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Mitral Stenosis in Emergency Medicine Clinical Presentation

  • Author: Ethan S Brandler, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 28, 2015
 

History

Although many patients are otherwise asymptomatic, fever, anemia, emotional upset or excitement, pregnancy, thyroid dysfunction, and exercise may precipitate symptoms.

Patients may present with complications of mitral stenosis (MS) including new onset atrial fibrillation, systemic embolism (including stroke and myocardial infarction), and infective endocarditis.

Inquire about a history of rheumatic fever, scarlet fever, skin infections, or repeated episodes of streptococcal pharyngitis. However, 50-60% of patients do not recall any of these.

Initial presenting complaints often include new exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Frank pulmonary edema is rare but may occur.

Chest pain should prompt consideration of right ventricular ischemia or failure and concomitant coronary atherosclerosis.

Hemoptysis from pulmonary venous hypertension may result from rupture of pulmonary veins or the capillary system.

Patients who complain of hoarseness may be presenting with Ortner syndrome, in which the left recurrent laryngeal nerve is compressed by an enlarged left atrium secondary to the increased valvular pressure gradient in worsening mitral stenosis.

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Physical

A complete physical examination, focusing on not just findings specific to mitral stenosis but also specific to right and/or left ventricular failure is essential.

Inspection

Findings are often unremarkable. Mitral facies, which are patches of pink-purple discoloration on the cheeks, are rare but are traditionally thought to result from elevated venous pressures and right heart failure. Elevated jugular pulse may be seen, but is a nonspecific finding.

Palpation

Neither diastolic thrill nor apical impulse is often appreciated in isolated mitral stenosis; left ventricular function is usually normal, and thrill is absent in mild stenosis.

With proper patient positioning, a peristernal lift may be infrequently felt when elevated pulmonary pressures induce increased right ventricular activity.

All peripheral pulses should be palpated to assess for embolization, especially in the setting of concomitant atrial fibrillation.

Auscultation

The classic murmur of mitral stenosis (ie, a low-pitched, rumbling, diastolic murmur best heard with the bell near the apex) can be accentuated by antecedent exercise and positioning the patient in the left lateral decubitus position. The length of the murmur, as opposed to the intensity, is used as a nonspecific guide to stenosis severity.

The S1 sound is loud and followed by an opening snap (OS), which is heard best with the diaphragm.

Further examination

As noted above, signs of left and/or right failure in general should be assessed.

The complications of mitral stenosis should be looked for when appropriate, including the following:

  • Endocarditis - Fever, changed murmur, Roth spots, Janeway lesions, splinter hemorrhages, and Osler nodes
  • Atrial fibrillation
  • Systemic embolizations
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Causes

Causes of mitral stenosis include the following:

  • Rheumatic fever (most common, all others are rare)
  • Congenital mitral stenosis
  • Systemic lupus erythematosus (SLE)
  • Rheumatoid arthritis (RA)
  • Malignant carcinoid
  • Mucopolysaccharidoses (of the Hunter-Hurler phenotype)
  • Fabry disease
  • Whipple disease
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Contributor Information and Disclosures
Author

Ethan S Brandler, MD, MPH Clinical Assistant Professor, Attending Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital

Ethan S Brandler, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Eric M Suess, MD Clinical Assistant Instructor, Resident Physician, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Eric M Suess, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

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

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors, Yiju Teresa Liu, MD, and Richard H Sinert, DO, to the development and writing of this article.

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Mitral stenosis.
Echocardiography of mitral stenosis. Courtesy of Michael B. Stone, MD, RDMS.
 
 
 
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