In acute disease, dyspnea is the most common presenting symptom, seen in 50 percent of patients. Many patients have acute pulmonary edema with pink frothy sputum. Patients may complain of fever and chills if endocarditis is the cause. Patients may present with systemic emboli or a persistent sinus tachycardia. Dissection of the ascending aorta typically produces a "tearing" chest pain that may radiate between the shoulder blades. Sudden death is common in patients with both acute and chronic aortic incompetence.
The two major causes of acute aortic incompetence present with different signs. Elevated temperature is common with acute endocarditis. ECG changes may be seen with aortic dissection, including ischemia or findings of acute inferior myocardial infarction, suggesting involvement of the right coronary artery. Patients commonly have signs of peripheral circulatory collapse, such as sweating, marked tachycardia, tachypnea, and rales. Classically there is a high-pitched blowing diastolic murmur heard immediately after S2, best heard in the right second or third intercostal parasternal area. There may be an S 3 with long diastolic murmurs, and there may be a systolic flow murmur. In the acute state, the chest radiograph demonstrates acute pulmonary edema with less cardiac enlargement than expected.
In the chronic state, about one-third of patients have palpitations associated with a large stroke volume and/or premature ventricular contractions. Frequently these sensations are noticed in bed. Patients may complain of stabbing chest pain, fatigue, or dyspnea. Two-thirds of patients have no symptoms for up to 20 years despite a hemodynamically significant lesion, defined as a diastolic blood pressure under 70 mmHg. Symptoms of left ventricular failure may occur late in the course of the disease and include dyspnea, pulmonary edema, ischemic chest pain, and sweating.
In the chronic state, signs include a wide pulse pressure with a prominent ventricular impulse, which may be manifested as head bobbing. "Water hammer pulse" may be noted; this is a peripheral pulse that has a quick rise in upstroke followed by a peripheral collapse. Other classic findings may include accentuated precordial apical thrust, pulsus biferiens, Duroziez sign (a to-and-fro femoral murmur), and Quincke pulse (capillary pulsations visible at the proximal nailbed, while pressure is applied at the tip). In chronic aortic incompetence, the ECG demonstrates LVH, and the chest radiograph shows LVH, aortic dilation, and possibly evidence of congestive heart failure.
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