A systolic murmur is a common presentation of aortic regurgitation detected by echocardiography

Abstract

The clinical investigation of Heidenreich et al. 1 recognizing a systolic murmur as a common presentation of aortic regurgitation invites two comments. The authors find a "high prevalence" of the murmur in contradistinction to its "rare" inclusion as a physical sign of the disorder. This is quite erroneous. A systolic murmur is known to be always present in aortic regurgitation and this was emphasized in the first and unquestionably best description of the disease by Corrigan in 1832. 2 His paper quite remarkably details the symptoms, the sign of the bounding pulse (which subsequently bore his name), the murmur heard best at the base and into the carotid and subclavian arteries, and the accompanying thrill. Corrigan only gave passing acknowledgment to the regurgitant murmur, ascribing it to the more severe insufficiency, but paid particular attention to the ejection murmur and the ways of differentiating the murmur-related diagnosis from aortic stenosis, mitral regurgitation, and ascending aortic aneurysm, by observation of other clinical signs. He also explained the mechanism of the findings and reported an experiment, published in the Lancet, reproducing the murmur and the thrill in a bench model of insufficiency, 175 years before Heidenreich's similar explanation.He presented, in his paper, pictures of the various pathologies, discussed the age and sex distribution, the relationship to rheumatic fever, and the eventual outcome of left ventricular hypertrophy and dilatation. He even noted the clinical advantages of a fast heart rate to minimize the regurgitation and argued against the use of digitalis for this reason. There is virtually nothing left to discuss about aortic regurgitation after Corrigan's one paper.The second issue is a more contemporary one. Heidenreich states that finding a systolic murmur should prompt a more careful examination. Surely, all examinations, by cardiologists and noncardiologists alike, should be careful and, when properly taught, should begin with a review, visibly and palpably, of the pulse and of the heart size and sounds before the murmurs are even considered. If this were the case, even noncardiologists, like Corrigan, could diagnose aortic regurgitation without the need for echocardiography.Dennis Bloomfield, M.D.Staten Island, New York Author's reply:Dr. Bloomfield provides us with clear evidence that the systolic murmur of severe aortic regurgitation has been known since Corrigan's description in 1832. Our point is that the systolic murmur may be the only physical finding in patients with less than severe aortic regurgitation. We stand by our assertion that aortic regurgitation is rarely included in the differential diagnosis of an isolated systolic murmur. One could argue that there has been little objective data to justify the mention of aortic regurgitation alongside common causes of a systolic murmur such as aortic stenosis and mitral regurgitation. Unfortunately, Corrigan did not determine the prevalence, sensitivity, and specificity of his physical findings in a sa...