A 25-year-old asymptomatic man is evaluated during a routine examination. His blood pressure is 150/40 mm Hg and his heart rate is 90/min. Estimated central venous pressure is normal. The carotid upstroke is brisk and collapses quickly. The apical impulse is displaced. A grade 3/6 high-pitched decrescendo diastolic murmur is heard at the second right intercostal space with radiation down the left sternal border. The murmur is heard best with the patient leaning forward and in end-expiration. There is evidence of nailbed pulsation. Femoral pulsations are full and collapse quickly. There is no change in the murmur with inspiration.
This patient most likely has aortic regurgitation. Physical findings of chronic aortic regurgitation may include cardiomegaly, tachycardia, a widened pulse pressure, a thrill at the base of the heart, a soft S1 and a sometimes absent aortic closure sound, and an S3 gallop. The characteristic high-pitched diastolic murmur begins immediately after S2 and is heard best at the second right or third left intercostal space with the patient leaning forward, and in end-expiration. Manifestations of the widened pulse pressure may include the Traube sign (pistol-shot sounds over the peripheral arteries), the de Musset sign (head bobs with each heartbeat), the Duroziez sign (systolic and diastolic murmur heard over the femoral artery), and the Quincke sign (systolic plethora and diastolic blanching in the nail bed with nail compression).
Mitral stenosis is associated with accentuation of P2 (evidence of elevated pulmonary arterial pressure), an opening snap (a high-pitched apical diastolic sound best heard with the diaphragm of the stethoscope) followed by a low-pitched, rumbling diastolic murmur best heard with the bell of the stethoscope at the apex with the patient in the left lateral decubitus position. Presystolic accentuation of the murmur may be present. As the severity of the stenosis worsens, the opening snap moves closer to S2 as a result of increased left atrial pressure, and the murmur increases in duration.
A small patent ductus arteriosus in an adult produces a continuous murmur that envelopes the S2 and is characteristically heard beneath the left clavicle. Patients with a moderate-sized patent ductus arteriosus may present with symptoms of heart failure, a continuous “machinery-type” murmur best heard at the left infraclavicular area, and bounding pulses with a wide pulse pressure.
Tricuspid valve regurgitation usually occurs as a secondary consequence of pulmonary hypertension, right ventricular chamber enlargement with annular dilatation, or endocarditis. The murmur of tricuspid regurgitation occurs during systole and is loudest at the lower left sternal border and becomes louder with inspiration.
- The characteristic high-pitched diastolic murmur of chronic aortic regurgitation begins immediately after S2 and is heard best with the patient leaning forward, and in end-expiration at the second right or third left intercostal space.