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ULY CLINIC

25 Septemba 2025, 01:08:24

Hill’s sign

Hill’s sign refers to a femoral systolic pulse pressure that is 60–100 mmHg higher in the right leg than in the right arm. It is a peripheral vascular sign of severe aortic regurgitation (aortic insufficiency).

Pathophysiology

In aortic regurgitation, the incompetent aortic valve allows blood to flow back into the left ventricle during diastole, leading to:
- Increased stroke volume to compensate.
- High systolic pressure due to increased ejection.
- Low diastolic pressure due to regurgitation.
The result is a widened pulse pressure, which is more pronounced in the lower extremities because of arterial amplification.
The difference in systolic pressure between the arm and leg becomes marked (>60 mmHg) in severe cases.

Examination Technique

Position the patient supine.
Use an appropriately sized cuff for both arm and thigh measurements.
Measure systolic and diastolic BP in the right arm.
Measure systolic and diastolic BP in the right leg (femoral artery region).
Compare results:
- A difference of >60–100 mmHg in systolic pressure between the leg and arm = positive Hill’s sign.

Clinical Features

Feature	Description
Key finding	Femoral systolic BP 60–100 mmHg higher than brachial
Associated cardiac murmur	Early diastolic, decrescendo murmur of AR
Peripheral findings	Bounding “water hammer” pulse, wide pulse pressure
Related signs of AR	Corrigan’s pulse, Quincke’s sign, Duroziez’s sign

Differential Diagnosis

Condition	Finding	Difference from Hill’s Sign
Normal physiologic difference	10–20 mmHg higher in leg	Much smaller difference than in AR
Peripheral arterial disease	Lower leg BP compared to arm	Opposite to Hill’s sign
Coarctation of aorta	Lower BP in legs than arms	Opposite gradient
Severe hypertension	High systolic pressures	Equal in arm and leg, not discrepant

Pediatric considerations

Rarely assessed in children; AR is uncommon in pediatrics.
In congenital heart disease with aortic regurgitation, Hill’s sign may still be present but is not routinely used in practice.

Geriatric considerations

In older patients with atherosclerosis, differences in BP between limbs may be due to arterial stiffness or occlusive disease, potentially confounding interpretation.
Always correlate with clinical context and echocardiography.

Limitations

Requires accurate cuff size and technique — errors can exaggerate or mask the difference.
May be absent in patients with severe peripheral arterial disease.
Not entirely specific — best used alongside other clinical signs and echocardiography.

Patient counseling

Explain that this test helps assess heart valve function.
Emphasize that it is a supportive sign, not a definitive diagnosis.
Reassure that further evaluation with echocardiography is essential to confirm severity.

Conclusion

Hill’s sign is a valuable clinical indicator of severe aortic regurgitation, identified when femoral systolic BP significantly exceeds brachial pressure. While useful at the bedside, it must be interpreted cautiously, considering potential confounders such as peripheral vascular disease.

References

Babu AN, Gross CM. Peripheral signs of aortic regurgitation: historical and current perspectives. Tex Heart Inst J. 2009;36(6):558–559.
Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia: Elsevier; 2019.
Perloff JK. Physical Examination of the Heart and Circulation. 4th ed. Philadelphia: Saunders; 2009.
Kumar P, Clark M. Kumar and Clark’s Clinical Medicine. 10th ed. Edinburgh: Elsevier; 2020.