eMedicine Specialties > Emergency Medicine > Cardiovascular

Mitral Stenosis: Differential Diagnoses & Workup

Author: Ethan S Brandler, MD, MPH, Clinical Assistant Instructor, Staff Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital
Coauthor(s): Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Aug 22, 2008

Differential Diagnoses

Aortic Regurgitation
Mitral Regurgitation
Atrial Fibrillation
Myocardial Infarction
Cardiomyopathy, Dilated
Myocarditis
Chronic Obstructive Pulmonary Disease and Emphysema
Pulmonic Valvular Stenosis
Congestive Heart Failure and Pulmonary Edema

Other Problems to Be Considered

Atrial myxoma (obstructing left atrial outflow)
Lutembacher syndrome (congenital atrial septal defect associated with mitral stenosis)
Infective endocarditis with large vegetations

Workup

Laboratory Studies

  • Ruling out other diseases is useful.
  • Brain natriuretic peptide may be useful in determining the presence of heart failure in an undifferentiated patient with dyspnea4
  • Troponin I and creatinine kinase levels may be useful in ruling out acute myocardial infarction in patients who present with symptomatic mitral stenosis.

Imaging Studies

  • Two-dimensional (2D) and Doppler echocardiography (echo) is the diagnostic study of choice.1 It should be performed in order to make the diagnosis and to assess valve function whenever a change in symptoms or physical examination findings is noted.
    • 2D echocardiography evaluates the morphology of the mitral valve, measuring orifice size and detailing leaflet mobility, thickness, calcification, fusion, and appearance of the commissures. It provides anatomic and functional information on cardiac chambers and facilitates recognition of other structural abnormalities.
    • Doppler echocardiography is the most accurate noninvasive technique to quantify the hemodynamic severity of mitral stenosis at rest or with exercise. It measures transvalvular pressure gradient and pulmonary arterial pressure and determines whether mitral regurgitation, aortic regurgitation, and other valvular abnormalities coexist.
    • If a question exists about the diagnosis after transthoracic echocardiography, a transesophageal echocardiography (TEE) provides better images of the mitral valve and is a more sensitive way to detect pathology such as valvular vegetations or atrial thrombus.
  • Chest radiography
    • Look for left atrial, pulmonary artery, right ventricle, and/or right atrium enlargement (eg, straightening of left heart border, loss of aortic window).
    • Rarely, calcification of the mitral valve may be seen.
    • Radiologic changes in the lung fields indirectly reflect the severity of mitral stenosis.
    • Interstitial edema manifests as Kerley B lines.
    • Severe, long-standing mitral obstruction results in Kerley A lines and findings of pulmonary hemosiderosis.
    • Pulmonary edema is seldom evident on the chest radiography.

Other Tests

  • ECG is relatively insensitive for mild mitral stenosis.
    • Ninety percent of patients with significant mitral stenosis and sinus rhythm display electrical evidence of left atrial enlargement: P-mitrale in lead II and/or a biphasic P wave in lead V1 with a wide negative deflection greater than 0.04 seconds.
    • The QRS axis in the frontal plane correlates with the severity of valve obstruction in pure mitral stenosis. A mean axis between 0 and +60 degrees suggests a mitral valve area >1.3 cm2, whereas an axis of more than 60 degrees suggests a valve area <1.3 cm2.
    • Atrial fibrillation usually develops in the presence of preexisting left atrial enlargement.
    • With severe pulmonary hypertension, right-axis deviation and right ventricular hypertrophy can be seen. The ECG of right ventricular hypertrophy typically shows tall R waves in the right chest leads, and the R wave may be taller than the S wave in lead V1. In addition, right-axis deviation and right precordial T-wave inversions are often present.

Procedures

  • Exercise stress testing
    • Exercise stress testing is indicated in situations where the degree of disability is in question.
    • Stress echocardiography will provide information about changes in the transmitral gradient and the degree of limitation of exercise and may guide decisions about valvotomy.
  • Cardiac catheterization
    • Cardiac catheterization is indicated when a discrepancy exists between Doppler-derived hemodynamics and the clinical status in a symptomatic patient.
    • Perform percutaneous mitral balloon valvotomy in properly selected patients.
    • Cardiac catheterization measures absolute left- and right-sided pressure when pulmonary artery pressure elevation is out of proportion to mean gradient and valve area.
    • Coronary angiography may be performed in selected patients.

