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The Rational Clinical Examination
Clinician's Corner
June 16, 1999

Does This Patient Have Aortic Regurgitation?

Author Affiliations

Author Affiliations: Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, University of Toronto and the University Health Network, Toronto, Ontario.


The Rational Clinical Examination Section Editors:David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.

JAMA. 1999;281(23):2231-2238. doi:10.1001/jama.281.23.2231

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 (κ=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.