In chronic aortic regurgitation, visible cardiac and arterial pulsations are common due to the large stroke volume, and the carotid pulse can commonly be seen. The point of maximal impulse is displaced laterally and caudally due to LV dilation and hypertrophy. On auscultation, the typical murmur of aortic regurgitation is a soft, high-pitched, early diastolic decrescendo murmur heard best at the 3rd intercostal space on the left (Erb's point) on end expiration, with the patient sitting up and leaning forward.
This murmur is often difficult to distinguish from the Graham-Steele murmur of pulmonic insufficiency. If aortic root disease is the cause of the aortic regurgitation, the murmur will be heard best at the right upper sternal border and not at Erb's point. As aortic regurgitation worsens, the murmur becomes shorter in duration due to less time needed for LV and aortic pressure equalization.
In addition to the above murmur, a systolic ejection murmur may be present at the right upper sternal border simply due to the large stroke volume passing through the aortic valve with each LV systolic contraction. An early diastolic rumble may also be heard at the apex due to the regurgitant jet striking the anterior leaflet of the mitral valve causing it to vibrate. This murmur is termed the Austin-Flint murmur.
A widened pulse pressure is often present due to the high flow state, as previously described. When severe heart failure develops, the pulse pressure will decrease and the below listed peripheral signs of aortic regurgitation are lessened. A fourth heart sound develops when LV hypertrophy becomes severe and limits diastolic filling. A third heart sound is often present due to the increased early diastolic filling into a compliant, dilated LV.