20 mm Hg diff in popliteal and brachial systolic cuff pressures, seen in chronic severe AI.8. Lighthouse sign (blanching & flushing of forehead)9. Landolfi's sign (alternating constriction & dilatation of pupil)10. Becker's sign (pulsations of retinal vessels)11. Muller's sign (pulsations of uvula)12. Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)13. Rosenbach's sign (pulsatile liver)14. Gerhardt's sign (enlarged spleen)15. Lincoln sign (pulsatile popliteal)16. Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)17. Ashrafian sign (Pulsatile pseudo-proptosis).In many patients with pure AR or with combined AS and AR, the carotid arterial pulse is bisferiens, i.e., with two systolic waves separated by a troughsAuscultation# In patients with severe AR, the aortic valve closure sound (A2) is usually absent.# An S3 and systolic ejection sound are frequently audible, and occasionally an S4 also may be heard.# The murmur of chronic AR is typically a high-pitched, blowing, decrescendo diastolic murmur, heard best in the third intercostal space along the left sternal border.# "Cooing" or musical diastolic murmurs suggest eversion of an aortic cusp vibrating in the regurgitant stream.# A mid-systolic ejection murmur is frequently audible in isolated AR. It is generally heard best at the base of the heart and is transmitted along the carotid vessels.# A third murmur frequently heard in patients with severe AR is the Austin Flint murmur, a soft, low-pitched, rumbling mid-diastolic murmur. It is probably produced by the diastolic displacement of the anterior leaflet of the mitral valve by the AR stream but does not appear to be associated with hemodynamically significant mitral obstruction.# The auscultatory features of AR are intensified by strenuous handgrip, which augments systemic resistance.ECG# In patients with chronic severe AR, the ECG signs of LV hypertrophy become manifest.# In addition, these patients frequently exhibit ST-segment depression and T-wave inversion in leads I, aVL, V5, and V6 ("LV strain").# Left axis deviation and/or QRS prolongation denote diffuse myocardial disease, generally associated with patchy fibrosis, and usually signify a poor prognosis.Echocardiogram# The extent and velocity of wall motion are normal or even supernormal, until myocardial contractility declines.# A rapid, high-frequency fluttering of the anterior mitral leaflet produced by the impact of the regurgitant jet is a characteristic finding.0# Color flow Doppler echocardiographic imaging is very sensitive in the detection of AR, and Doppler echocardiography is helpful in assessing its severity.# With severe AR, the central jet width exceeds 65% of the left ventricular outflow tract, the regurgitant volume is 60 ml/ beat, the regurgitant fraction is 50%, and there is diastolic flow reversal in the proximal descending thoracic aorta.Chest X-RayIn chronic severe AR, the apex is displaced downward and to the left in the frontal projection. In the left anterior oblique and lateral projections, the LV is displaced posteriorly and encroaches on the spine.Aortic Regurgitation: TreatmentAcute Aortic RegurgitationPatients with acute severe AR may respond to intravenous diuretics and vasodilators (such as sodium nitroprusside), but stabilization is usually short-lived and operation is indicated urgently. Intra aortic balloon counterpulsation is contraindicated. Beta-blockers are also best avoided. Surgery is the treatment of choice.Chronic Aortic RegurgitationEarly symptoms of dyspnea and effort intolerance respond to treatment with diuretics, and vasodilators (ACE inhibitors, dihydropyridine calcium channel blockers, or hydralazine) may be useful as well. Surgery can then be performed in more controlled circumstances. Expert consensus is strong regarding the need to control systolic blood pressure (goal">