Mitral Regurgitation in Emergency Medicine Clinical Presentation

  • Author: Daniel DiSandro, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Nov 1, 2010
 

History

  • Mitral regurgitation can be tolerated for many years.
  • The initial symptoms of dyspnea and fatigue can rapidly progress to orthopnea and paroxysmal nocturnal dyspnea.
  • Patients with anginal-type pain may have underlying ischemia.
  • Atypical chest pain can be associated with MVP syndrome.
  • In patients with mitral valve prolapse (MVP), palpitations and atypical chest pain are the most frequent complaints. Two thirds of these patients are female, often with an underlying panic disorder.
  • With underlying coronary artery disease (CAD), regurgitation usually is associated with symptoms of angina pectoris.
  • Regurgitation also can develop acutely with myocardial infarction, secondary to papillary muscle rupture.
  • Coronary artery disease often is accompanied by dyspnea, fatigue, orthopnea, and fluid retention. Chest pain is usually minimal in these patients.
  • When mitral regurgitation is due to left ventricular dilatation and altered valve function, patients often have chronic left-sided heart failure.
  • In acute mitral regurgitation from sudden disruption of the mitral valve, the symptoms are due to acute pulmonary edema.
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Physical

  • The classic murmur of mitral regurgitation is a high-pitched holosystolic murmur beginning with the first heart sound and extending to the second heart sound.
    • The intensity usually is constant throughout systolic ejection, often radiating to the axilla.
    • The harshness of the murmur does not correlate with the magnitude of the valvular defect.
    • Patients with severe disease often have a third heart sound, a consequence of the increased ventricular filling volume that is ejected into the left ventricle under higher than normal pressure.
    • Patients with mitral valve prolapse often have a mid-to-late systolic click and a late systolic murmur. These patients are usually female and often have orthostatic hypotension.
  • Patients with coronary artery disease can have the above mentioned murmur any time during systole, accompanied by an atrial gallop.
  • In acute mitral regurgitation, the examination usually is consistent with acute pulmonary edema and left ventricular failure.
    • The heart size usually is normal, but an audible systolic thrill is often present.
    • The murmur often is harsh. It may be heard over the back of the neck, vertebra, and/or sacrum and may radiate to the axilla, back, and left sternal border.
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Causes

  • Acute rheumatic heart disease remains a significant consideration in those with mitral regurgitation who are younger than 40 years.
  • Mitral valve prolapse (MVP) (ie, myxomatous degeneration) accounts for approximately 45% of the cases of mitral regurgitation in the Western world.
    • The causative agent is unknown in this condition.
    • Myxomatous degeneration is usually a slow process, with a major complication being the rupture of the chordae tendineae. (Acute regurgitation, as mentioned earlier, can be caused by chordae tendineae rupture or papillary muscle dysfunction.)
    • The literature now seems to suggest that MVP has become the most common cause of mitral regurgitation in the adult population.
  • In addition, MVP and coronary artery disease (CAD) have become major mechanisms for incompetence of the mitral valve.
    • Ischemia is responsible for 3-25% of mitral regurgitation.
    • The severity of regurgitation is directly proportional to the degree of left ventricular hypokinesis.
  • Mitral annular calcification can contribute to regurgitation. Impaired constriction of the annulus results in poor valve closure.
  • Left ventricular dilatation and heart failure can produce annular dilatation and poor valve closure resulting in mitral regurgitation.
  • Tendineae rupture can be due to endocarditis, myocardial infarction, or trauma.
  • Papillary muscle dysfunction usually is caused by myocardial ischemia or infarction.
  • Other causes include the following:
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Contributor Information and Disclosures
Author

Daniel DiSandro, MD  Clinical Assistant Professor, Department of Emergency Medicine, Drexel University

Daniel DiSandro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert M McNamara, MD, FAAEM  Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. [Guideline] Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. Sep 23 2008;52(13):e1-142. [Medline]. [Full Text].

  2. Borer JS, Bonow RO. Contemporary approach to aortic and mitral regurgitation. Circulation. Nov 18 2003;108(20):2432-8. [Medline].

  3. Carabello BA. Management of valvular regurgitation. Curr Opin Cardiol. Mar 1995;10(2):124-7. [Medline].

  4. Carabello BA. Mitral valve disease. Curr Probl Cardiol. Jul 1993;18(7):423-78. [Medline].

  5. Fenster MS, Feldman MD. Mitral regurgitation: an overview. Curr Probl Cardiol. Apr 1995;20(4):193-280. [Medline].

  6. Filsoufi F, Salzberg SP, Adams DH. Current management of ischemic mitral regurgitation. Mt Sinai J Med. Mar 2005;72(2):105-15. [Medline].

  7. Gaasch WH, Eisenhauer AC. The management of mitral valve disease. Curr Opin Cardiol. Mar 1996;11(2):114-9. [Medline].

  8. Schon HR. Medical treatment of chronic valvular regurgitation. J Heart Valve Dis. Oct 1995;4 Suppl 2:S170-4. [Medline].

  9. Wisenbaugh T. Mitral valve disease. Curr Opin Cardiol. Mar 1994;9(2):146-51. [Medline].

 
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Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
Severe mitral regurgitation as depicted with color Doppler echocardiography.
Four-chamber apical view of a 2-dimensional transthoracic echocardiogram demonstrates mitral valve prolapse (MVP), a common cause of mitral regurgitation.
 
 
 
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