Clinical Features

• Sudden, severe dyspnea

• Rapid cardiac decompensation secondary to heart failure

• Pulmonary edema

• Symptoms related to underlying disease (e.g., fever due to endocarditis, chest pain due to aortic dissection)

Auscultation

• Soft S1

• Soft and short early diastolic murmur

• May be asymptomatic for up to decades despite progressive LV dilation

• Palpitations

• Symptoms of high pulse pressure

  • Water hammer pulse of peripheral arteries characterized by rapid upstroke and downstroke

  • Corrigan pulse: pulse of carotid arteries characterized by rapid upstroke and downstroke

  • Traube sign: pistol shot-like sounds heard over the femoral artery on auscultation

  • Duroziez sign: to-and-fro bruit over the femoral artery that is heard when slight pressure is applied with a stethoscope

  • Quincke sign: visible capillary pulse when pressure is applied to the tip of a fingernail

  • De Musset sign: rhythmic nodding or bobbing of the head in synchrony with heartbeats

• Symptoms of left heart failure

  • Exertional dyspnea

  • Angina

  • Orthopnea

  • Easy fatigability

  • Syncope

• Point of maximal impulse (PMI): diffuse, hyperdynamic, and displaced inferolaterally

• S3

• High-pitched, blowing, decrescendo early diastolic murmur

  • AR due to valvular disease: heard best in the left third and fourth intercostal spaces and along the left sternal border (Erb point)

  • AR due to aortic root disease (e.g., aortic dissection): heard best along the right sternal border

  • Worsens with squatting and handgrip

• Austin Flint murmur

  • Rumbling, low-pitched, middiastolic or presystolic murmur heard best at the apex

  • Caused by regurgitant blood striking the anterior leaflet of the mitral valve, which leads to premature closure of the mitral leaflets

• In more severe stages, possibly a harsh, crescendo-decrescendo midsystolic murmur that resembles the ejection murmur heard in aortic stenosis

• See also “Auscultation in valvular defects.”