presents with a systolic murmur, which can be heard over the left lower sternal border or over the xiphoid process 5, 3, 6, 7
- Pulmonary Regurgitation (PR): often characterized by a diastolic murmur, which can be heard over the left upper sternal border 3
Key Features of Valvular Regurgitation
Some key features of valvular regurgitation include:
- The presence of TR is associated with higher mortality in patients with severe AR 3
- Concomitant MR and TR are frequently present in patients with aortic stenosis (AS) and are associated with poor outcomes 5
- The severity of TR is associated with higher rates of morbidity and mortality after aortic valve replacement (AVR) 7
- Correction of TR at the time of surgical AVR can improve long-term outcomes 7