More on Mitral Stenosis

Overview: Mitral Stenosis
Differential Diagnoses & Workup: Mitral Stenosis
Treatment & Medication: Mitral Stenosis
Follow-up: Mitral Stenosis
Multimedia: Mitral Stenosis
References
[ CLOSE WINDOW ]

References

  1. Bonow RO, Carabello BA, Kanu C, et al. 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): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. Aug 1 2006;114(5):e84-231. [Medline].

  2. Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. Aug 2 2007;357(5):470-6. [Medline].

  3. Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA. Oct 13 1993;270(14):1731-6. [Medline].

  4. Zehtabchi S, Brandler ES. Evidence-based emergency medicine/rational clinical examination abstract. Does this patient have congestive heart failure?. Ann Emerg Med. Jan 2008;51(1):87-90. [Medline].

  5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  6. ACC/AHA Task Force Report. ACC/AHA 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 (Committee on Management of Patients with Valvular Heart Disease). J Am Coll Cardiol. Nov 1998;32(5):1486-588. [Medline].

  7. Bonow RO, Braunwald E. Valvular heart disease. In: Zipe's: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. WB Saunders Co; 2005:1553-63.

  8. Braunwald E. Valvular heart disease. In: Harrison's Principles of Internal Medicine. 16th ed. 2005:chap 219.

  9. Carabello BA. Modern management of mitral stenosis. Circulation. Jul 19 2005;112(3):432-7. [Medline].

  10. Carabello BA, Crawford FA Jr. Valvular heart disease. N Engl J Med. Jul 3 1997;337(1):32-41. [Medline].

  11. Carapetis JR, Currie BJ, Kaplan EL. Epidemiology and prevention of group A streptococcal infections: acute respiratory tract infections, skin infections, and their sequelae at the close of the twentieth century. Clin Infect Dis. Feb 1999;28(2):205-10. [Medline].

  12. Chiang CW, Lo SK, Ko YS, et al. Predictors of systemic embolism in patients with mitral stenosis. A prospective study. Ann Intern Med. Jun 1 1998;128(11):885-9. [Medline].

  13. Cline DM. Valvular emergencies. In: Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Co Inc; 2004:chap 54.

  14. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Emerg Med. Jun 2001;37(6):711-9. [Medline].

  15. Itoh A, Kobayashi J, Bando K, et al. The impact of mitral valve surgery combined with maze procedure. Eur J Cardiothorac Surg. Jun 2006;29(6):1030-5. [Medline].

  16. Janz TG. Valvular heart disease: clinical approach to acute decompensation of left-sided lesions. Ann Emerg Med. Mar 1988;17(3):201-8. [Medline].

  17. Lung B, Gohlke-Barwolf C, Tornos P, et al. Working Groups Report: Recommendations on the management of the asymptomatic patient with valvular heart disease. Eur Heart J. Aug 2002;23(16):1252-66. [Medline].

  18. Massie BM, Granger CB, McPhee SJ. Valvular heart disease. In: Tierney's: Current Medical Diagnosis & Treatment. Online Eds. 2005.

  19. Rahimtoola SH, Dell'Italia LJ. Mitral valve disease. In: Fuster's: Hurst's The Heart. 11th ed. McGraw-Hill Medical Publishing Division; 2004:chap 67.

  20. Rahimtoola SH, Durairaj A, Mehra A, et al. Current evaluation and management of patients with mitral stenosis. Circulation. Sep 3 2002;106(10):1183-8. [Medline].

  21. Reyes VP, Raju BS, Wynne J, et al. Percutaneous balloon valvuloplasty compared with open surgical commissurotomy for mitral stenosis. N Engl J Med. Oct 13 1994;331(15):961-7. [Medline].

  22. Selzer A, Cohn KE. Natural history of mitral stenosis: a review. Circulation. Apr 1972;45(4):878-90. [Medline].

  23. Shipton B, Wahba H. Valvular heart disease: review and update. Am Fam Physician. Jun 1 2001;63(11):2201-8. [Medline].

  24. Stoltz C, Bryg RJ. Mitral stenosis. In: Crawford's: Current Diagnosis & Treatment in Cardiology. 2nd ed. McGraw-Hill Co; 2003:chap 10.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

mitral stenosis, mitral valve, MS, stenotic mitral valve, rheumatic fever, rheumatic heart disease, mitral valve replacement

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ethan S Brandler, MD, MPH, Clinical Assistant Instructor, Staff Physician, Departments of Emergency Medicine and Internal Medicine, University Hospital of Brooklyn, Kings County Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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.

CME Editor

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, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, 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: Schering  Honoraria Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.