What are the peripheral signs of aortic regurgitation?

Peripheral Signs of Aortic Regurgitation

The peripheral signs of aortic regurgitation include exaggerated arterial pulsations, low diastolic blood pressure, wide pulse pressure, bounding pulses, and specific eponymous signs such as de Musset's sign, Quincke's sign, and Austin-Flint murmur. 1

Key Peripheral Manifestations

Arterial Pulse Abnormalities

• Bounding pulses (water-hammer or Corrigan's pulse): Characterized by rapid rise and fall of the arterial pulse 2
• Wide pulse pressure: Due to elevated systolic pressure and decreased diastolic pressure 2
• Bisferiens pulse: Double-peaked pulse often palpable in severe AR

Blood Pressure Findings

• Low diastolic pressure: Often below 60 mmHg in significant AR
• Elevated systolic pressure: Due to increased stroke volume
• Wide pulse pressure: The difference between systolic and diastolic pressures exceeds 40 mmHg 1

Classic Eponymous Signs

1. de Musset's sign: Rhythmic head nodding with each heartbeat
2. Quincke's sign: Visible capillary pulsations in the nail beds when light pressure is applied
3. Duroziez's sign: Systolic and diastolic murmurs heard when the femoral artery is partially compressed
4. Traube's sign (pistol shot sounds): Booming systolic and diastolic sounds heard over the femoral artery
5. Hill's sign: Popliteal systolic pressure exceeding brachial pressure by >60 mmHg
6. Müller's sign: Visible pulsations of the uvula
7. Mayne's sign: Marked decrease in diastolic pressure with arm elevation

Auscultatory Findings

• Austin-Flint murmur: A mid-to-late diastolic rumbling murmur at the apex, resembling mitral stenosis but caused by the regurgitant jet impinging on the anterior mitral leaflet 1
• Early diastolic decrescendo murmur: Best heard at the left sternal border with patient leaning forward and breath held in expiration
• Third heart sound: Often present due to volume overload 1

Differences Between Acute and Chronic AR

Acute AR

• Peripheral signs are often attenuated or absent despite severe regurgitation 1
• Poor functional tolerance with symptoms of pulmonary edema and hypotension 2
• Tachycardia is common as a compensatory mechanism
• Narrow pulse pressure compared to chronic AR

Chronic AR

• Prominent peripheral signs due to adaptive mechanisms 1
• Exaggerated arterial pulsations more evident
• Wide pulse pressure more pronounced
• LV dilation and hypertrophy develop over time

Clinical Significance and Diagnostic Value

The peripheral signs of AR are most useful in:

• Identifying the presence of significant AR when combined with auscultatory findings
• Estimating the chronicity of the regurgitation (prominent signs suggest chronic AR)
• Monitoring disease progression over time

However, these signs have limitations:

• They may be less evident in acute AR despite its severity and urgency 1
• They can be attenuated in patients with heart failure or reduced cardiac output
• Some signs may be present in other high-output states (anemia, thyrotoxicosis)

Correlation with Imaging

While peripheral signs are helpful clinical indicators, definitive assessment requires echocardiography to:

• Confirm the diagnosis and quantify severity
• Determine the etiology of AR
• Assess LV dimensions and function
• Evaluate the aortic root and ascending aorta 1

The presence of multiple peripheral signs generally correlates with moderate to severe AR on echocardiography, but imaging remains essential for accurate assessment and management decisions.