A 52-year-old woman with a history of acute rheumatic fever presents with dyspnea and a diastolic murmur. Echocardiography confirms severe aortic regurgitation. Regarding the pathophysiology and clinical consequences of chronic aortic regurgitation, all of the following are true EXCEPT:

Explanation

## Chronic Aortic Regurgitation: Hemodynamics and Clinical Features ### The EXCEPT Answer: Option B — Elevated Diastolic Blood Pressure **Key Point:** In chronic aortic regurgitation, the diastolic blood pressure is characteristically **DECREASED** (not elevated). Option B is therefore FALSE and is the correct "EXCEPT" answer. The hallmark hemodynamic finding in chronic AR is a **widened pulse pressure** resulting from: - **Elevated systolic BP** — due to the large combined (forward + regurgitant) stroke volume ejected into the aorta - **Decreased diastolic BP** — due to retrograde flow of blood back into the LV during diastole, causing the aortic diastolic pressure to fall | Hemodynamic Parameter | Chronic AR | |----------------------|------------| | Systolic BP | ↑ (increased stroke volume) | | Diastolic BP | ↓ (regurgitation into LV) | | Pulse pressure | ↑↑ (widened) | | LV end-diastolic volume | ↑↑ (volume overload) | **High-Yield:** A diastolic BP that is *elevated* would actually work against the regurgitant gradient and is not a feature of AR. Classic bedside signs of the wide pulse pressure include Corrigan's (water-hammer) pulse, Quincke's sign, and Hill's sign. ### Why the Other Options Are TRUE (and thus not the EXCEPT) 1. **Option A (TRUE):** In acute severe AR, the LV is non-compliant and its diastolic pressure rises rapidly, equalizing with aortic diastolic pressure early in diastole. This terminates the pressure gradient early, producing a **shorter and softer** murmur compared to chronic AR — a classic board trap. 2. **Option C (TRUE):** The early diastolic decrescendo murmur of AR is best heard at the **left lower sternal border (3rd–4th ICS)** with the patient **leaning forward** in held expiration — a well-established auscultatory technique (Harrison's Principles of Internal Medicine). 3. **Option D (TRUE):** Chronic volume overload in AR leads to **eccentric hypertrophy** — sarcomeres are added in series, causing chamber dilation with proportional wall thickening. This allows the LV to accommodate the large regurgitant volume (Robbins Pathologic Basis of Disease). ### Clinical Pearl: Bedside Signs of Chronic AR **Clinical Pearl:** The wide pulse pressure in chronic AR produces several eponymous signs: - **Corrigan's pulse** — bounding, collapsing pulse - **Quincke's sign** — visible nail-bed capillary pulsations - **Hill's sign** — popliteal systolic BP exceeds brachial by >60 mmHg - **de Musset's sign** — head bobbing with each heartbeat - **Duroziez's sign** — femoral artery to-and-fro murmur All of these reflect the combination of high systolic and **low** diastolic pressure — confirming that an *elevated* diastolic BP is incompatible with the pathophysiology of aortic regurgitation. *Reference: Harrison's Principles of Internal Medicine, 21st ed.; Robbins & Cotran Pathologic Basis of Disease, 10th ed.*