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Aortic regurgitation
A 50-year-old woman has increasing breathlessness on exertion. The pulse is 82 and collapsing, blood pressure 165/48 mmHg, and the apex beat is displaced and heaving. There is a soft early diastolic murmur at the left sternal edge, best heard with the patient sitting forward in held expiration. What is the diagnosis?
- A. Mitral stenosis
- B. Patent ductus arteriosus
- C. Severe aortic stenosis
- correctD. Chronic aortic regurgitation
Explanation
Key fact
A wide pulse pressure with a collapsing pulse and an early diastolic murmur is aortic regurgitation. The wide pulse pressure is the giveaway.
Chronic aortic regurgitation. Blood runs back into the ventricle in diastole, so the diastolic pressure falls and the pulse collapses.
Why
The pulse pressure is 165 minus 48, which is 117 mmHg - grossly widened.
Regurgitant flow in diastole drains the aorta, dropping the diastolic pressure.
The ventricle then ejects a large stroke volume, raising the systolic pressure.
That rapid rise and fall is the collapsing or water-hammer pulse.
The murmur is early diastolic, high-pitched and best heard leaning forward in expiration.
Volume overload displaces the apex and makes it heaving.
A wide pulse pressure is the diastolic leak made visible
Why not the others
- A. Mitral stenosis — gives a mid-diastolic murmur with a presystolic accentuation at the apex, a tapping apex beat and a loud first heart sound - not a collapsing pulse.
- B. Patent ductus arteriosus — also widens the pulse pressure, but the murmur is continuous and machinery-like below the left clavicle, not confined to diastole.
- C. Severe aortic stenosis — gives a narrow pulse pressure and a slow-rising pulse, with an ejection systolic murmur radiating to the carotids.
Remember
Wide pulse pressure with a diastolic murmur equals aortic regurgitation. Narrow pulse pressure with a systolic murmur equals aortic stenosis.
Go deeper
The eponymous signs all come from the same wide pulse pressure: Corrigan's neck pulsation, de Musset's head nodding, Quincke's nail bed pulsation, Traube's pistol shot femorals and Duroziez's murmur.
An Austin Flint murmur is a mid-diastolic rumble at the apex caused by the regurgitant jet striking the anterior mitral leaflet - not mitral stenosis.
Surgery is indicated for symptoms, or in asymptomatic severe regurgitation once the ejection fraction falls below 50% or the left ventricle dilates.
Acute aortic regurgitation is different: no time to dilate, so the pulse pressure is not wide and the patient is in shock - a surgical emergency.
Harrison's Principles of Internal Medicine, 22nd ed. (McGraw Hill, 2025).