Aortic regurgitation: is diagnosed by an early diastolic murmur.

Clinical bottom line (level 1a)

  1. Cardiologists agree well about diastolic murmurs but non-cardiologists do not.
  2. 13% of elderly patients have aortic regurgitation.
  3. A typical early diastolic murmur makes moderate or greater aortic regurgitation more likely (LR+8.3) , and the absence of one less likely (LR-0.1) .
  4. A Flint murmur makes AR much more likely (LR+25) .
  5. A popliteal-brachial gradient > 20 mmHg (LR+8.4) or a murmur that increases in intensity on arterial occlusion makes AR more likely (LR+8.2) .
Choudhry and Etchells: Journal of the American Medical Association 1999; 281: 2231-2238
Expires November 2003

The study

Systematic review of all diagnostic studies of
  • Patients: cardiology
  • Intervention: diastolic murmur
  • Outcome: aortic regurgitation


    • Articles found in English using Medline, 1966 to 1997 (search terms: ) and reviewing reference lists of potentially useful articles, and contacted authors of relevant studies for additional information.

    Selection criteria: by 2 independent reviewers: see above and below
    Appraisal criteria: by 2 independent reviewers - detailed in text based on independent blinded reference standard, consecutive patients and number of patients enrolled
    Articles excluded if:
    • review articles
    • patients younger than 18 years
    • less than 20 participants
    • involved prosthetic heart valves
    • no clinical examination reported or performed
    • no acceptable reference standard (Doppler echocardiography or cardiac catheterization)


    16 studies were found.

    The evidence


    diagnostic test moderate or greater aortic regurgitation mild or no aortic regurgitation LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    typical early diastolic murmur (level 1b) 8.3
    (6.2 to 11)     		55% 0.1
    (0.0 to 0.2)     		1%
    Flint murmur (low-pitched late diastolic apical murmur) (level 4) 25
    (2.8 to 240)     		79% 0.5
    (0.2 to 0.7)     		7%
    popliteal brachial gradient > 20 mmHg (level 4) 8.2
    (1.5 to 78)     		55% 0.2
    (0.1 to 0.5)     		3%
    transient arterial occulusion increases the murmur intensity (level 4) 8.4
    (1.3 to 81)     		56% 0.3
    (0.1 to 0.8)     		4%
    total

    • Peripheral haemodynamic signs are rarely found in patients with aortic regurgitation and are not clearly help in diagnosing it.
    • pre-test probability of aortic regurgitation in elderly patients: 13%
    • interobserver agreement
      • cardiologists listening to audiotapes: K 0.51
      • cardiologists: simple agreement 94%
      • non-cardiologists: simple agreement 78%
      Few non-cardiologists correctly identify diastolic murmurs - in one study only 20% of residents and medical students identified AR on an audiotape, and 10% detected mitral regurgitation.

    Comments

    1. By limiting the search to English, important articles may have been missed.

    Citation

    1. Choudhry NK, and Etchells EE: Does this patient have aortic regurgitation?. Journal of the American Medical Association 1999; 281: 2231-2238
    Search Terms:
    Contributor: Chris Ball and Musab Hayatli, November 1999
    Reviewer: William Rhoton

    Clinical Question.
    Patient cardiology
    Intervention or Exposure diastolic murmur
    Outcome aortic regurgitation