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Page 14 of 24 Rao. Vessel Plus 2022;6:22 https://dx.doi.org/10.20517/2574-1209.2021.105

Table 6. Causes of early diastolic murmurs. Modified from Rao [5]

Aortic regurgitation
Pulmonary regurgitation
Pulmonary hypertension (Graham-Steel murmur)

Figure 3. Artist’s rendition of diastolic murmurs classifying into: (1) early (top); (2) mid (middle); and (3) late or pre-systolic (bottom)
[5]
diastolic murmurs are illustrated. Modified from Rao .
examination are helpful in coming up with a diagnosis.

Aortic regurgitation
Early diastolic murmurs of aortic regurgitation (AR) have a decrescendo character and are auscultated at
the RUSB and LMSBs. The murmur has a high pitch and is auscultated better with the stethoscope’s
diaphragm. The murmur begins with the aortic component of the 2nd sound (Figure 3; top) and is better
auscultated when the patient sits up, leans forward, and holds the breath at end-expiration. It may transmit
inferiorly to the LLSB. The LV impulse is typically prominent. Diastolic thrills are rarely felt. Generally,
there are no abnormal cardiac sounds. If the AR is due to a bicuspid aortic valve, an aortic systolic click is
auscultated. A systolic ejection murmur is heard at upper right or at mid left sternal borders; this may be
related to the increased amount of blood that has to be pumped back via the aortic valve and not due to
additional AS [Figure 4]. Alternatively, the systolic component may be due to associated aortic valve
stenosis.

An Austin-Flint type of mid-diastolic murmur may be appreciated at the apex (please review the discussion
in the section on mid-diastolic murmurs). In mild AR cases, the peripheral pulses are normally felt. But they
are amplified and “bounding” in patients with moderate and severe AR. The pulse pressure is increased
because of increased systolic blood pressure with concurrently decreased diastolic pressure. Peripheral signs
of AR such as water-hammer pulse (quick increase and decrease of pulse when palpating the forearm),
Corrigan’s pulse (strikingly augmented carotid pulses), Duroziez’s murmur [bruits (both systolic and
diastolic) auscultated in the femoral artery region while it is partly blocked], pistol shot (Traube’s) sounds,