Review Question - QID 216606

This patient with a history of hypertension and new exertional dyspnea, widened pulse pressure (140 - 60 = 80 mmHg) and a diastolic decrescendo murmur along the left sternal border is most likely presenting with aortic regurgitation.

Aortic regurgitation is characterized by a high-pitched, decrescendo diastolic murmur. The location of the murmur depends on the cause of aortic regurgitation. In valvular disease, the murmur is best auscultated in the left 3rd and 4th intercostal spaces and along the left sternal border. In aortic root disease, the murmur is best heard along the right sternal border. The murmur is best heard when the patient leans forward, and it increases in intensity with increased afterload, such as with the squatting and handgrip maneuvers which increase afterload and thus regurgitation. Aortic regurgitation is diagnosed by echocardiogram, which would reveal valvular dysfunction and/or aortic root dilation. Treatment is with aortic valve replacement.

Akinseye et al. review the presentation and management of aortic regurgitation. They outline several signs of chronic severe aortic regurgitation, including the de Musset sign and water-hammer pulse. They recommend surgical treatment in severe cases.

Incorrect Answers:
Answer 2: Aortic stenosis presents with a systolic, not diastolic, crescendo-decrescendo murmur that radiates to the neck. It also presents with “pulsus parvus et tardus” referring to a weak and delayed carotid upstroke. Patients will present with syncope, angina, and dyspnea. Treatment is with valvuloplasty or valve replacement.

Answer 3: Mitral stenosis presents with an opening snap and late diastolic rumble best auscultated at the apex of the heart, in the left lateral decubitus position. It does not present with widened pulse pressure. Patients will present with dyspnea and fatigue. Treatment is with valvuloplasty or valve replacement.

Answer 4: Pulmonic regurgitation presents with an early diastolic murmur best auscultated over the left 2nd and 3rd intercostal spaces. The murmur does not typically accentuate when the patient is leaning forward; rather, it increases with inspiration. Patients can present with peripheral edema and dyspnea. Treatment is with valve replacement.

Answer 5: Tricuspid stenosis presents with a rumbling, mid-diastolic murmur best auscultated over the left lower sternal border. It is a rare condition in developed countries and does not present with a widened pulse pressure. Patients can present with peripheral edema and dyspnea. Treatment is with valve replacement.

Bullet Summary:
Aortic regurgitation presents with a widened pulse pressure and a diastolic decrescendo murmur best heard when the patient is leaning forward.