Aortic insufficiency results from rheumatic fever, syphilis, hypertension, endocarditis, or trauma. In some patients, it may be idiopathic.

Left ventricular failure usually occurs. The patient may develop fatal pulmonary edema if a fever, infection, or cardiac arrhythmia develops. The patient also risks myocardial ischemia because left ventricular dilation and elevated left ventricular systolic pressure alter myocardial oxygen requirements.

In chronic severe aortic insufficiency, the patient may complain that he has an uncomfortable awareness of his heartbeat, especially when lying down. He may report palpitations along with a pounding head.

Dyspnea may occur with exertion, and the patient may experience paroxysmal nocturnal dyspnea with diaphoresis, orthopnea, and cough. He may become fatigued and syncopal with exertion or emotion. He may also have a history of anginal chest pain unrelieved by sublingual nitroglycerin.

On inspection, you may note that each heartbeat seems to jar the patient’s entire body and that his head bobs with each systole. Inspection of arterial pulsations shows a rapidly rising pulse that collapses suddenly as arterial pressure falls late in systole. This is called a water-hammer pulse.

The patient’s nail beds may appear to be pulsating. If you apply pressure at the nail tip, the root will alternately flush and pale (called Quincke’s sign). Inspection of the chest may reveal a visible apical impulse. In left-sided heart failure, the patient may have ankle edema and ascites.

In palpating the peripheral pulses, you may note rapidly rising and collapsing pulses (pulsus biferiens). If the patient has cardiac arrhythmias, pulses may be irregular. You’ll be able to feel the apical impulse. (The apex will be displaced laterally and inferiorly.) A diastolic thrill probably will be palpable along the left sternal border, and you may be able to feel a prominent systolic thrill in the jugular notch and along the carotid arteries.

Auscultation may reveal an S₃, occasionally an S₄, and a loud systolic ejection sound. A high-pitched, blowing, decrescendo diastolic murmur is best heard at the left sternal border, third intercostal space. Use the diaphragm of the stethoscope to hear it, and have the patient sit up, lean forward, and hold his breath in forced expiration.