A diastolic murmur at the left sternal border may be due to aortic insufficiency or to pulmonary hypertension (Graham Steell murmur). Aortic insufficiency is accompanied by the physical signs above. If the diastolic murmur is also heard at the right sternal border - it is likely to be due to aortic insufficiency. Conversely, if the diastolic murmur at the left sternal border is accompanied by a second heart sound that is louder at the left sternal border than at the right sternal border - pulmonary hypertension should be suspected.
Diagnosis by Auscultation
JAMA. 1999 Jun 16;281(23):2231-8.
The rational clinical examination. Does this patient have aortic regurgitation?
Choudhry NK, Etchells EE.
Department of Medicine, University of Toronto and the University Health Network, Ontario, Canada.
OBJECTIVE: To review evidence as to the precision and accuracy of clinical examination for aortic regurgitation (AR). METHODS: We conducted a structured MEDLINE search of English-language articles (January 1966-July 1997), manually reviewed all reference lists of potentially relevant articles, and contacted authors of relevant studies for additional information. Each study (n = 16) was independently reviewed by both authors and graded for methodological quality. RESULTS: Most studies assessed cardiologists as examiners. Cardiologists' precision for detecting diastolic murmurs was moderate using audiotapes (kappa = 0.51) and was good in the clinical setting (simple agreement, 94%). The most useful finding for ruling in AR is the presence of an early diastolic murmur (positive likelihood ratio [LR], 8.8-32.0 [95% confidence interval [CI], 2.8-32 to 16-63] for detecting mild or greater AR and 4.0-8.3 [95% CI, 2.5-6.9 to 6.2-11] for detecting moderate or greater AR) (2 grade A studies). The most useful finding for ruling out AR is the absence of early diastolic murmur (negative LR, 0.2-0.3 [95% CI, 0.1-0.3 to 0.2-0.4) for mild or greater AR and 0.1 [95% CI, 0.0-0.3] for moderate or greater AR) (2 grade A studies). Except for a test evaluating the response to transient arterial occlusion (positive LR, 8.4 [95% CI, 1.3-81.0]; negative LR, 0.3 [95% CI, 0.1-0.8]), most signs display poor sensitivity and specificity for AR. CONCLUSION: Clinical examination by cardiologists is accurate for detecting AR, but not enough is known about the examinations of less-expert clinicians.
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